Management of HB

International Journal of Multidisciplinary Studies and Innovative Research
ISSN: 2737-7180 (Print), ISSN: 2737-7172 (Online)

DOI: http://doi.org/10.21681/IJMSIR-1.2.043.4018-2021
FACTORS, PRACTICES, AND ATTITUDE OF HEPATITIS B

INFECTION AMONG NEWLY ADMITTED HEALTH TRAINEES
IN GHANA: META EVALUATION
David Kwabena Adu
Department of Medical Diagnostics, College of Health and Well-being, Kintampo, Ghana
kwabenaadu41@gmail.com
Albert Bonsu
Department of Disease Control and Epidemiology, College of Health and Well-being, Kintampo
albbons68@gmail.com
Israel Patkuan Gamba
Department of Oral Health, College of Health and Well-being, Kintampo, Ghana
gabbiesgh@gmail.com
Dr. Kwabena Opoku-Adusei
College of Health and Well-being, Kintampo, Ghana
drkopa2310@gmail.com
Abstract: Hepatitis B virus is a contagious infection that can lead to acute and chronic liver disease and
hepatocellular carcinoma (HCC). In preventing infection and developing chronic liver disease and HCC due to
hepatitis B, vaccination against hepatitis B is 95% successful. The Centers for Disease Control revised their
recommendations in 2011 to recommend that adults at high risk of hepatitis B infection, including those
with diabetes mellitus (D.M.), be vaccinated against hepatitis B. We hypothesize that adults at high risk for
hepatitis B infection are not adequately screened and vaccinated for help in a comprehensive urban health
care system. This review's main objective was to evaluate the Factors, Practices, and Attitudes of Hepatitis
B Infection among Newly Admitted Health Trainees in Ghana. The specific objectives were Attitude and
practices towards hepatitis B, hepatitis B vaccine and attitudes towards hepatitis B testing and vaccination,
and factors associated with hepatitis B testing and vaccination. However, this study highlights the urgent
need for continued health education on HBV infection and strategies that health trainees are screened and
fully vaccinated against the infection to prevent potential future exposure to the virus. The students'
representative council can organize free HBV testing and vaccination for all fresh students to preclude
prospective risk.
Keywords: Hepatitis Africa, HBV, Vaccination practices, Health Trainees
INTRODUCTION 33 % of those who develop persistent infection

would end up with chronic hepatitis, of which 20 to
Hepatitis B virus (HBV) is a significant cause of acute 50 % may develop liver cirrhosis. HCC is a highly
and chronic liver disease (CLD) both in the United aggressive cancer with limited treatment options,
States and worldwide. More than 350 million people often lacking in many resource-poor settings such as
worldwide are infected with HBV, of whom Africa (Aroke et al., 2018). Sub-saharan Africa (SSA)
approximately 1.4 million reside in the United States has one of the highest HBV-related liver cancer rates
(World Health Organization, 2019). HBV is one of the globally (Kruglanski & Sleeth-Keppler, 2007). HBV-
leading causes of cirrhosis and the most common related liver cancer also remains the most common
cause for hepatocellular carcinoma (HCC), cancer among males and the third most common
accounting for 50% of all HCC cases and virtually all cancer among females in the African region (Jacob
childhood cases of this condition (World Health et al., 2019). Of significant importance is that the
Organization, 2019). Chronic HBV increases average age of HCC development in Africa is
individuals' risk of progressive liver disease and considerably younger than in other more advanced
hepatocellular carcinoma (HCC). In the natural regions (mean age 33 years compared to 60 years in
history of HBV infection, it is estimated that 10 to Western Europe), meaning HBV-related HCC affects
Volume 02, pp. 30-37 January 2021 Journal Homepage: https://www.ijmsir.org Page 30
patients in their most productive and reproductive factors associated with their profession in the
years (Aroke et al., 2018). Therefore, HBV transmission of diseases such as HBV (Jacob et al.,
represents a critical threat to health and other 2019). Although the three main transmission routes
developmental and economic parameters on the of HBV in Ghana are transfusion of infected blood,
African continent. unprotected sex, and mother-to-child transmission,
most Ghanaians with chronic hepatitis B were
Several factors may account for the observed high infected at birth or childhood. However, HBV has
HBV prevalence in Ghana. This includes a lack of often been framed as a sexually transmitted
adequate information and understanding among infection in many communities and even among
Ghanaians of the transmission dynamics of the virus. health workers (Jacob et al., 2019). Stigmatization
For instance, in an assessment of 200 barbershops arising from such misconceptions has often
within the Kumasi metropolis, only 7 % knew the prevented patients from finding their way to proper
transmission route of HBV (Jacob et al., 2019). care and subsequently reducing their infectivity
Akumiah and Sarfo further point out that the barber rates.
community in Ghana paid more attention to the
decoration (e.g., availability of television, air
conditioning, sound system, etc.) other than the risk
Figure 1
Hepatitis B viral replication cycle. The hepatitis B virus virion enters the hepatocyte via endocytosis. Viral
nucleocapsids are uncoated and transported into the nucleus, where viral DNA is transformed into covalently
closed circular DNA (cccDNA). Replication subsequently occurs through reverse transcription. The mature
nucleocapsids are responsible for mediating viral persistence and may be released to infect neighboring
hepatocytes. HBsAg: Hepatitis B surface antigen.
Figure 2
National Institute for Health and Care Excellence ATTITUDE AND PRACTICES TOWARDS HEPATITIS B
algorithm for initiation of treatment in chronic
hepatitis B infection. Current indications for Attitude refers to a favorable or unfavorable
treatment are based on a combination of levels of reaction towards objects, situations, people, or
serum hepatitis B virus (HBV) DNA, serum alanine other aspects of the world (Henry, 2008). This
transaminase (ALT), and the severity of liver encompasses cognitive, affective, and behavioral
disease. Specifically, patients with a transient factors (Kruglanski & Sleeth-Keppler, 2007). The
elastography score ≥ of 11 kPa are likely to have cognitive aspects refer to a person's knowledge
cirrhosis, and liver biopsy confirmation is not about something. The affective components touch
needed. Abnormal ALT, measured by two on the individual's feelings and evaluation that
consecutive tests conducted 3 more apart, is influence the standpoint against or for something.
defined as ≥ 30 IU/mL in males and ≥ 19 IU/mL in The behavioral factors deal with how a person acts
females. towards a situation or a person and motivates
changes. Attitudes can be comprehensive or
This review's main objective was to evaluate the unspecific. A comprehensive attitude is stable and
factors, practices, and attitudes of hepatitis B firmly held by the owners. They are usually difficult
infection among newly admitted health trainees in to influence as compared to unspecific attitudes
Ghana. The specific objectives were attitude and (Kruglanski & Sleeth-Keppler, 2007).
practices towards hepatitis B, hepatitis B vaccine
and attitudes towards hepatitis B testing and Based on the strength and the consistency in
vaccination, and factors associated with hepatitis B Attitude, one can predict the behavior of another.
testing and vaccination. Attitudes of which one is aware or based on
experience can be predicted to a higher degree a related practices (Afihene et al., 2015). 89.3%
person's behavior than those that do not meet any believed that HBV vaccination should be compulsory.
criteria (Henry, 2008). Despite the knowledge level On the vaccination issues, 25.13% stated that they
of a person, it is not a guarantee that a person will were scared, and 2.28% of the respondents stated
show the right Attitude. That is to say; that they did not trust the vaccine. HBV vaccination
knowledgeable individuals are still known to do is the most effective measure to prevent hepatitis B
things they esteem risky. Therefore, a right infection and its sequelae, including acute liver
knowledge level on HBV alone is not enough and failure, cirrhosis, HCC, and overall liver-related
does not necessarily lead to the subject's death. However, HBV vaccination among high-risk
appropriate behavior change. Instead, beliefs patients has been limited by several factors,
(cultural norms and practices), values, and attitudes including a lack of appropriate physician
of peers, families, and the media greatly influence a implementation of CDC recommendations and
person's behavior (Kruglanski & Sleeth-Keppler, inadequate insurance coverage to pay for patient
2007). vaccination, especially in resource-limited settings.
Most health insurance plans in the developed world
Attitudes, perceptions, and practices of hepatitis cover recommended vaccines for adults at little or
are similarly graded like knowledge. It could be no cost, but many people in the United States
graded as good, average, and low. Jacob et al.; 2019 remain without health insurance coverage. A 2012
demonstrated that a higher proportion of medical U.S. National Health Interview Survey (NHIS) study
students (84.3%) had good attitudes while a lesser on vaccination coverage (defined as those having
number of students (44.8%) had acceptable practices received at least the three recommended
(Jacob et al., 2019). A report from India on an vaccination doses) reported only 24.6% of adults
assessment of the knowledge, Attitude, and aged ≥ 19 yr being vaccinated (16.5% among adults
practices regarding HBV among medical students in a aged ≥ 50 yr) with rates of 42% in adults deemed at
private Medical College in Kochi revealed 84.3% high-risk (Centers for Disease Control and
positive attitude of students towards HBV and a 9.2% Prevention, 2013; WHO, 2019). Despite CDC
of students likely to complete their vaccination recommendations and significant public health
schedule. However, 79.1% had a good knowledge of efforts, HBV vaccination rates increased by less than
the subject of HBV (Jacob et al., 2019). Boakye's 5% between 2004 and 2009, in the United States
study in Ghana (2014) among high school students on (Afihene et al., 2015). Since diabetes mellitus
Attitude and perception of students on HBV revealed (D.M.'s) addition as a vaccination criterion in 2011,
that students had a right attitude towards HBV. Most HBV vaccination rates in the high-risk population are
students pointed out that vaccination of healthy unclear. Previous epidemiological studies on HBV
people was vital in the prevention of the disease. vaccination rates have also demonstrated that
The students pointed out that the HBV vaccine's low underrepresented high-risk patient populations have
patronage was mainly due to the cost and difficulty been noted to have the highest prevalence of HBV
in assessing facilities to get the vaccine (Boakye, infection (Afihene et al., 2015).
2012). A study in Cameroon on the awareness and
vaccine coverage of hepatitis B among medical HEPATITIS B VACCINE AND ATTITUDES TOWARDS
students revealed that only 26.05% of respondents HEPATITIS B TESTING AND VACCINATION
had been vaccinated at least once against HBV. The
general Attitude towards HBV vaccination was As early as 1982, a vaccine for HBV was introduced
positive, with a mean of 81.96% (29.41-97.13). A in the United States (U.S.) (Weinbaum et al., 2009).
negative attitude was attributed to the fear of the The Hepatitis B vaccine is the first human vaccine
injection and the possibility of developing adverse known to prevent hepatocellular carcinoma
effects after vaccination (Aroke et al., 2018). development in children (Ward & Van Damme,
2018). A vaccine given at birth within the first 24
Another study in Ghana among health staff reported hours prevents 80-90% of virus transmission between
a positive attitude and practices among health mother and the child (World Health Organization,
professionals in Ghana (Afihene et al., 2015). Among 2019).
others, the health professionals knew and pointed
out making vaccinations compulsory in the When the vaccination schedule is appropriately
prevention against hepatitis B but shoddy work- followed, the HBV vaccine gives healthy infants,
children, and adults a protective anti-hepatitis vaccination is the best way of prevention of
(anti-HB) concentration of 90-100% (World Health infection. The WHO in 2016 reported on the
Organization, 2019). The vaccine is given in three effectiveness and safety of the vaccine and that it
(3) doses series. The World Health Organization has a 95% capacity of preventing both children and
recommends the first dose at the first month of adults from HBV infection (Feldstein et al., 2017).
vaccination (1st month) followed by another dose a
month from the first dose and then finally the third Through the Ministry of Health and its agencies, the
dose, taken six months from the first dose (World Government of Ghana has been committed to
Health Organization, 2019). However, vaccination is providing vaccines to newborns under the Expanded
not recommended for immunocompromised persons Programme on Immunization (EPI) since 2002. The
and adults over 40 years as they are less likely to EPI focuses primarily on early childhood
develop protective anti-HB concentrations (World immunization to offer children immunity, especially
Health Organization, 2019). It is recommended that those below six years (Vision, 2014). Unfortunately,
the booster dose be taken years after the third dose. not all newborns benefit from these vaccination
This is because the vaccine is known to protect for programmes due to limited access to health
at least 10-15 years when the proper vaccination facilities, refusal to vaccinate, and pregnant women
schedule is adhered to. No significant side-effects not seeking antenatal and postnatal care (Nyaku et
have been recorded; however, fever and pain at the al., 2017). The vaccination practice among health
injection site may occur. Allergic reactions in few workers varies from one region to another. Munawar
populations have also been reported (Ward & Van and colleagues reported that the majority (93.75%)
Damme, 2018; Weinbaum et al., 2009). of health professionals in Pakistan had been
vaccinated against hepatitis B Virus (Munawar et al.,
Globally, early implementation of universal 2019).
vaccination programmes in endermic
areas/countries is known to reduce the prevalence Conversely, a study conducted in India among allied
and infection rate of HBV. Although various health students revealed that only 12% of
countries adopted different approaches of respondents had completed their vaccination
vaccination partly due to financial resources and schedules while most (70%) received only two doses.
epidemiologic status, the countries that started this The remaining 18% had never been vaccinated at all
program earlier have HBV infection rate declined to (Aasaithambi et al., 2019). Mesfin et al. reported
below 1% regardless of the initial rate before the that many medical students representing (85.7%)
exercise (Centers for Disease Control and had never tested for hepatitis B. Only 13.4% of the
Prevention, 2013; WHO, 2011). These include study population were vaccinated against HBV. Out
Taiwan (1984), Hong Kong (1988), Israel (1989), of this, only 4.7% had taken the full dose (3 doses)
Malaysia (1990), Gambia (1990), Italy (1991), Spain while the other 8.7% had uncompleted vaccination
(1991), and the United States in 1991 (Centers for schedules (Mesfin & Kibret, 2013).
Disease Control and Prevention, 2013; WHO, 2011).
On health student's Attitude towards testing and
In the United States, Taiwan, Italy, and Spain, HBV
immunoglobulin is given within the first 24 hours vaccination against hepatitis B in Ghana, Osei et al.
after birth to infants of HBsAg positive mothers found that out of the 326 undergraduate public
(Seto et al., 2018; Ward & Van Damme, 2018). In health students enrolled in a study, approximately
fifty percent (50%) indicated that they had never
Taiwan, for instance, vaccination against HBV
reduced the rate of infectivity with the virus in tested for hepatitis B virus (Osei et al., 2019).
adults while a combination of HBV vaccine and HBV Primary reasons for not testing included having no
specific reasons (36.3%), financial constraints (8.4%),
immunoglobulin given within the first 24 hours after
no idea about testing sites/facilities (2.7%), fear of a
birth to newborns of mothers tested positive for
positive result outcome (1.7%), and lack of time
HBsAg conferred immunity up to about 85-95%
among the populace (Su et al., 2012). In high- (1.33%) (Osei et al., 2019). Further, Osei et al.
income countries, chronic HBV is treated with a reported that only 30% of study participants were
combination of drugs, organ transplantation, and fully vaccinated against hepatitis B. Majority (55.6%)
of these health students were unvaccinated against
chemotherapy for liver cancer (Feldstein et al.,
HBV, while fewer students (13.7%) started the
2017). The story is, however, different in low-
income countries. In low-income countries, vaccination process but did not complete the full
dose regime. Reasons enumerated by students for vaccination uptake among men than women
non-vaccination include lack of money, no specific (Adekanle et al., 2015). In a cross-sectional survey
reasons, not sick, lack of knowledge on where to get in Brazil among 15-24 years old students, Guimaraes
vaccinated, lack of time, and known hepatitis B and Matos reported a significant association
virus carriers (Osei et al., 2019). Another similar between age and HBV vaccination coverage, but no
study among health workers in Ghana reported that significant association between sex and vaccinations
about 70% of study participants had been vaccinated was found (Guimarães & de Matos, 2015).
against hepatitis B virus. Of these, only 36.5% had
tested for immunity against HBV after vaccination CONCLUSION
(Afihene et al., 2015).
The knowledge of the virus is known to correlate
well with the disease's prevalence and thus serves as
FACTORS ASSOCIATED WITH HEPATITIS B TESTING a guide in designing remedies. A review of texts
AND VACCINATION reveals that health care workers generally have good
knowledge about HBV. This, however, may not
It is postulated that an individual's knowledge level translate into attitudes and practices of these
regarding an infectious disease can be correlated to individuals against the disease. Vaccination is a
the person's response in seeking medical care universal measure that provides immunity to an
regarding that disease. This could be related to the individual against the disease. The Government of
fact that people with good knowledge about Ghana, through the Ministry of Health, started
hepatitis B are well informed of its health threats. newborn vaccination against HBV in 2002. This may
In a cross-sectional study conducted by Osei et al., help protect beneficiaries from contracting the
2019 in Ghana, they identified students' level of disease. This notwithstanding, the adult population
knowledge as independent predictors of hepatitis B and other young people who did not benefit from
testing. Students with requisite knowledge of the the childhood vaccination programme have greater
hepatitis B virus had more fantastic than four times chances of becoming infected with the virus. This
the likelihood of getting tested for hepatitis B. study reviewed important literature and the
Further, the level or year of study of these allied attitudes of health professionals towards hepatitis B
health students was significantly associated with testing and vaccination. The level of knowledge of a
hepatitis B testing. The greater the number of years person may influence individual health-seeking
spent in school, the greater the odds of seeking behaviors. A review of relevant literature on
hepatitis B testing and vaccination (Osei et al., hepatitis B reveals varying variables as predictors of
2019). In a study in Nigeria, Ochu and Beynon in uptake of hepatitis B testing and vaccination. These
2017 found a significant association between female include but are not limited to gender, age group,
gender and the likelihood of being fully vaccinated and years spent in health training. However, most
against HBV. Further, they reported that increasing patients still require life-long treatment with
knowledge of respondents regarding hepatitis B nucleos(t)ide analogs, which is associated with
were significant independent indicators of full substantial costs and a high risk for developing
vaccination uptake among study participants (Ochu antiviral resistance. In our opinion, further studies
& Beynon, 2017). are required to identify mechanisms by which the
low viral load in the persistent carrier state may be
A study by Hunt et al. postulated that women were eliminated.
more likely to seek medical consultation than men
ACKNOWLEDGEMENT
(Hunt et al., 2011). Similarly, Osei et al. has
reported the female gender to be positively The authors are grateful to Dr. A. K. Peprah for his
associated with the odds of being fully vaccinated. valuable suggestions and editing of the manuscript.
Other studies have similarly reported that females
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International Journal of Multidisciplinary Studies and Innovative Research

ISSN: 2737-7180 (Print), ISSN: 2737-7172 (Online)

FACTORS, PRACTICES, AND ATTITUDE OF HEPATITIS B

Keywords: Hepatitis Africa, HBV, Vaccination practices, Health Trainees

INTRODUCTION 33 % of those who develop persistent infection

Su, W. J., Liu, C. C., Liu, D. P., Chen, S. F., Huang,

Vision, G. I. (2014). MINISTRY OF HEALTH - GHANA

Ward, J. W., & Van Damme, P. (2018). Hepatitis B

Weinbaum, C. M., Mast, E. E., & Ward, J. W. (2009).

WHO Organization. (2011). Management of hepatitis

World Health Organization. (2019). Hepatitis B

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