THE UNITED REPUPLIC OF TANZANIA

MINISTRY OF HEALTH

KAM COLLEGE OF HEALTH SCIENCE (KCHS)

RESEARCH REPORT
ORDINARY DIPLOMA IN PHARMACEUTICAL SCIENCES
TITLE: ASSESSMENT OF KNOWLEDGE, ATTITUDE AND USE OF
HEPATITIS B VACCINE AMONG RESIDENTS OF KIMARA WARD.

COURSE INSTRUCTOR : PHARMACIST LWITIKO MWAKITALIMA

COURSE SUPERVISOR : PHARM LWITIKO MWAKITALIMA
NAME OF STUDENT : MIRACLE GODWIN
REGISTRATION NUMBER : NS3547/0079/2016
SUBMISSION DATE : 03.07.2023

DURATION : MAY-JULY

2023
 DECLARATION AND COPYRIGHT.

I MIRACLE GODWIN, I declare that this Research Report is my original work and that
it has not been presented and will not be presented at any other academic institution for
similar or any other Ordinary Diploma award.

Name; MIRACLE GODWIN

Signature ………………………..

Date; 03/07/2023

I, the undersigned, certify that this Research Work is the work of the candidate who
carried it out under my direct supervision. The undersigned certify that he/she has read
and hereby recommends consideration by the KAM COLLEGE OF HEALTH
SCIENCE the report entitled.

SUPERVISOR APPROVAL

Supervisors’ name; PHARM. LWITIKO MWAKITALIMA

Signature………………………………

Date; 03/07/2023

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 TABLE OF CONTENTS
DECLARATION AND COPYRIGHT...............................................................................................i
ACKNOWLEDGEMENT.................................................................................................................iv
LIST OF ABBREVIATIONS...........................................................................................................vi
TABLE OF FIGURES.....................................................................................................................vii
ABSTRACT......................................................................................................................................ix
CHAPTER ONE: INTRODUCTION................................................................................................1
1.1 Background to the study...............................................................................................................3
1.2 Problem statement........................................................................................................................5
1.3 Research objectives......................................................................................................................5
1.3.1 Main objective...................................................................................................................5
1.3.2 Specific objectives.............................................................................................................5
1.4 Research questions.......................................................................................................................6
1.4 Hypothesis...................................................................................................................................6
1.5 Research questions.......................................................................................................................6
1.6 Purpose and findings of the study................................................................................................6
1.7 Chapter summary.........................................................................................................................6
2.0 LITERATURE REVIEW.............................................................................................................7
2.1 Chapter overview.........................................................................................................................7
2.2 Theoretical Literature Review......................................................................................................7
2.2.1 Theoretical definition of key terms..................................................................................11
2.2.2Conceptual / theoretical framework..................................................................................11
2.3 Empirical Literature Review......................................................................................................15
2.3.1 Developed countries........................................................................................................16
2.3.2 Developing countries.......................................................................................................17
2.4 Chapter summary.......................................................................................................................26
2.5 Conceptual framework...............................................................................................................27
CHAPTER THREE.........................................................................................................................28
3.0 RESEARCH METHODOLOGY...............................................................................................28
3.1 Chapter overview.......................................................................................................................28

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3.2 Research design.........................................................................................................................28
3.3 Study area..................................................................................................................................28
3.4 Study population........................................................................................................................29
3.5 sample size.................................................................................................................................29
3.6 Sampling & recruitment procedures...........................................................................................30
3.7 Study protocols / procedures......................................................................................................30
3.8. Questionnaire............................................................................................................................30
3.9 Methods for ensuring validity and reliability.............................................................................31
3.9.1 Reliability........................................................................................................................31
3.9.2 Validity...........................................................................................................................31
3.10 Data analysis methods and plan...............................................................................................31
3.11 Ethical considerations..............................................................................................................31
3.12 Plan for dissemination of research results................................................................................32
3.13 Inclusion and Exclusion Criteria..............................................................................................32
3.13.1 Inclusion criteria............................................................................................................32
3.13.2 Exclusion criteria...........................................................................................................32
3.14 Limitation and Delimitations of the study................................................................................32
3.14.1 Limitation of the study..................................................................................................32
3.14.2 Delimitation of the study...............................................................................................33
3.15 Chapter summary.....................................................................................................................33
CHAPTER FOUR............................................................................................................................34
4.0 RESULTS..................................................................................................................................34
CHAPTER FIVE.............................................................................................................................53
DISCUSSION..................................................................................................................................53
CHAPTER SIX................................................................................................................................56
6.0 CONCLUSION AND RECOMMENDATIONS.......................................................................56
6.1 Conclusion.................................................................................................................................56
6.2 Recommendations......................................................................................................................56
CHAPTER SEVEN.........................................................................................................................57
7.0 REFERENCES..........................................................................................................................57

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CHAPTER EIGHT..........................................................................................................................68
8.0 APPENDICES...........................................................................................................................68
8.1 QUESTIONNAIRE ENGLISH VERSION........................................................................68
8.2 APPENDIX C. QUESTIONNAIRE (SWAHILI VERSION)............................................72

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 ACKNOWLEDGEMENT.

First and foremost, I would like to thank the ALMIGHTY GOD for his protection and
guidance throughout all years of my studies at KAM COLLEGE OF HEALTH
SCIENCE

I would also like to thank our course tutor and supervisor Pharm. L. MWAKITALIMA
for dedicating his time to lead us through this research course, without forgetting all
tutors whom in one way or the other have been a helping hand to accomplish this work.

Lastly, my sincere gratitude to my loving and supporting parents, Mr. & Mrs. GODWIN
KABUNGO for their never ending support and prayers. Also to my friends whom in one
way or the other helped me to accomplish my research proposal.

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 LIST OF ABBREVIATIONS.

HBV: Hepatitis B Virus

HIV: Human Immunodeficiency Virus

AIDS: Acquired Immune Deficiency Syndrome

DTP: Diptheria Tetanus Pertusis

DNA: Deoxyribonucleic Acid

ECTC: Extended Temperature Controlled chain

WHO: World Health Organization

CHB: Chronic Hepatitis B

HBsAg: Hepatitis B surface antigen

HBeAg: Hepatitis B envelope antigen

MOHCDGDEC: Ministry of Health Community Development, Gender, Elderly and

Children

TTIs: Transfusion Transmitted Infections

MNH: Muhimbili National Hospital

MTCT: Mother to Child Transmission

HCWs: Health Care Workers

RRT: Renal Replacement Therapy

HBIG: Hepatitis B Immunoglobulin

TNBT: Tanzania National Blood transfusion

IPC: Infection Prevention and Control

CDC: Center for Disease Control and prevention

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 TABLE OF FIGURES.

Fig 4.1 Distribution of respondents according to their age

Fig. 4.2 Distribution of respondents’ gender

Fig. 4.3 Distribution of respondents according to their awareness about hepatitis B virus

Fig. 4.4 Distribution of respondents’ awareness on hepatitis B vaccination services

Fig.4.5 Distribution of respondents’ awareness on sources of information about hepatitis B virus

Fig. 4.6 Distribution of respondents according to their knowledge on transmission

Fig 4.7 Distribution of knowledge on hepatitis B prevention

Fig 4.8 Distribution of respondents according to their knowledge on the cure of hepatitis B

Fig. 4.9 Distribution of respondents’ awareness on vaccination services provided

Fig .4.10 Distribution of respondents according to their awareness on the importance of

vaccination services

Fig 4.11 Distribution of respondents according to their level of satisfaction

Fig 4.12 Distribution of respondents according to their opinion on charges of Hepatitis B

vaccination services

Fig 4.13 Distribution of respondents according to their reasons for not receiving vaccination

Fig.4.14 Distribution of respondents according to their attitude on risks of being infected

Fig. 4.15 Distribution of respondents’ attitudes about telling others of vaccination services

Fig. 4.16 Distribution of respondents according to their use of vaccination services

Fig.4.17 Distribution of respondents’ reasons to go for vaccination services

Fig 4.18 Distribution of respondents according to number of doses received

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 DEFINITION OF TERMS

Knowledge: Refers to the understanding, awareness, and familiarity that individuals

possess regarding the use, benefits, risks, and appropriate practices related to a particular
subject matter, in this case, the use and abuse of topical antifungal agents in the
management of fungal infections..

Attitude : The attitude is the way a person or behavior that an individual apply to make
things. In other hand it defined as a way to act, behave also can be considered some form
of social motivation - in nature, it promotes and guides the action towards specific
objectives and goals.

Prevention: : is an action or a set of actions designed to stop something before it

actually occurs.
Vaccine: is the substance use to stimulate immunity to a particular infection diseases or
pathogens, typically prepared from an inactivated or weakened form of the causasative
agents.

Heppatitis B : is the serious liver infections caused by hepatitis b virusn commonly

spread by exposure to infected bodily fluid that is easily prevented by a vaccine.

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 ABSTRACT
Hepatitis B virus is one of the smallest hepadnaviridae viruses that cause hepatitis B infection,
hepatitis B vaccine is an important anticancer vaccine that prevents Hepatitis B infections, it is
safe and effective. Hepatitis B infections can be acquired during infancy from mother to child,
blood transfusions and through other body fluids. In Tanzania hepatitis B vaccination services
were introduced so as to provide screening, counseling and vaccination services. Hepatitis B
Virus infections occur predominantly in infants and young children through vertical
transmission, routine infant immunization with hepatitis B vaccine is the most appropriate
prevention strategy, in Tanzania the strategy is already being practiced, this research intends to
inform policy makers the need to extend vaccination services to other groups such as youths
because of the increase of transmission of the infection among active persons who are not in
long term monogamous relationship hence youths are exposed to increased risk of acquiring the
infection, This study was aimed at assessing attitude, knowledge and use of hepatitis B
vaccination services among people in Kimara ward .The hypothesis was set to evaluate, poor
knowledge, attitude and use of hepatitis B vaccination services in people of Kimara ward.
The study was a descriptive cross sectional study and it was conducted in Kimara ward, located
in Kimara Ward. The study involved the use of structured questionnaires to collect primary data
from people attending Kimara Ward. The study enrolled 138 participants girls were 81 and
boys were 57. The results of the 8 knowledge questions asked was poor (35.56%), the results of
the 5 attitude questions asked was poor (26.51%) and the results of 3 use questions asked was
poor (43.64%).Provision of public education on viral infections, training health workers and
extending the vaccination programs to other groups can help in increasing knowledge and use of
vaccination services. The budget of the study was 300,000 Tanzanian shillings which covered
stationary services, transport charges, internet charges and other miscellaneous charges. The
results will be used to scale up vaccination services programs and formulate evidence based
policy and data for action.

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 CHAPTER ONE: INTRODUCTION

Hepatitis B infection is a disease of global significance affecting large number of people

. Chronic Hepatitis B which embraces a large spectrum of the disease remains to be a
serious public health problem globally with over 240 million people being affected and
causing 650 deaths annually (WHO,2015).

Hepatitis B infection can be prevented by vaccination, hepatitis B vaccine was

introduced in Tanzania in 2002 and is administered as DTP hepatitis B at 4, 8 12 weeks
of life .More than two-thirds of children under 5 years have protective anti-Hbs levels
(Metodi,2010).

Hepatitis B infection is spread when blood, semen or other body fluid infected with the
hepatitis B virus enters the body of a person who is not infected. people can become
infected through: birth, sharing items such as razors or tooth brushes with an infected
person, contact with the blood or open sores on an infected person, sex with an infected
partner, sharing needles, syringes or other drug injection equipment and exposure to
blood from needle stick or other sharp instrument (CDC, 2019).

Storage above or below the recommended +2oc to +8oc will reduce potency. In particular
hepatitis B vaccine is very sensitive to colder temperatures. The vaccine must be stored
in a fridge which is monitored daily to ensure the correct temperature of +2 oc to +8oc is
maintained but should not be frozen, (WHO, 2006).

Hepatitis B vaccine is very safe and it is effective at preventing hepatitis B infection.

Vaccine like any medicine has side effects. Most people who get hepatitis B vaccine
show no side effects at all but some people report having mild side effects, like a sore
arm from the shot or fever for a day or two. The most common side effects are usually
mild and last for a day or two. On extremely rare occasions people may experience
severe (anaphylactic) allergic reactions after the shot. Hepatitis B is not recommended
for anyone who is allergic to yeast (CDC, 2020).

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Pregnancy is not a contraindication to vaccination. Limited data suggests that
developing fetuses are not at risk for adverse events when hepatitis B vaccine is
administered to pregnant women. Available vaccines contain non-infectious HBsAg and
should cause no risk to of infection to pregnant women who are identified as being at
risk for HBV infection during pregnancy should be vaccinated (CDC, 2006).

Studies indicate that immunologic memory remains intact for at least 30 years among
healthy people who initiated hepatitis B vaccination at >6 months of age. The vaccine
confers long-term protection against clinical illness and chronic hepatitis B virus
infection. Cellular immunity appears to persist even though antibody levels might
become low or decline below detectable levels. Among vaccinated cohorts who initiated
hepatitis B vaccination at birth, long-term follow-up studies are ongoing to determine
the duration of vaccine-induced immunity (Bruce et al, 2016).

Vaccination services include screening, counseling and vaccination. Screening is a test

done to find a condition before symptoms begin, screening tests help find disease and
conditions early, when they are easier to treat. Routine health screenings are
recommended for people throughout life as an important part of preventive care. It
enables people to make better informed decisions about their health (O’Toole, 2013).

Counseling is a structured conversation aimed at facilitating a client’s quality of life in

the face of adversity. The core aim is to lead the client towards a positive change. There
are two types of counseling, pre counseling and post counseling; pre counseling refers to
the preparation of the client for the test and possible results of the test also it educates
the client about the disease. Post counseling helps the client to cope with the impact and
prepares the client for results (Shilomunyhu, 2015).

Vaccination is the administration of a vaccine to help the immune system develop

protection from a disease; vaccines contain a microorganism or virus which is
weakened, live or in a killed state or proteins or toxins from the organism, vaccination is
the most effective way of preventing disease (CDC, 2011)

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1.1 Background to the study
The hepatitis B vaccine is the first anti-cancer vaccine which helps to prevent liver
cancer. Worldwide, chronic hepatitis B&C causes 80% of all liver cancer which is the
second common cause of cancer death. Therefore a vaccine that protects against
hepatitis B infection can also prevent liver cancer (Hepatitis B Foundation, 2020)

The hepatitis B virus was discovered in 1965 by Dr. Banich Blumberg who won the
Nobel Prize for his discovery. Originally, the virus was called the “Australian Antigen”
because it was named after an Australian aborigine’s blood sample that reacted with
antibody in the serum of an American hemophilia patient (Hepatitis B Foundation, 2020)

Working with Dr. Blumberg microbiologist Irving Millman helped to develop a blood
test for the hepatitis B virus. Blood banks began using the test in 1971 to screen blood
donations and the risk of hepatitis B from a blood transfusion decreased by 25 percent.
Four years after discovering the hepatitis B virus Dr. Blumberg and Millman developed
the first hepatitis B vaccine, which was initially a heat treated form of the virus
(Hepatitis B Foundation, 2020)

In 1981, FDA approved a more sophisticated plasma derived hepatitis B vaccine for
human use. This “inactivated” type of vaccine involved the collection of blood from
hepatitis B virus-infected (HBs Ag-positive) donors. The pooled blood was subjected to
multiple steps to inactivate the viral particles that included formaldehyde treatment and
heat treatment (or “pasteurization”). Merck Pharmaceuticals manufactured this plasma
vaccine as “Heptavax” which was the first commercial hepatitis B virus vaccine. The
use of this vaccine was discontinued in 1990 and it is no longer available in the US
(hepatitis B Foundation, 2020)

In 1986, research resulted in a second generation of generally engineered (or DNA

recombinant) hepatitis B vaccines. These new vaccines are synthetically prepared and do
not contain blood products. It is impossible to get hepatitis B from the new recombinant
vaccines that are currently approved in the United States (hepatitis B Foundation, 2020).

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Hepatitis B Vaccine Schedule; Hepatitis B vaccine is produced by a recombinant DNA
technology most common in yeast. The complete vaccination series consists of three
doses of vaccine, the first two doses are usually given 1 month apart, with the third dose
1-12 months later. The WHO- recommended schedule for hepatitis B immunization of
children to consist of a dose within 24 hours of birth followed by a second and third
dose of hepatitis B containing vaccines at intervals of at least 4 weeks (WHO,2020).

A complete series of immunization provides protection for at least 25 years and

according to current scientific evidence probably for life. Boosters are not recommended
for routine immunization programs. Infants should get their first dose of Hepatitis B
vaccine at birth and will usually complete the series at 6 months of age (sometimes it
will take longer than 6 months to complete the series).Children and adolescents younger
than 19 years of age who have not yet gotten the vaccine should also be vaccinated
(WHO,2020).

Hepatitis B vaccine is also recommended for certain unvaccinated adults: people

whose sex partners have hepatitis B, sexually active partners who are not in a long term
monogamous relationships, persons seeking evaluation or treatment for a sexually
transmitted disease, men who have sexual contact with other men, people who share
needles, syringes or drug injection equipment, people who have household contact
with someone infected with the hepatitis B virus, health care and public safety workers
at risk of exposure to blood and body fluids, residents and staffs at facilities for
developmentally disabled persons, persons in correctional facilities, victims of sexual
assaults or abuse, travelers to regions with increased rate of hepatitis B, people with
chronic liver disease, kidney disease, HIV infection, infection with hepatitis C or
diabetes and also to anyone who wants to be protected from hepatitis B. Hepatitis B
vaccine may be given at the same time as other vaccines (CDC,2019).

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1.2 Problem statement
Hepataitis B Virus infection is a health hazard preventable by vaccination. A reliable
vaccination status is important for people to prevent the spread of the infection and
eventually eliminate its existence. In Tanzania, people are at risk of acquiring the
infection through contact with other body fluids such as saliva, tears, sweat, blood and
unsafe sex practices. Once acquired hepatitis B victims are given antiviral such as
Tenofovir and Entacavir to suppress the infection, the treatment does not cure the
infection but only suppresses the replication of the virus. Tanzania is regarded to be a
higher endemic country, (Schweitzer, 2015).

In Tanzania Hepatitis B Vaccine was introduced in 2002 (Sarin, 2016), it is provided in

the form of intramuscular injection in three doses. Despite its introduction the majority
have not been vaccinated, studies have been done on the acceptance of the vaccine to
hospital workers, other researchers have done studies concerning Hepatitis B infection in
Tanzania current status and challenges, a little is known concerning knowledge, attitude
and use of Hepatitis B vaccination services among people in Kimara ward, there is an
information gap that needs to be worked upon concerning knowledge, attitude and use of
hepatitis B vaccination services among people in Kimara ward.

1.3 Research objectives

1.3.1 Main objective

Assessment of knowledge, attitude and use of hepatitis B vaccination services among
people in Kimara ward.

1.3.2 Specific objectives

Specific objectives focus on people ’ knowledge, attitude and use in Kimara Ward.

 To identify knowledge about hepatitis B vaccination services.

 To find out the people ’s attitude about hepatitis B vaccination services.
 To determine if people receive vaccination services.

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  To propose suitable solutions towards modifying people ’s knowledge, attitude
and use of vaccination services.

1.4 Research questions

1.4 Hypothesis
The people of kimara has poor knowledge, attitude, and use of hepatitis B vaccination

1.5 Research questions

Research questions to assess knowledge, attitude and use of vaccination services among
people in Kimara ward.

 How are the attitudes of people towards Hepatitis B vaccination services?

 Do people have knowledge on vaccination services of hepatitis B?
 Have people received hepatitis B vaccine?
 Are there solutions towards modifying the knowledge, attitude and use of
hepatitis B vaccination services among the people of Kimara?

1.6 Purpose and findings of the study

The study assesses the knowledge, attitude and use of hepatitis B vaccination services
among people in Kimara ward. The findings of this study will guide policy and
intervention programs in similar settings towards the prevention and control of hepatitis
B infection, extend the access of vaccination services to unvaccinated adults who wish
to be vaccinated, update existing information, inform policy makers on the state of
hepatitis B vaccinations in the country, improve the knowledge of people concerning
hepatitis B vaccination services and promote the concept of vaccination to adults.

1.7 Chapter summary

Vaccination is the most cost effective method of disease prevention, Hepatitis B vaccine
is an important measure to prevent diseases such as liver cancer and liver cirrhosis,
which will save millions of lives and money to individuals and the society. The research

6
assesses the attitude, knowledge and use of Hepatitis B vaccination services among
people in Kimara ward.

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 CHAPTER TWO: LITERATURE REVIEW

2.1 Chapter overview

A literature review is a comprehensive summary of previous research on a topic. The
literature review surveys scholarly articles, books and other sources relevant to a
particular area of research. The review should enumerate, describe, summarize,
objectively evaluate and clarify this previous research and help the author to determine
the nature of the research. The literature review acknowledges the work of previous
researchers and in so doing assures the reader that my work has been well conceived. It
is assumed that by mentioning a previous work in the field of the study, that I have read,
evaluated and assimilated that work into the work at hand. “In writing the literature
review, the purpose is to convey to the reader what knowledge and ideas I have
established on a topic, and what their strengths and weaknesses are. The literature
review must be defined be defined by a guiding concept (e.g. my research objective, the
problem or issue I am discussing or my argumentative thesis). “It is not just a descriptive
list of the material available or a set of summaries” (Baglione, 2012).

2.2 Theoretical Literature Review

HBV is one of the smallest enveloped DNA virus and the prototype member of the
family of Hepadnaviridae that causes acute and chronic infections of mammals
(including human) and birds.HBV has evolved an extreme adaptation and dependency to
differentiated hepatocytes of its host. Despite its very limited coding capaward with only
four open reading frames, HBV is able to evade the immune system of the host and
persist lifelong within infected hepatocytes. During active replication HBV produces
enormous viral loads in the blood a massive surplus of sub viral surface antigen particles
in the serum of infected patients without killing their hepatocytes (Lin, 2011)

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Together with the use of a reverse transcriptase during replication it provides enormous
genetic flexibility for selection of viral mutants upon selective pressure, by the immune
system or antiviral therapy. In addition viral wild type and mutated genomes are stably
archived in the nucleus of the infected hepatocyte in an episomal DNA form that
provides independence from cellular replication or integration within the host genome.
We are just beginning to understand the delicate molecular and cellular interactions
during the HBV replicative cycle within the infected hepatocytes, so further diagnostic
and therapeutic options (Sunbul , 2014).

There has been a reduction of 60-75% in the prevalence of HBV infection, hepatitis B
surface antigen (HbsAg) carriage since HBV vaccination was introduced. Receiving the
first dose at more than 2 months after birth was one of the factors associated with
infection in the child; hence the recombinant vaccine the recombinant vaccine has
contributed to the reduction of the infection in the highly endemic area of Colombia.
Further efforts are required to improve timely vaccination for children at high risk (De la
Hoz et al,2008)

Hepatitis B infections are responsible for more than 300 thousands deaths per year in the
western pacific Region. Because of this high burden, the countries and areas of the
region established a goal of reducing Hepatitis B chronic infection prevalence among
children to less than 1% by 2017.This study was conducted to measure the progress in
Hepatitis B prevention and asses the status of achievement of the 2017 Regional
Hepatitis B control goal. The majorities of countries and areas (22 out of 36) were
estimated to have over 8% prevalence of chronic hepatitis B infection among persons
born before vaccine introduction. After introduction of Hepatitis B vaccine most
countries and areas (24 out of 36) had chronic infection prevalence of less than 1%
among children born after vaccination introduction. It was estimated that in the past 25
years immunization programs in the Western Pacific Region have averted, 167, 128
deaths that would have occurred in the life time of children, born between 1990-2014 if
hepatitis vaccination programs had not been established. Regional prevalence among

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children born in 2012 was estimated to be 0.93% meaning that the region hepatitis B
control goal was achieved.

While additional efforts are needed to further reduce hepatitis B transmission in the
region this study demonstrates the great success of the hepatitis B vaccination efforts in
the Western Pacific Region (Wiesen et al, 2016).

There is an established long lasting protection resulting from Hepatitis B Vaccine

despite the loss of HBV surface antigen. The study conducted involved 44 participants
who were selected regardless of anti-HBs level, tested positive for tumor necrosis factor,
α interleukin 10 or interleukin 6 productions by HBV surface antigen-specific T cells.
The frequency of natural killer T cells correlated with the level of anti-Hbs
(P=0.008).The proportion of participants who demonstrated T-cell responses to HBV
core antigen varied among the cytokines measured, suggesting some natural exposure to
HBV in the study group. No participant had evidence of breakthrough HBV infection.
Hence an evidence of long lasting cellular immunity regardless of anti-HBs level,
suggests that protection afforded by primary immunization with plasma derived hepatitis
B vaccine during childhood and adulthood lasts at least 32 years (Simons et al, 2016).

To ensure the safety of the vaccine a study concerning the quantification of anaphylaxis
after vaccination of children and adolescents was conducted were 5 cases of potentially
vaccine associated anaphylaxis after administration of 7 644 049 vaccine doses, for a
risk of 0.65 cases/million doses(95% confidence interval:0.21-1.53).None of the
episodes resulted in death. Vaccines that were administered before the anaphylactic
episodes were generally given in combination and included measles, mumps-rubella
vaccine, hepatitis B, diphtheria-tetanus, diphtheria-tetanus-pertusis, haemophilus
influenza type b, and oral polio vaccine. At the site additional allergy codes were
reviewed, 1 case after 653 990 vaccine doses was identified for a risk of
1.53cases/million doses(95% confidence interval:0.04-8.52)Therefore anaphylaxis
occurs very rarely nevertheless providers should be prepared to provide immediate
medical treatment in case it occurs (Bohlke, et al, 2003 ).

10
Thermo stability factors of the vaccine is an essential factor to consider since lack of
vaccines in cold storage may reduce birth-dose hepatitis B vaccine coverage and thus
place infants risky to perinatal transmission.

One mechanism to address this issue would be to allow vaccine to be out of the cold
chain at the point of delivery, but few manufacturers have pursued an on label indication
for storage at > 80o C known as the extended temperature controlled chain [ECTC],
including the (WHO) CTC programmatic approach allowing for the vaccine to be stored
at 40⁰ for three days this is important so as to ensure no transmission of HBV in poor
resourced countries (WHO, 2016).

Perinatal transmission of Hepatitis B virus occurs if the mother has had acute Hepatitis
B infection during late pregnancy or in the first months postpartum or if the mother is a
chronic Hepatitis B antigen carrier. Vertical transmission exceeds 90% and account to
up to 40 % of the world chronic carriers in endemic areas. Hepatitis B is not increased
with increased abortion rate, still birth or congenital malformation. However pre
maturity seems to be increased if hepatitis is acquired in the last trimester. Although
infection is rarely symptomatic 70-90% of the babies will remain chronically infected
into adult life and be prone to cirrhosis and hepatocellular carcinoma. Because of such
high risks and the safety and efficacy, it is recommended that HB vaccine be given to
pregnant women at high risks (Levy, 1991).

Hepatitis B virus is the second most important known human carcinogen, after tobacco,
HBV can be prevented by one of the safest and most vaccine available. The Hepatitis B
(Hep B) vaccine not only protects children and adults from HBV infection, but clinical
trials have established that if given within 24 hours after birth and followed by at least
two subsequent doses, the vaccine can prevent HBV infection in newborns even after
they have been exposed to the virus from their mothers. Protecting newborns is
important because infections at this point in the lifecycle is much more likely to persist
as chronic HBV infection and lead to premature death (Losonsky, et al, 1999).

11
Co infection of HBV-HIV seems to affect all –cause mortality and strategies to reduce
liver damages in patients confected with HIV and HBV are justified, the increased rates
of death among co-infected individuals was observed in the meta-analysis of studies
conducted both before (pooled effect estimate, 1.60; 95% confidence interval, 1.07-2.39)
and after (pooled effect estimate, 1.28; 95% confidence interval, 1.03-1.60)
commencement of highly active antiretroviral therapy. Serum samples obtained from
HIV-seropositive patients from 1984 to 2003 were retrospectively tested for hepatitis B
surface antigen. Multivariable analyses were performed using Poisson and logistic
regression models. For Meta analytic purposes, eligible articles were identified and
relevant data were extracted. Pooled estimates of effects were calculated applying fixed
& random effect models. Hence it was observed that the co infection of HBV-HIV
seems to affect all-cause mortality (Nikolopoulos, et al, 2009).

2.2.1 Theoretical definition of key terms

Hepatitis B virus: Is a viral infection that attacks the liver and can cause both acute and
chronic disease (WHO, 2019).

Hepatitis B vaccine: It is a vaccine that prevents Hepatitis B (WHO, 2017).

Knowledge: understanding of information about a subject that you can get by

experience or study, either known by one person or by people generally (Cambridge
University Press, 2020).

Attitude: the way you feel about something or someone or a particular feeling or
opinion (Cambridge University Press, 2020).

Use: the use of something in an effective way (Cambridge University Press, 2020).

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2.2.2Conceptual / theoretical framework

In this study the Health Belief Model, Theory of planned behavior, Social Cognitive
theory and Diffusion of Innovation Theory are chosen as theoretical frameworks to
guide thinking toward susceptibility, attitude, knowledge acquisition and use of hepatitis
B vaccination services.

The Health Belief Model is one of the most commonly used frameworks in research of
health behavior since it was developed in the 1950s.The Health Belief Model has six
primary concepts. They are used to predict why people decide, or do not decide, to
control, prevent or screen for different illness conditions. The primary concepts are
perceived susceptibility, benefits, severity, barriers and [cues to action and self efficacy].

Perceived susceptibility is defined as the belief in the chance of suffering a risk or

getting a disease or condition, for example hepatitis B. Perceived severity is the ability
to believe in the seriousness of a disease and its consequences, that hepatitis B is
harmful. Believing in the efficacy of health care and advised action, to attempt to reduce
the risk or the impacts’ seriousness is a part of perceived barriers are about weighing
concrete and emotional cost of following advised action, to return and get the vaccine at
least three times during six months. A young adult also has to have certain cues to
action, namely strategies to be provided with information and activate readiness.
Without confidence in one self to take action, a young adult is at higher risk of suffering
from anxiety. Strengthening young adults’ confidence and providing suitable training
and progressive goal setting counteract this (Glanz, 2008).

The health belief model helps the researcher to understand what drives people to use
vaccination services, it also enables the researcher to understand the perception of the
people toward the disease and how severe it can get if they are not vaccinated and also
to understand if they believe in the efficacy of their health system.

The theory of planned behavior was developed by social psychologists and has been
used to understand a variety of behaviors including health behaviors, it was proposed by

13
IcekAjzen (1985),developed from the theory of reasoned action which was proposed by
Martin Fishbein and IcekAjzen (1980).It links one’s belief and behavior, it guides
understanding, how humans can change a behavior.

According to the theory of reasoned action, if people perceive use of hepatitis B

vaccination services as positive(attitude), and if they think it is significant and others
would want them to perform the vaccination(subjective norm),this will result in a higher
intention towards use of the services(motivation) and they are more likely to do so. A
high correlation to of attitudes and subjective norms to vaccination services will be
confirmed (Sheppard, 1988). The addition of another factor perceived behavior control,
to which a person believe they control any given behavior, it suggests that people are
more likely to enact a certain behavior when they think they can enact them
successfully, therefore if the people perceives high control they increase confidence
and capability of performing a specific behavior. Finally when given sufficient control,
people are expected to carry out use of hepatitis B vaccination services when
opportunity arises (Ajzen, 2002).

The relevance of this theory is observed in the world today, for example people
perceive cancer as life threatening so when they hear there is vaccination for a certain
type of cancer they tend to go for vaccination example hepatitis B vaccine, also such a
scenario is observed with HIV, people go for screening so as to be sure they are not
infected and after screening they tend to protect themselves for example by being
faithful, wearing condoms and avoiding the use of unsterile piercing objects.

Social Cognitive Theory is used in psychology, education and communication, holds

that portion of an individual’s knowledge acquisition. It was advanced by Albert
Bandura as an extension of social learning theory, The theory states that, “when people

14
observe a model performing a behavior, they remember a sequence of events and use
this information to guide subsequent behaviors Observing a model can also prompt the
viewer to engage in behavior they have already learned (Bandura, 2008).

To learn a particular behavior people must understand what a potential outcome might
occur if they repeat a behavior. The core concepts of this theory are explained by using
three determinants; personal, behavioral and environmental.

Personal; explains whether a people has high or low self-efficacy toward use of
vaccination of hepatitis B vaccination services. Behavioral; explains the response a
people receives after they perform a use of hepatitis B vaccination services.
Environmental; explains the aspects of the environment or setting that influences the
people ’s ability to successfully use hepatitis B vaccination services (Edutech, 2019).

It is relevant to today’s world as observed in many organizations such as the World

Health organizations and United Nations since they use different advertisements so as to
motivate people to use health services such as vaccinations and Human
Immunodeficiency Virus/Acquired Immunodeficiency Virus advertisements or articles
so as to increase efficacy and improve response of individuals.

Diffusion of innovation is a theory that seeks to explain how, why and at what rate new
ideas and technology are spread. Everret Rogers popularized the theory in his book
which was first published in 1962 and is now its fifth edition (2003) (Rogers, 2003).

He proposed that four main elements influence the spread of a new idea; the innovation
itself, communication channels, time, adopters and social system. In this study the
innovation refers to hepatitis B vaccine which is perceived as new (Rogers,1983);
adopters are people (Mayer G,2004);communication channels are the ways that
information is transferred from one unit to the other,(Rogers,1983);time is necessary for
innovations to be adopted according to the study done by Ryan and Gross(1943) on the
hybrid corn adoption, adoption occurred over more than 10 years,(Ryan,1943);social

15
system refers to the combination of external influences(mass media, organizations and
government)and internal influences(strong and weak social relationships, distance from
opinion leaders(Strang,1998).

According to Rogers, Diffusion is a five stage process it involves knowledge,

persuasion, decision, implementation and confirmation. In the knowledge stage, the
individual is exposed to an innovation but lacks information about the innovation.

In the persuasion stage, the individual is interested in the innovation and actively seeks
related information. In the decision stage, the individual takes the concept of change and
decides whether to adopt or reject the innovation by measuring the advantages and
disadvantages. Rogers notes it as the most difficult stage. In the implementation stage
the individual also determines the usefulness of the innovation and may research further
about it. In the confirmation stage, the individual finalizes his or her decision to continue
using the innovation (Rogers, 1962).

In today’s world, the theory of diffusion of innovation is observed by the introduction of

synthetic drugs, after drugs were introduced people didn’t know about them, they
wanted to get more information, then people changed their view on synthetic drugs
after measuring the advantages like availability, affordability and flavor, after that stage
people decided whether to use the synthetic drugs or not, at last people will decide
whether to continue using the drugs or stop using them.

2.3 Empirical Literature Review

Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic
disease. It is a major global health problem, and the most serious type of viral hepatitis
B, It is estimated that 780,000 die each year due to consequences such as liver cirrhosis
and liver cancer. The virus is highly contagious and it is transmitted through contact
with the blood or other body fluids of an infected person .Hepatitis B virus can survive

16
outside the body, and is an important occupational hazard for health workers. Hepatitis
B is preventable with currently available and safe vaccines (WHO, 2018).Various
researches have been conducted so as to assess the severity and how to prevent this
deadly infection that causes loss of lives globally. Below are some of the researches
done in Developed and developing countries throughout the world.

2.3.1 Developed countries

In a study done in china, on knowledge and attitude towards hepatitis B and its
transmission from mother to child among pregnant women in Guangdong Province,
China. A cross sectional study was conducted in pregnant women to measure knowledge
and attitude using a questionnaire, at one tertiary and two rural hospitals (Han, et al,
2017).

Results obtained were, the total response rate was 94.5% (737/780).Of the 11 knowledge
questions, the score was 6.73± 3.04 (mean ±SD). Most pertinent to preventing mother to
child transmission, 53.3% of the respondents did not know that HBV can be transmitted
through unprotected sexual intercourse and nearly 20% did not know HBV can be
transmitted from mother to infant. The results of the four attitude questions was better
with 83% and 85% being willing to be screened for HBV and let their baby receive
HBV vaccine and HBIg, respectively. However only 16.5% of respondents agreed that,
they would be willing to take drugs that are known not to harm the fetus, to prevent
mother to child transmission of HBV. In multivariable analysis higher education level
was associated with better knowledge and attitude score (Han, et al, 2017).

The researcher reported that, knowledge about HBV among pregnant women was poor
and needs to be improved, to prevent mother to child transmission of HBV, Health
education needs to be directed towards pregnant mothers, particularly the less educated
mothers in high HBV endemiward settings, despite most respondents being aware of the

17
importance of antenatal screening, neonatal vaccination and postnatal follow up of HBV,
very few were willing to receive antiviral therapy to prevent mother to child
transmissions of HBV. This deficiency in knowledge and attitude was prominent in less
educated women. Additional efforts to enhance HBV public health education programs
in understandable languages are needed to achieve the goal of eliminating mother to
child transmission of HBV. Future studies could be aimed towards determining the
impact of such education (Han, et al, 2017).

In a study done in Germany, concerning viral hepatitis in Germany: poor vaccination

coverage and little knowledge about transmission in target groups. In order to estimate
vaccination coverage in adult groups and overall adult population, to assess knowledge
and attitude, a nationwide cross sectional telephone survey was conducted among 412
person in November 2004.Participants were recorded as vaccinated if they reported at
least one previous vaccination against hepatitis B (Schenkel, et al,2008).

The results obtained to estimate vaccination coverage standardized for age, sex and
residence was (29.6%) in the general population and (58.2%) in target groups for
hepatitis B vaccination. Particular gaps in vaccine coverage were detected among health
care workers (69.5%) and chronically ill persons (22%).Knowledge on risk factors and
transmission was far below expectations, whereas the acceptance of vaccination in the
majority of the population was good (79.0%).Knowledge about hepatitis B and its risk
factors in Germany were far below expectations and needs to be improved. Also
vaccination coverage in target groups was unsatisfactory. The researcher concluded that
educational measures could lead to higher vaccination uptake in adult target group
(Schenkel, et al, 2008)

2.3.2 Developing countries

In a study done in a Nigerian Tertiary Hospital on the Knowledge of Hepatitis B Virus
Infection and Immunization with hepatitis B Vaccine together with Risk Perception and

18
Challenges to control Hepatitis among Hospital workers (Adekankle, 2015). Studies had
reported high rate of hepatitis B infection among hospital workers, with low
participation in vaccination programs, especially those whose work exposes them to the
risk of HBV infection. A descriptive cross sectional study consenting health care
workers completed a self-administered questionnaire that assessed respondents’ general
knowledge of HBV vaccination, history and HBsAg status, risk perception and
challenges to control hepatitis (Belo, 2000).

A good knowledge of HBV virus means and modes of infection as well as adequate
vaccination may reduce infection rate. HBV could be transmitted through many other
routes and inadequate knowledge of HBV among health workers may reflect their
behavioral patterns to vaccination and safety measures (Fatusi, 2000).

A total of 382 questionnaires with complete data were analyzed (response rates of 76%).
The mean age of the study participants was 33.8±8.9 years (age range 20-59 years).
There were 182 males and 200 females, the respondents are comprised of 94 (25%)
medical laboratory technologists and 52 (14%) pharmacists. The knowledge of the
transmission of HBV was good for blood as a medium for all categories of transmission;
however knowledge of other body fluids as source of infection varies among
respondents (Bakiri, 2012).

Awareness levels of 96% for HBV among the respondents were similar to that reported
by (Okwara, et al., 2012). This may probably have been as a result of the education
programs on hepatitis received from the place of work and the news media as well as
patients and staff members with complications of chronic hepatitis B virus infection that
presents regularly to the hospital. Some respondents did not know about the chronic
complications of HBV like liver cirrhosis and liver cancer. This shows the lack in depth

19
knowledge about HBV among these healthy workers beyond ordinary awareness
(Adekankle, et al, 2010).

The proportions of the respondents that ever screened for HBV infection was
particularly low among the nurses and pharmacists. The implication of this is that health
workers who are infected with HBV may present with any of the chronic complications
of HBV such as hepatocellular carcinoma or liver cirrhosis as it is usually observed in
the general population. Furthermore the implication of a negative HBsAg test was not
known to some respondents as very few sought vaccination. There seems to be a high
level of vaccine awareness and low vaccination coverage among health workers in
Nigeria. Only 54% of health workers completed HBV vaccination exercise while 65% of
respondents reported complete HBV vaccine in this study (Fatusi, et al, 2000).

This is despite the fact that the hospital carries out occasional vaccination programs.
This pattern is similar to reports from other centers. The reason between the level of
awareness and vaccination in the study by (Okeke, et al., 2008) was due to the lack of
opportunities and forgetting to be vaccinated (Okwara et al., 2012) reported high
response among those that had tertiary education with a vaccination rate of 65%
(Kesieme, et al.,2011) in south-south geopolitical zone of Nigeria reported 87%
awareness level but only 27% vaccination coverage, while in north central Nigeria
reported that only 48% completed their HBV vaccination with an awareness level of
92%. The hospital workers of this institution have low perceived risk of HBV vaccine
therefore a policy of mandatory HBsAg screening and vaccination may need to be put in
place to protect both staff and patients of the institutions. Free HBsAg screening for
newly employed staff before vaccination may need to be incorporated into the policy to
make it effective (Okeke, et al, 2008).

In a study done in northern Vietnam, on knowledge, attitudes and practices of hepatitis

B prevention and immunization of pregnant women and mothers (Hang Pharm et
al,2019)S since infection at births due to mother-to-child (MTC) transmission is the
most common cause of chronic hepatitis B (HBV) infection in Vietnam. A cross

20
sectional survey was conducted in QuangNinh and HaoBinh provinces in 2017. The
results highlighted the need to prior educating pregnant women and mothers in future
public health campaigns in order to increase knowledge, reduce misperception, and
improve hepatitis B vaccine birth dose coverage in Vietnam. Vietnam has the sixth
highest incidence of liver cancer and third leading cause, if its cancer deaths in Vietnam
(WHO, 2018). The transmission of HBV can be effectively prevented through
immunization with hepatitis B vaccine (Ngunyen, et al, 2014).

Out of 18 HBV questions the mean knowledge score was 12.05± 3.38 (mean± SD) and
the median was 12 (inter quartile range was 10-15). Only 10.8% of study participants
provided correct answers to all 12 questions on HBV transmission modes and preventive
measures. 36.1% provided correct answers to all 4 questions regarding prevention from
mother to child. Only 25.8% were aware of high prevalence of chronic hepatitis B
infection in Vietnam.

Only 57.9% of participants were aware that chronic HBV can cause serious
consequences such as liver cirrhosis, liver failure, liver cancer or premature death. Study
participants were highly aware that HBV can be transmitted through mother to child
(84.2%), unprotected sex (75.3%), and blood transfusions (85.8%). However there were
common misconceptions that HBV can be transmitted through sneezing (41.8%),
contaminated water (45.8%), and eating with or sharing food with chronic HBV patients
(52.4%). The percentage of participants who were aware that HBV can be prevented by
receiving the hepatitis B vaccine, not reusing or sharing needles/syringes and using
condoms were 92.6%, 90.0% and 77.6% respectively. 71.3% had the misconception that
cooking and cleaning of food can prevent HBV transmission. 59.7% thought avoiding
sharing food and utensils or eating with a person with chronic HBV can prevent HBV
transmission (Hang Pharm, et al, 2019).

About a third of surveyed women and mothers had concerns about having casual contact
(31.8%) working with or sharing food with HBV patients (37.4%). Moreover, 40.8% of
respondents expressed having concerns if their children were in the same class with a

21
child with chronic HBV infection. While most participants were aware that infant
hepatitis B vaccination is necessary(86.1%) and the best time to provide a healthy and
stable child the first dose of HBV vaccine is within 24 hours after birth (80.0%) their
confidence in giving their own children the hepatitis B vaccine birth dose was lower.
Only 66.1% of mothers responded that they would definitely be willing to have their
own child vaccinated within 24 hours even if their doctors tell them the vaccine is safe
(Hang Pharm, et al,2019).

This study shows that pregnant women and mothers have insufficient knowledge and
practice regarding HBV infection regardless of age, education, socio-economic status
and poor exposure to HBV information during pregnancy. Misconception about HBV
transmission through contaminated water, sharing foods and casual contacts were
common and perpetuated the stigma associated with chronic HBV infection. Although
most participants were aware of the benefits of hepatitis B vaccine safety for newborn
were prevalent.

This emphasizes the need to enhance public health education efforts to improve hepatitis
knowledge among women in reproductive age and demystify issues surrounding HBV
transmission and vaccine safety to improve hepatitis B birth dose vaccination rate and
eliminate mother to child transmission. Public health interventions to improve HBV
antenatal screening and hepatitis birth dose practices are needed, particularly at primary
health care settings, to eliminate mother- to- child transmission (Hang Pharm, et al,
2019).

In a study done in Uganda, concerning Hepatitis B virus perceptions and health seeking
behaviors among pregnant women in Uganda: Implications for prevention and policy
(Mutyoba et al, 2019). Globally chronic infection with hepatitis B virus is a public
health challenge, affecting more than 350 million individuals (Schweitzer et al 2015).
Chronic Hepatitis B virus infection results in high mortality from cirrhosis and liver
cancer (Fattosich et al, 2008).Recent analysis from the global burden of disease data
reveals that HBV and its complications of liver cirrhosis and primary liver cancer are

22
not only among the leading 20 causes of death but are on the rise (Naghavi et al
2016).The two regions of Africa and south East Asia collectively contribute to the
highest prevalence and 70% of liver cancer prevalence worldwide (WHO,2018).

Intentions to prevent HBV were hinged on the theory of planned behavior (Ajzen, 1991)
which interprets perceived self-efficacy and individual behavior control, as predictors of
behavior intention. The theory of planned behavior has been used in disease prevention
studies including liver cancer prevention research (Bastani, et al, 2010).Individuals’
perceived risk was assessed using three approaches: absolute lifetime risk, comparative
risk and conditional risk also perceived severity barriers and benefits were assessed by
using different statements with participants requested to select statements which
represented their beliefs (Schweitzer, et al, 2015).

The study involved a total of 455 pregnant women, 300 from the central region and 155
from the north region. About half of all participants perceived their lifetime risk of
acquiring HBV (225/455, 49.5%) and liver cancer (229/455, 50.3%) to be low.

More than a third, (161/455, 35.4%), overall reported too low perceived risk of acquiring
liver cancer given HBV infection, In bi-variable regression analysis, perceived barriers
and self-efficacy showed an inverse and a direct association to screen for hepatitis B
respectively. For each unit increase in level of perceived barriers to screening, there was
a three percent lower prevalence of intention to screen for HBV. In multi- variable
models perceived health efficacy showed a consistent association with intention to
screen for HBV (Mutyoba,et al, 2019).

In bivariate analysis, intentions to get HBV vaccination was significantly related to

perceived health efficacy associations with border line significance we also observed
with perceived disease severity, perceived benefits and perceived barriers in the
multivariate analysis only perceived self- efficacy was statistically significant associated
with the intentions to get HBV vaccination (Mutyoba, et al, 2019).

23
HBV education triggers formulation of decisions to seek HBV care and preventions
services, but it is more effective if it is routed in a clear understanding of existing
populations’ perceptions regarding disease risks and prevention. High perceived self-
efficacy was associated with intention to screen, vaccinate and seek treatment for
hepatitis B. few pregnant women all inclusive, had high perceived risk of acquiring
HBV and liver cancer, for themselves, their children and their spouses compared to
those from the northern region. This finding is similar to a study by Kue and colleagues
among Chinese immigrants in USA (Kue, 2006).

Perceived self-efficacy in this study was independently related to hepatitis B prevention.

Behavioral intentions, including intentions to screen for hepatitis B, to seek treatment
and to receive hepatitis B vaccination, if individuals are self-assured in their ability to
prevent HBV, they are more likely to participate in preventive actions. A recent study
among Iranian patients with non-alcoholic fatty liver disease also found that both
perceived duration of illness and self-efficacy were predictive of adopting healthy
nutritional habits (Zelber-Sagi, et al, 2017).

In an obstetric population setting without antenatal HBV services, evaluation of

perceptions of hepatitis B and liver cancer risk also attendant benefits, barriers and self-
efficacy in relation to preventive behaviors .Low perception of risk of both HBV and
liver cancer were found. High perceived self-efficacy of region and religion were
significant determinants which associated with intention to screen, to vaccinate and to
seek treatment for hepatitis B. These findings may be relied on to lay a foundation for
strengthening HBV and liver cancer prevention programs, in order to maximize their
impact on national HBV elimination strategy (Mutyoba, et al, 2019).

In a study done in Tanzania, concerning Hepatitis B Virus infection in Tanzania: Current

status and Challenges in diagnosis, treatment and prevention (Kilonzo et al, 2018).
Hepatitis B virus is a disease of global significance affecting large number of people .
Chronic Hepatitis B (CHB) infection which embraces a large spectrum of the disease

24
remains to be a serious public health problem globally with over 240 million people
being affected and causing 650,000 deaths annually (WHO,2015).

Most of the African countries (99%) are in higher intermediate and higher endemic zone
with HBsAg seroprevalence of 5.7% and ˃8%, respectively. Tanzania is regarded to be a
higher endemic country (Schweitzer, 2015).The blood donors which are an eminent
population in epidemiology of the disease appear to have significant higher rates of
HBV markers. According to Tanzania National Blood Transfusion Services (TNBTS)
report, HBV infection was the most transfusion transmitted infection (TTI) detected in
all blood units collected in the country. The rate of HBV detection was 6.2% and carried
42% of all TTIS. Moreover family replacement donors had excessive risk of being
infected by 21.5% as compared to voluntarily unpaid donors compared to the voluntary
ones. In a survey done at Muhimbili National Hospital (MNH) with the rates of 9.5%
and 7.2% respectively (Matee, 2006).

In the intermediate and high endemic zones of HBV infection where vertical
transmission is frequent, pregnant women carry an important role in transmission of the
virus. Major risk factors for mother to child transmission (MTCT) of HBV are high
viral load and presence of maternal hepatitis B envelope antigen (HB eAg) (Wen,
2013).HCWs are at risk of acquiring HBV infection due to the frequent occupational
contact with the infected body materials and contaminated tools. The risk is four times
higher than in non-HCWs which increase with prevalence of infection on the general
population. On the other hand, the HCW s that have been infected with HBV are similar
at risk of transmitting the infection to their clients, though only rare cases have been
reported worldwide (Lewis, 2015).

25
Due to an increased exposure to blood products and shared hemodialysis equipment,
patients receiving renal replacement therapy (RRT) are at increased risk of HBV
transmission which if the major causes of morbidity and mortality among them. These
transmissions do not point to inadequacies in the strict infection control guidelines in
dialysis but rather to shortcomings in following such recommendation (Edey,
2010).Indication for HBV treatment are strict, as it has to be offered only to CHB
patients with inflammation of the liver, fibrous, high viral replication, and/or at high risk
of disease progression to cirrhosis or HCC. A patient is therefore entailed to undergo a
bunch of serial investigations prior to the commencement of treatment. To date seven
antiviral agents (Lamivudine, Adefovir, Entecavir, Telbivudine, Tenofovir,
Emtricitabine, standard and Pegylated Interferon) have been approved for the treatment
of CHB (WHO, 2015).

Suppression of HBV-DNA to undetectable level with a serological response for HB sAg

and HBeAg (in HBeAg - positive) is a desired goal for CHB treatment and most guidelines
recommend this to be achieved within 48 weeks of treatment. Unavailability of most of
these tests and drugs in the country posses’ difficulty in decision to treat and subsequent
follow-up of management. The only widely available potent anti-HBV drug in the
country is Tenofovir, which is usually supplied in a combination therapy with other
antiretroviral drugs that is deemed for treatment of HIV infection.

This creates a challenging situation in management of HBV mono infected cases. HBV
in and in HIV co infected patients is known to have extensive resistance to Lamivudine
(Hammers, 2013).

Available anti HBV drugs cannot eradicate the virus hence a lifelong treatment is
usually required. The regular availability of these drugs in most of low and middle
income countries is also a problem. This necessitates the scaling up of preventive
measures especially in the population that is at high risk of infection. In its Global
Health Sector Strategy on Viral Hepatitis (2016-2021) for elimination of Hepatitis B by
2030, WHO recommends a comprehensive approach in reduction of MTCT? These

26
includes routine HBV screening with a subsequent treatment of pregnant women
diagnosed to have HBV infection, providing HBV vaccine to an infant within 24 hours
of birth, safe delivery practices and the development of new interventions based on
maternal antiviral treatment (WHO, 2016).

Tenofovir or Telbivudine given during the second or third trimester of pregnancy in

addition to HBV vaccine and Hepatitis B immunoglobulin (HBIG) to the newborn baby
have been shown to decrease perinatal MTCT in several trials. Despite this call, these
strategies have not yet been introduced in Tanzania. Various countries have already
adapted this regime (Terrault, 2016).Most of antenatal care centers in the country have
not yet been integrated their services to accommodate the care of HBV- infected
patients. The transmission rates of HBV from mother to child are not known. Median
overall risk of becoming infected with HBV from blood transfusion in SSA is estimated
to be 4.3 per 1000 units of blood. This is largely contributed by incomplete screening of
TTI in transfused blood (Mosha, 2009). Before the establishment of NBTS in the
country in 2004, family donation was the significant source of the transfused blood that
was mostly used for replacement purposes. To date, about one third of the blood that is
being transfused is being issued by NBTS blood banks, which is usually rigorously
screened and tested for all TTIs including hepatitis B (Drammeh, 2017).

The plans are underway to scale up the NBTS services to cover the larger part of the part
of the country. Due to health workers occupations, there is an increased risk of
contracting HBV, screening and vaccination to all HCW s to maintain an anti-HBs
˃10mlu/ml are recommended and for those who are HB sAgpositive a potent antiviral
agent should be provided to maintain the HBV DNA ˂ 2000 IV/ml. In addition, a port
exposure prophylaxis of HBIG with active vaccination (in non-immune) has to be
commenced immediately following an occupational hazard (Sarin, 2016).

27
The Ministry of Health Community Development, Gender, Elderly and Children
(MOHCDGEC) published several guidelines on IPC in which extensive instructions on
proper hand washing, surgical hand preparations, use of gloves, injection safety, safe
cleaning of equipments and shares disposal have been provided (Ng’weg’weta,
2017).Despite several incongruities in the Tanzanian health system in almost all aspects
regarding the imminent HBV infection, the government is taking appropriate measures
to address these constraints. It has already been announced that HBV vaccines will be
freely offered to the high risk groups from the year 2018 (Nachilongo, 2017).

Moreover, a comprehensive 5 year HBV treatment plans have been launched using
MNH as a pilot with the future plans of extension to cover the whole country. In
addition the government is scaling up the blood safety program by expanding the NBTS
centers. On top of the available zonal NBTS centers, nine regional NBTS stations have
been constructed to date and an expansion to the remaining is on the way. In recognition
of these efforts, the countries has been recently attributed by WHO to be among that are
significantly advancing in the efforts to eliminate viral hepatitis B (John, 2016).

2.4 Chapter summary

This chapter consists of different researches throughout the world that will contribute to
the researcher’s understanding of this topic, a lot have been discovered concerning
transmission, risk perception, challenges and coverage and the current status of hepatitis
B, this research will contribute to the knowledge, attitude and use of vaccination services
in among people in Wards.

2.5 Conceptual framework

CHAPTER THREE: RESEARCH METHODOLOGY

3.1 Chapter overview

Research methodology is the specific procedures or techniques used to identify select,
process and analyze information about a topic. In a research paper, the methodology

28
section allows the reader to critically evaluate a study’s overall validity and reliability.
The methodology question answers two main questions. How was the data collected or
generated? How was it analyzed? “Methodology is the philosophical framework within
which the research is conducted or the foundation upon which the research is based
(Brown, 2006).

3.2 Research design

The study was a descriptive cross sectional study. It examined the relationship between
disease (and other related state) and other variables of interest as they exist in a define
population at a single point in time or over a short period of time. The data was collected
at the same time from people who were similar in other characteristics (all are
people ) but different in key factors of interest such as age, sex, occupation, marital
status and ethniward (Schimidt et al, 2008). It was used to prove and/or disprove
assumptions; it contained multiple variables and many findings and outcomes that were
analyzed from this research study. The Shortcomings of Cross-Sectional study is
findings can be flawed or skewed if there is a conflict of interest with the funding
source, to overcome that a trustful financial source is important to improve efficiency.

3.3 Study area

The study was conducted in Kimara Ward focusing mainly in Kimara Ward. The
school is located in the heart of Kimara Ward near Makole health centre and Sabasaba
market. It provides ordinary and advanced level education. It is located 4.9 kilometers
from St John’s University of Tanzania. Kimara ward is the capital ward of Tanzania
with a population of 2.084 million people according to the 2012 census (Global Data
Lab, 2020). Males cover 48.7% while women are 51.3%.The study area of Kimara is
2576 km2 and its weather is 240C.The main tribes of the region are Gogo, Warangi and
Wasandawi.

29
3.4 Study population
The study included people attending Kimara Ward. In Kimara ward, at the ordinary
level both male and female people were included while in the advanced level only girls
were included because it is a unisex school therefore only female people were
included. The average number of people in a class is 45 although there are some
variations. The age of people ranges from 12-20 years in Tanzania. All people were
enrolled regardless of their ethniward, demographics and religion.

3.5 sample size

According to the nature of the study, consecutive sampling technique will be used which
will involve a number of respondents available at school on that particular day. This
research applied Cochran’s formula (Cochran, 1968). The proportion that was used was
50%.
2 2
z p (1− p) z p (100− p)
n= 2 orn=
ε ε2
Whereby;
n is the required sample size
z is the level of confidence interval of the study which is 1.96 for 95% confidence
level
p is the proportional values for success (expected population based on previous
studies or pilot studies
ε is the margin of error 5% (0.05)
From the above formula
2
1.96 × 0.9(1−0.9)
n=
0.052
n=138
Therefore, the sample size of respondents was 138.

3.6 Sampling & recruitment procedures

The sampling technique employed was non-probability purposive sampling. Primary
data was collected and the results were used to assess the study objectives. Primary data

30
was collected directly from the respondents who were willing to participate in the study;
the data was collected from the respondents by using well organized and structured
questionnaire. Primary data has the advantage of being accurate, providing up to date
information and resolving specific research issues.

3.7 Study protocols / procedures

The study involved provision of questionnaires to people from all classes among
people , who were be approached after being granted permission from the school
administration. The questionnaires were collected upon completion. Respondents were
required to complete the questionnaires voluntarily. After collection of the
questionnaires data was interpreted by using sophisticated software and then results were
discussed and later presented.

3.8. Questionnaire

A questionnaire is a research instrument consisting of a series of questions for the

purpose of gathering information from respondents. In this study questionnaires were an
effective means of measuring the knowledge, attitudes and use among respondents. Both
open and closed questionnaires were used to obtain quantitative and qualitative data
(McLeod,2008).They were simple to administer to respondents and also a large number
of people was contacted at a relatively low cost, people are literate that is why this
tool will be used. Respondents may interpret questions differently; there is no guarantee
that the respondents will answer all the questions and respondents may provide false
information because of the tendency of people to communicate therefore this problem
was solved by proper supervision. Well prepared questionnaires have been attached at
the end of the proposal work.

3.9 Methods for ensuring validity and reliability

3.9.1 Reliability
The data collection tools were pre-tested so as to measure data reliability with 10
people who were not to be part of the study, so as to ensure completeness and

31
consistency. This enabled the researcher to do fine tuning of the questions and remove
questions that were ambiguous, it also enabled the researcher to test whether respondents
understood what the researcher needed to measure. It provided valuable feedback so that
the researcher could measure feedback and therefore increased the likelihood of success.

3.9.2 Validity
Validity is the extent to which a concept, conclusion or measurement is well founded
and likely corresponds accurately to the real world (NCME, 2020).Two types of validity
were in my data collection tool, content validity and face validity. Face validity is an
estimate to whether a test appears to measure certain criterion while content validity is
the type of validity in which items are chosen so that they comply with the test
specification which is drawn up through a thorough examination of the subject domain.
(Foxcroft, 2004)

3.10 Data analysis methods and plan

The data collected was analyzed by using SPSS version 16.0. Data was analyzed
differently depending on the objectives of the study and criteria of the respondents.
Advantages of SPSS over other methods were that people can import data from other
sources when data is organized, quick and easy to use, can handle large amounts of data
and also it has a greater user interface. Results of data were presented by using graphs,
and charts.

3.11 Ethical considerations

The ethical form was obtained from St John’s University of Tanzania then, participants
were informed of the consequences of the research and the data was collected after
permission was granted from the mentioned institutions and guardians signed the written
consent on behalf of people . The researcher guaranteed the participants confidentiality.
The participants voluntarily participated and the questions asked were only assessing
relevant components, the research did no harm to the participants

32
3.12 Plan for dissemination of research results
Upon completion of the research, the results were presented and uploaded online as a
digestible summary to be read by others and listened as a podcast in a concise form that
everyone understood. The importance of dissemination of research findings was making
sure that the results reached the target audience. The most effective ways used to
communicate research findings included social media, articles and websites that were
easily accessed by members of the community.

3.13 Inclusion and Exclusion Criteria

3.13.1 Inclusion criteria

Inclusion criteria are characteristics that the prospective subjects must have if they are to
be included in the study. Only people in Kimara ward were included because other
participants were not considered eligible on the selection criteria based on the research
topic.

3.13.2 Exclusion criteria

people outside kimara ward were excluded. Staff, other workers and visitors who were
not leaving kimara area was excluded. The study was more meaningful because people
who were eligible were the ones who participated in the study.

3.14 Limitation and Delimitations of the study

3.14.1 Limitation of the study

The study had several limitations: the presence of the researcher during data collection
affected the subjects’ response; the subjects were re-assured that the data was
confidential and not used otherwise also financial constraints could be the results of the
data therefore it was important to ensure that the budget was sufficient so as to overcome
the stated problems. The study was also affected by guessing, people tend to guess the
answers so as not to seem ignorant which provided false results.

33
3.14.2 Delimitation of the study
Collection of data was done after people completed the questionnaires and provided
information about knowledge, attitudes and use of vaccination services then data was
sorted and analyzed. To overcome the problems such as financial constraints the
researcher asked for more support from parents which contributed to avoiding errors and
ensuring the results obtained were the best. The researcher tried to be as friendly as
possible which enabled the respondents to be as comfortable as possible.

3.15 Chapter summary

Chapter three of this proposed work consisted of, research design, study setting,
Sampling & recruitment procedures, Study protocols / procedures, Data collection
methods (description, justification, strengths and weaknesses) whereby these methods
were essential for collecting data from respondents. it included the use of questionnaires
also the chapter contained methods for ensuring validity and reliability, Data analysis
methods and plan, Ethical considerations (included informed consent, confidentiality
issues, risk-benefit analysis, protection of human subjects, gender & minority inclusion),
Operational definitions, Plan for dissemination of research results, Limitation and
Delimitations of the study, all these procedures or techniques were used to identify,
select, process, and analyze information about assessing knowledge, attitude and use of
hepatitis B vaccination services among people in Kimara ward in Kimara ward.

34
 CHAPTER FOUR: RESULTS FINDINGS

This chapter covers results and analysis of the study. The sampled population
represented people from Kimara ward, the following aspects were considered in the
study; Age and sex, differentiated one people from the other. The total of 138 people
participated in the study. The following results were obtained:

DEMOGRAPHIC FEATURES:

Age

The people were grouped into five groups, which started from 16 years of age to
people with the age > 19; the range between the groups was 4. Participants with 17
years of age had the highest percentage which was (33.3%), followed by those >19
(23.2%), then those with 18 (19.6%), after that those with 19 (17.4%) and lastly those
with 16 (6.5%) which was the lowest.

Fig 4.1 Distribution of respondents according to their age

35
Gender

The number of males who participated were (59) and female were (81) making a total of
138. In the form of percentage males covered (41.3%) while females covered (58.7%)
together making a summation of (100%).
Fig. 4.2 Distribution of respondents’ gender

36
KNOWLEDGE ASSESSMENT
In assessing knowledge, the following issues were addressed;

Awareness of Respondents about Hepatitis B Virus

95(68.8%) people have heard about the virus while 43(31.2%) people have never
heard about it. The number of people who heard about the virus is high compared to
those who have never heard about the virus at all.

37
 Fig. 4.3 Distribution of respondents according to their awareness about hepatitis B virus

Awareness of Respondents on Hepatitis B Vaccination Services

92 (66.7%) people have never heard about hepatitis B vaccination services of which
some had heard about hepatitis B virus, 46 (33.3%) people have heard about hepatitis
B vaccination services.

38
 Fig. 4.4 Distribution of respondents’ awareness on hepatitis B vaccination services

Awareness of Respondents on Sources of Information Regarding Hepatitis B Virus

41 (29.7%) people did not answer this question because they had no information about
hepatitis B virus; two major sources of information were obtained (Television/Radio)
which was answered by 32 (23.2%) people and (School) which was also answered by
32 (23.2%).Social media was the second with 8 (5.8%).The third source was others for
example parents which was answered by 1 (0.7%)

39
 Fig.4.5 Distribution of respondents’ awareness on sources of information about hepatitis B
virus

Knowledge on Hepatitis B Transmission

45(32.6%) people did not answer this question because they have never heard about
hepatitis B virus, 1 (0.7%) answered that the virus is transmitted by contact, 91 (65.9%)
people answered that the virus is transmitted through contact with body fluids, 1(0.7%)
answered that the virus is transmitted through airways.

40
 Fig. 4.6 Distribution of respondents according to their knowledge on transmission

Knowledge on Prevention of Hepatitis B

45 (32.6%) people did not answer the question because they didn’t know how the virus
can be prevented, 48 (34.8%) people knew the virus can be prevented by avoiding
contact with body fluids, 23 (16.7%) knew the virus can be prevented by vaccination
and 22 (15.9%) knew hepatitis B virus can be prevented by both avoiding contact with
body fluids and vaccination.

41
 Fig 4.7 Distribution of knowledge on hepatitis B prevention

Knowledge on How Hepatitis B Can Be Cured

45 (32.6%) people did not answer the question because they didn’t know about hepatitis
B, 16 (11.6%) people strongly agree that hepatitis B can be cured, 40 (29%) people
agree that hepatitis B can be cured, 15 (10.9%) people knew about the virus but did not
know if hepatitis B can be cured, 15 (10.9%) disagree that hepatitis B can be cured and
7(5.1%) strongly disagree that hepatitis B can be cured.

42
Fig 4.8 Distribution of respondents according to their knowledge on the cure of hepatitis B

Awareness on Vaccination Services Provided

90 (65.2%) people did not answer the question because they didn’t know about hepatitis
B vaccination services some of them knew about hepatitis B virus but not the services,
26 (18.8%) people who answered this question knew about (counseling, screening and
vaccination).10 (7.2%) people knew about counseling only, 9 (6.5%) people knew
about vaccination only while 3 (2.2%) people knew about screening only.

43
 Fig. 4.9 Distribution of respondents’ awareness on vaccination services provided

Awareness of Respondents on the Importance of Hepatitis B Vaccination Services

83 (60.1%) people did not know the importance of hepatitis B vaccination services, 35
(25.4%) people answered protecting others from acquiring the infection,18 (13.0%)
answered preventing themselves from acquiring the infection,2 (1.4%) answered both 1
and 2 as important.

44
 Fig .4.10 Distribution of respondents according to their awareness on the importance of
vaccination services

ASSESSMENT OF ATTITUDE
In assessing attitude the following issues were addressed;
Ranking of Vaccination Services According to their Level of Satisfaction\

106 (76.8%) did not answer this question because they did not know about the
vaccination services and have not received them, 13 (9.4%) people were satisfied with
the services they received,10 (7.2%) people were very satisfied,6 (4.3%) people were
not satisfied and 3 (2.2%) were extremely satisfied.

45
 Fig 4.11 Distribution of respondents according to their level of satisfaction

Attitude of people about Charges of Hepatitis B Vaccination Services

54 (39.1%) people did not know whether to agree or disagree with hepatitis B
vaccination services being given for free, 39 (28.3%) people strongly agreed with
hepatitis B vaccination services being given for free, 26 (18.8%) people agreed with
hepatitis B vaccination services being given for free, 13 (9.4%) people disagreed with
hepatitis B vaccination services being given for free and 6 (4.3%) people who strongly
disagreed with hepatitis B vaccination services being given for free.

46
47
 Fig 4.12 Distribution of respondents according to their opinion on charges of Hepatitis B
vaccination services

Attitude of people on Reasons for Not Receiving Vaccination

21 (15.2%) people did not answer this question because they have received vaccination,
81 (58.7%) people haven’t received vaccination because they are not aware of
vaccination services, 9 (6.5%) people haven’t received vaccination because they don’t
know where to go for vaccination, 8 (5.8%) people haven’t received vaccination
because they don’t have time and 16 (11.6%) people haven’t received vaccination
services because it was expensive while 3(2.2%) did not see the need.

48
 Fig 4.13 Distribution of respondents according to their reasons for not receiving vaccination

Attitude of people on Risk of Being Infected

This question was answered by all the participants where by 51 (37%) people thought
they were likely to be infected with hepatitis B virus if they were not vaccinated while
87 (63.0%) people thought they were unlikely to be infected with the virus if they aren’t
vaccinated.

49
 Fig.4.14 Distribution of respondents according to their attitude on risks of being infected

Attitude of people on Telling Others about Vaccination Services

3 (2.2%) people did not answer this question, 11 (8%) people thought it is not
important to tell others about vaccination services, 25 (18.1%) people thought it is
important to tell others about vaccination services, 64 (46.4%) people thought it is very
important to tell others about vaccination services and 35 (25.4%) people thought it is
extremely important to tell others about vaccination services.

50
 Fig. 4.15 Distribution of respondents’ attitudes about telling others of vaccination services

USE ASSESSMENT
In assessment of use, the following were addressed;

Use of Vaccination Services

107 (77.5%) people have never been screened, counseled or vaccinated, 18 (13.0%)
people have been screened, counseled and vaccinated, 7 (5.1 %) have been screened and
counseled but not vaccinated, 6 (4.3%) have been counseled only.

51
 Fig. 4.16 Distribution of respondents according to their use of vaccination services

Reasons that Made Respondents Use Vaccination Services

107 (77.5%) people didn’t answer this question because they had not gone for
vaccination services, 14 (10.1%) went to receive vaccination services because of fear of
being infected, 14 (10.1%) went to receive vaccination services after being advised by
friends/doctors/family and 2.2% of people went for vaccination because it was free.

52
 Fig.4.17 Distribution of respondents’ reasons to go for vaccination services

Number of Doses of Hepatitis B Vaccine Received by Respondents

116 (84.1%) people did not answer this question because they have not been
vaccinated,5 (3.6%) people have received a single dose of hepatitis B vaccine,10 (7.2%)
people have received 2 doses of hepatitis B vaccine, 1 (0.7%) has received all three
doses of hepatitis B vaccine and 6 (4.3%) have received more than two doses of hepatitis
B vaccine.

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Fig 4.18 Distribution of respondents according to number of doses received

54
 CHAPTER FIVE

DISCUSSION

This study aimed at assessing knowledge, attitude and use of hepatitis B vaccination
services among ward people in Kimara Ward. 138 questionnaires were collected in
which the number of girls was 81(58.7%) and 59(41.3%) of which were boys.
95(68.8%) people heard of the virus while 43(31.2%) have never heard of the virus. The
results differed with the study conducted by (Han et. al, 2017). obtained their
knowledge of HBV from different sources such as television and schools that
contributed to (46.4%) of the total knowledge 92 (66.7%) people have never heard of
hepatitis B vaccination services and 46 (33.3%) have heard of hepatitis B vaccination
services, these results differ from the study of Okeke et al who reported HBV
vaccination awareness level of (92%). (1.4%) people had the misconception that
hepatitis B virus is transmitted through airways and contact while (65.9%) people
answered that the virus is transmitted through contact with body fluids. (82%) people
did not know how the virus is transmitted. 32.6% people did not know how the virus
could be prevented, (16.7%) people answered the virus could be prevented by avoiding
contacts with body fluids and (15.9%) people answered the virus could be prevented by
both avoiding contact with body fluids and vaccination. (40.6%) people agreed that
hepatitis B can be cured, (43.5%) did not know if it can be cured or not while (16%)
people disagreed that hepatitis B virus can be cured, this emphasizes the need to
enhance public education, efforts to improve transmission and prevention knowledge
(Hang Pharm, et al, 2019)

Also (60.1%) of the people did not know the importance of hepatitis B vaccination
services, (38.4%) of the people knew at least one type of vaccination services meaning
protection or prevention, only (1.4%) knew that vaccination provides both protection
and prevention.(15.2%) of the people have received vaccination because they have
enough knowledge of hepatitis B vaccination services and understand its importance.

55
(58.7%) haven’t received vaccination services because they are not aware therefore
provision of knowledge can increase awareness.

(11.6%) of the people don’t see the need therefore it is important to provide more
knowledge about the severity of the disease, (5.8%) of the people don’t have time this
signifies the need for hepatitis B vaccination services to be provided in schools as this is
where the people are mostly found and (6.5%) of the remaining people don’t know
where to go for vaccination this shows that people still lack information concerning
hepatitis B vaccination services therefore the most prioritized sources that should be
used include televisions and schools. The results obtained concerning knowledge agrees
with the hypothesis that people have poor knowledge of (35.56%) by average of all
knowledge questions asked, about hepatitis B and they are similar to those obtained by
(Hang Pharm et al, 2019) who reported the mean knowledge of 12.05%.

The results of the three attitude questions have shown the following (63%) people had
low perception of risk, they answered that they were unlikely to acquire hepatitis B virus
if they were not vaccinated their answer was associated with poor knowledge concerning
hepatitis B virus and the misconception that the disease can be cured. (37%) answered
that they were likely to acquire the disease this was associated with few people who had
proper knowledge about hepatitis B virus. Among the people (39.1%) did not know
whether to agree or disagree with hepatitis B vaccination services being given for free,
(47.1%) agreed with hepatitis B vaccination services being give for free while (13.7%)
disagreed with hepatitis B vaccination services being given for free. Therefore it is
important to review the cost of hepatitis B vaccination services so as to increase the
attitude of people towards them, increasing affordability to youths although there is no
assurance that reducing the costs will motivate to go for vaccination services. If people
perceive vaccination services as important they will tell others about them. (89.9%)
people thought it is important to tell others about vaccination services, (8%) of people
thought it is not important to tell others and (2.2%) did not answer the question.

56
Therefore the majority showed a poor attitude towards vaccination services of (26.51%)
by average of attitude questions asked. These results are not similar to those provided by
(Han et. al, 2017) which showed a positive attitude of (83%) and (85%) respectively.

The results of use questions asked were as follows, (65.2%) did not answer the question
because they did not know about the virus. (18.8%) people knew about the three types
of services provided (counseling, screening and vaccination) while (15.9%) people
knew about at least one type of service. Few people (22.4%) have received vaccination
services, of those who have received them only (13%) people have used all the three
services provided (screening, counseling and vaccination). (9.4%) have received at least
one of the services this shows a gap of knowledge concerning the severity and
susceptibility of the disease. Of the (22.4%) who went for vaccination services, (10.1%)
went because of fear of being infected, (10.1%) were advised by their families and
friends the remaining (2.2%) went because the services were given for free. 18.8% of
those who received vaccination services were satisfied the remaining were not satisfied
therefore it is important for health care workers to improve their health care skills,
communication skills. Only (15.8%) have received vaccine doses where (10.8%) of
those who have received vaccination have received incomplete doses and only (5%)
have received all the doses. The results of 5 use questions asked, reported low use
(43.64%). The results were similar to those obtained by (Kesieme et al, 2011) in south-
south geopolitical zone of Nigeria that reported low vaccination coverage of (27%).
These results agree with the hypothesis provided that, people have poor use of hepatitis
B vaccination services.

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 CHAPTER SIX

6.0 CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion
In conclusion, the aim of this study was to assess knowledge, attitude and use of
hepatitis B vaccination services among ward people in Kimara ward. The hypothesis
was set to evaluate poor knowledge, attitude and use of hepatitis B vaccination services
in ward of Kimara ward. The results obtained showed poor knowledge of (35.56%),
poor attitude of (26.51%) and poor use of vaccination services of (43.64%). This
research is significant not only to youths but also will represent the most active age
group in the society, it will contribute to the efforts done by the government to minimize
the spread of Hepatitis B virus infection, targeting provision of more knowledge and
measures to enhance use which includes training of health workers working in
vaccination departments on better communication skills, educating people more about
viral infections and their severity. This can be easily achieved by the participation of the
private sector. It will be used to design better policies, follow up programs will be
initiated, and the research will also be used to widen the scope of vaccination in the
country.

6.2 Recommendations
This study was conducted in an urban area. A similar study can be conducted in rural
area to evaluate knowledge, attitude and use of Hepatitis B vaccination services. Also
further studies can be conducted to assess the impact of the suggested measures. Also
time should be given for people to adapt the vaccine technology because adaptation
takes time.

58
59
 CHAPTER SEVEN

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