Risk perception of hepatitis B infection and uptake of hepatitis B vaccine among students of tertiary institution in Jos.

BACKGROUND: Hepatitis B virus (HBV) Infection is endemic in Nigeria. Healthcare students are more vulnerable because of direct contact with patients' body fluids and blood. Risk perception of HBV and HB vaccine uptake are also poor. The aim of this study was to assess the level of risk perception of hepatitis B infection, and uptake of the HBV vaccine, between medical and other students of the University of Jos.
METHODS: A comparative cross sectional study was conducted among 1,200 students of the departments of Medicine, Nursing sciences and Public Administration, University of Jos (400 from each arm) using a pretested self-administered questionnaire. A five point Likert scoring system was used to assess risk perception. Data was analyzed using SPSS version 20. A P -value of <0.05 was considered significant.
RESULTS: Awareness on HB vaccine prevention was high (88.4%) among University of Jos students. Awareness was similar among medical and nursing students (36.2% and 36.0% respectively) but lower among public administration student (27.8%), P< 0.001. The overall risk perception was 76.8%. This was also similar for medical and nursing students (40.7% and 40.1% respectively), but lower for public administration students (9.1%), P< 0.001. Risk perception is 5x higher among medical students compared to public administration students (OR = 5.22, 95% CI = 2.19 - 12.93; P < 0.001). The uptake of full dose HB vaccine was 60.2%, 20.6% and 15.1% for medical, nursing and public administration students respectively. Medical students are 4x more likely to go for HB vaccination compared with public administration students (OR=3.62; 95% CI=2.39 - 5.48; P< 0.001).
CONCLUSIONS: Awareness and risk perception on HBV infection are high among University of Jos students, but uptake of HB vaccine is low. Findings are worst for non-health students.

Introduction

Hepatitis B viral (HBV) infection is a vaccine-preventable disease which puts an increased economic burden on families, communities, and the country. HBV infection is one of the major public health problems globally. It is the tenth leading cause of death and is 50–100 times more infective than human immunodeficiency virus.[1]

Hepatitis B (HB) is a DNA virus assigned to the family hepadnaviridae. Humans are the only known natural host.[2] Transmission of the virus may occur through percutaneous or mucosal exposure to infected blood and various body fluids, as well as through saliva, menstrual, vaginal, and seminal fluids; transmission may also be vertical (transplacental).[2] Sexual transmission of HB is a major route, especially when there are multiple sex partners or contact with sex workers, hence classified as a sexually transmitted disease (STD). In addition, infection may occur through the reuse of needles and syringes, either in health-care settings or among persons who inject drugs.[34] In addition, infection occurs during medical, surgical, and dental procedures; tattooing; or through the use of razors and similar objects that are contaminated with infected blood.[2]

The average prevalence rate of HBV infection in Nigeria ranges between 11% and 13.7%. Approximately, 19 million Nigerians are chronically infected.[1] There is no male-female predilection with both sexes almost equally affected, but young adults have been found to have a higher prevalence of infection.[15]

Individuals are more at risk include medical personnel, especially surgeons and dentists, other health workers, commercial sex workers, and long distance drivers.[3] In addition, at risk are individuals who are exposed to unsafe practices such as local circumcision, uvulectomy, scarification of body with tribal marks, body piercing, delivery at home, and blood and blood product transfusion.[67]

The clinical manifestations of HBV infection vary with age. Clinical acute HB is more frequent in adults than children while the probability of becoming a chronic carrier of HB is greater in children than adults. Infection in adulthood leads to chronic hepatitis in 5% of cases which may result in cirrhosis or liver cancer.[28]

There is no known cure as prevention is the only safe strategy against the high prevalence of viral hepatitis. Safe and effective HBV vaccines have been available since 1982.[7] The World Health Organization has recommended the implementations of mass immunization programs since 1991.[9] Since its global expanded coverage, the incidence of HBV infection and liver cancer among infants, children, and adolescents has dramatically decreased.[3] Prevention is focused on vaccination of population groups most at risk.[5]

It is alarming that adults suffer from higher morbidity and mortality from serious vaccine-preventable diseases when compared to children such as vaccine-preventable hepatitis, influenza, and pneumococcal disease which kill far more adults than children each year. Most countries including Nigeria have public health policies focusing on childhood immunization, but adult vaccination is not emphasized. The Federal Ministry of Health of Nigeria have rolled out a strategic plan in which one of its objectives is to reduce by 50% transmission of viral hepatitis by the year 2020 through vaccination. However, the focus is still on children.[5]

Worldwide, more than 2 billion of the population have evidence of past or recent HBV infection, and 500 million people are estimated to be infected with the HBV.[2] This virus kills 1.5 million people a year, and one in every three people have been exposed to the virus with most infected people being asymptomatic.[6] Less than 5% of other healthy persons who are infected as adults will develop chronic infection; 20%–30% of adults who are chronically infected will develop cirrhosis and/or liver cancer.[67] More than 780,000 people die every year due to complications of HBV infection.[6] The proportion of people living with this infection is greatest in Asia, Sub-Saharan Africa, and Egypt.[7]

Approximately, 95% of new HBV infections occur among young adults, who have been unvaccinated exposing their household contacts and sex partners at the risk of getting infected.[6]

Young adults (15–24 years old) represent 25% of the sexually active population and almost 50% of all newly acquired STDs is mainly due to sexual ignorance, sexual abuse, nonuse of condoms, increased number of relationships between young persons and older partners, use of psychoactive substances, and poor attitude in utilization of health-care services.[10]

In Nigeria, the vaccination of young adults does not have the same implementation success as compared to infant vaccinations. The national policy for the control of viral hepatitis in Nigeria emphasizes the need for public enlightenment on the transmission of viral hepatitis and vaccination, especially among health-care workers, mothers of infants, and sex workers, but there is no information provided that focuses on young adults as a high-risk group.[1]

Medical, dental, and nursing students compared to other health-care students are more vulnerable to HBV infection not only because they directly come in contact with patients’ body fluids and blood and also deal with blood transfusion, surgical instruments during procedures and injections, but they also have a higher preponderance as young adults to have unprotected sexual intercourse with multiple sexual partners.[11] HB infection is a major health hazard throughout the world, and ideally, health-care students should have adequate knowledge about this disease and higher risk awareness.

Inadequate knowledge of HBV among health-care students may be reflected in the behavioral pattern to their perception of risk, vaccination, and safety measures.[10] A good knowledge of HBV infection and route of transmission as well as adequate vaccination may reduce infection rate and is the cornerstone of preventing transmission. Health-care students have a very important role in preventing the disease by improving the disease knowledge among themselves and the patients they treat.

This study was carried out to assess the risk perception of HB infection and uptake of HB vaccine among medical students compared with nonmedical students of the University of Jos, Plateau State, and to identify the factors impeding the uptake of the HB vaccine among them.

Materials and Methods

This study was conducted at the University of Jos, one of the Federal Universities in Nigeria, located at Jos, Plateau State. The university has 12 faculties (which offer courses in law, medicine, pharmacy, natural sciences, social sciences, environment sciences, as well as arts and humanities).[12] It has a health-care center, a youth friendly center, open air theater, and football field - for recreation with a total students population of 22,340.[12]

This was a cross-sectional, descriptive, comparative study among medical students compared with other students of the University of Jos. Information was obtained from the students and comparison was made between students in the Faculty of Social Sciences (Department of Public Administration and Management) with students of the Faculty of Medical Sciences (Department of Nursing Sciences and the Medicine/Surgery Department).[131415]

The study population comprised students from three selected departments who were <25 years of age in their 2nd, 3rd, and 4th years at the time of the study who gave informed consent for the study.

Sample size was determined using the formula for sample size for comparison of subgroups.[16] A minimum sample size of 276 was obtained. This was rounded up to 310 participants per group to take care of poorly filled questionnaires which could not be analyzed and those that were not returned.

A multistage sampling technique was used to select participants in the study. The first stage was the purposive selection of the faculties of medical and social sciences. In the second stage, the departments of public administration and management, medicine/surgery, and nursing sciences were selected through simple random sampling. In these departments, the 200, 300, and 400 level classes were selected. The levels of students were considered as clusters and all students in the selected classes who met the inclusion criteria were selected.

A semistructured, self-administered questionnaire was adapted from the Centre for Disease Control and Prevention; risk assessment tool was used to collect information.[6] It has four sections and sought information on respondents’ sociodemographic variables, their knowledge and transmission of HBV, risk perception, and HBV vaccine uptake.

Quantitative variables were described using mean and standard deviation and are summarized in tables and graphs. Chi-square was used to test significance between proportions and compare qualitative variables and a P ≤ 0.05 was considered statistically significant.

Data were organized into Microsoft Excel Spreadsheet, and data were analyzed and processed using IBM Statistical Package for Social Science (SPSS) version 20 (Students version for Universities).

Ethical clearance was obtained from the Jos University Teaching Hospital Ethical Committee. Permission was then obtained from the dean of selected faculties and the heads of the three departments. In seeking for these permissions, the aims and objectives of the study were clearly spelled out in the application and its benefits are stated in the application. The objective of the study was explained, and an informed written consent was obtained from the participants before the administration of the questionnaire.

After the collection of data from participants, they received health education on the transmission of HBV, symptoms of infection, and prevention. In addition, incentives (pens and jotters) were given to them in appreciation of their participation.

Results

The sociodemographic characteristics of the participants are shown in Table 1. The mean age of the participants was 21.2 ± 1.7 years, with an age range of 18–24 years. There were 641 (53.4%) female, 1092 (91.0%) Christians, and 1071 (89.3%) of the students were single.

Table 1

Sociodemographic characteristics of participants (n=1200)

Sociodemographic characteristics	Frequency (%)
Age group
18-19	140 (12)
20-21	330 (27)
22-23	428 (36)
>23	302 (25)
Total	1200 (100)
Sex
Male	559 (46.6)
Female	641 (53.4)
Marital status
Married	125 (10)
Single	1071 (89)
Widowed	4 (1)
Religion
Christianity	1092 (91)
Islam	104 (8)
Others	4 (1)

Awareness of vaccine prevention of hepatitis B viral infection

Overall awareness on HB vaccine prevention was high 1061 (88.4%) among the students studied. It was about the same among medical and nursing students, 384 (36.2%) and 382 (36.0%), respectively, but comparatively lower among the public administration student 294 (27.8%). This difference in awareness of vaccine prevention between medical and nonmedical students was statistically significant P < 0.001 [Table 2].

Table 2

Awareness of vaccine prevention for hepatitis B viral (n=1184)

Departments	Yes (%)	No (%)	χ2	P
Medicine/surgery	384 (36.2)	14 (11.4)	107.183	<0.001
Nursing	382 (36.0)	18 (14.6)
Public admin	295 (27.8)	91 (74.0)
Total	1061 (100)	123 (100)

Risk perception of hepatitis B viral transmission

Of the 1200 students studied, 922 (76.8%) were found to have a good risk perception of HB. Three hundred and ninety-four (40.7%) medical and 370 (40.1%) nursing students had a good risk perception of HB, respectively. However, the risk perception of HB was found to be 198 (9.1%) among public administration students which is comparatively lower. The difference in risk perception among medical and other students was statistically significant, P < 0.001 [Table 3].

Table 3

Comparison between students’ department and risk perception of hepatitis B infection

Departments	Poor knowledge	Good knowledge	χ2	P
Medicine/surgery	6 (22)	394 (40.7)	473.87	<0.001
Nursing	30 (10.9)	370 (40.1)
Public admin	242 (87.1)	158 (9.1)
Total	278 (100.0)	922 (100.0)

Risk perception was also found to be five times higher among medical students compared to public administration students (odds ratio [OR] =5.22, 95% confidence interval [CI] =2.19–12.93; P < 0.001) [Table 4].

Table 4

Relationship between students’ department and receiving complete dose of hepatitis B viral vaccine

Departments	Frequency (%)		χ2	P
	Received full dose	Did not receive full dose
Medicine/surgery	215 (60.2)	58 (27.6)	58.79	<0.001
Nursing	88 (20.6)	86 (40.6)
Public admin	54 (15.1)	68 (32.1)
Total	357 (100)	212 (100)

Uptake of full dose of hepatitis B vaccine

Findings from the study showed that 215 (60.2%) of medical students, 88 (20.6%) of nursing students, and 54 (15.1%) of public administration students, respectively, had full (3) doses of HBV. Medical students were four times more likely to receive the full doses of HB vaccination compared with public administration students (OR = 3.62; 95% CI = 2.39–5.48; P < 0.001) [Tables 5 and 6].

Table 5

Logistic regression analysis of the association between students’ department and good risk perception

Departments	Risk perception (%)	OR	95% CI	P
Medicine/surgery	394 (40.7)	5.32	2.191-12.939	<0.001
Public admin	158 (9.1)	0.05	0.035-0.081	<0.001
Nursing	370 (40.1)	Reference

OR=Odds ratio, CI=Confidence interval

Table 6

Logistic regression analysis of the relationship between students’ department and uptake of full dose of hepatitis B viral vaccine

Departments	Uptake of full dose HBV vaccine (%)	OR	95% CI	P
Medicine/surgery	215 (60.2)	3.62	2.392-5.487	<0.001
Public admin	54 (15.1)	0.78	0.488-1.235	0.285
Nursing	88 (24.6)	Reference

OR=Odds ratio, CI=Confidence interval, HBV=Hepatitis B viral

Barriers to uptake of hepatitis B vaccine

Of the 597 students who did not receive full doses of HB vaccination, 253 (42%) of the respondents ascribed poor access (geographical) as reason for nonuptake, 95 (15.9%) feel it is due to lack of awareness, 108 (18.1%) had a negative screening result which they felt did not necessitate vaccination, 103 (17.3%) had positive screening results, and 38 (6.4%) associated it to fear of needles [Table 7].

Table 7

Frequency table of responses given for not taking hepatitis B viral vaccine

Reasons for lack of uptake of HBV vaccine	Frequency (%)
Lack of awareness	95 (16)
Poor access	253 (42)
Tested negative to HBV	108 (18)
Others	141 (24)
Total	597 (100)

HBV=Hepatitis B viral

Discussion

This study describes the awareness of vaccine prevention of HBV, the risk perception of HBV infection, awareness of HBV vaccine, and the vaccination status of students in the University of Jos, Nigeria. Ideally, health-care workers and medical students should have sufficient knowledge of blood-borne diseases such as HBV and should be cautious to reduce the risk of transmission of these diseases and should be vaccinated against them.[1]

Studies have reported the highest occupational risk of HBV infection among students during medical training leading to professionalism.[1718] Lack of experience, insufficient training, duty overload, and fatigue may lead to sharp occupational injuries and alongside having a higher tendency as young adults to have unprotected sexual intercourse with multiple sexual partners.[19]

We found that the awareness of HBV vaccine prevention was high (88.4%); however, it was higher among medical and nursing students (36.2%) and (36.0%), respectively, but lower among public administration students (27.8%). The difference in awareness can be attributed to the exposure to lectures in virology which is a part of the medical and nursing curricula and its absence in the social science curriculum. This is similar to a study carried out among medical students in a tertiary institution in Nigeria where 91.6% of the 346 students studied were aware of the availability of a vaccine against HBV.[19] It was slightly lower in another study in Iraq where 64% of the 200 medical students studied correctly identified vaccination as a way of preventing HBV infection.[20] In contrast to the low awareness among public administration students in our study, 67.8% nonmedical students respondents in Karachi, Pakistan, were aware that there is a vaccine available for the prevention of HBV.[21] This difference could be attributed to a probably higher public health.

The overall risk perception among the students studied was moderately high (76.8%) with medical and nursing students having a relatively fair risk perception of 40.7% and 40.1%, respectively, and lower for public administration students 9.1%. The study revealed that it was five times more likely for medical students compared to public administration students to have a higher risk perception. The risk perception among health-care students in our study was found to be lower than that in a study among nursing and medical students in Hyderabad, India (61.27%).[22] This difference could be attributed to the study population chosen which included preclinical whose exposure to virology lecture is limited unlike the Hyderabad study which included only clinical students who have more expansive lectures in applied virology.

The uptake of the full dose HB vaccine was 60.2%, 20.6%, and 15.1% for medical, nursing, and public administration students, respectively. This result among medical students was higher than other studies conducted among medical students in Nigeria and Cameroon where 47.7% and 18% were adequately vaccinated against HBV.[1923] Nursing students in this study, on the other hand, showed a lower uptake of HBV vaccines compared to nursing students in India in which 57.41% were completely vaccinated.[22] This study also revealed that it was four times more likely for medical students to receive the full doses of HBV vaccination compared with public administration students.

The low HBV vaccine uptake among the nonmedical respondents in this study is in keeping with their awareness of vaccine prevention of HBV infection (27.8%). This is worrisome as they have a higher risk of HBV infection as young adults compared to the general population and both awareness and uptake of the vaccine are essential to limiting its spread and reducing morbidity and mortality from the infection.

Almost half (42.4%) of the respondents in this study stated that not knowing where to get the vaccines (geographical access) was the barrier to the uptake of HBV vaccines. This reason was dissimilar to other studies where barriers found ranged from lack of time and opportunity, low motivation and the fear of needles among up to half of their study population.[34171924]

Conclusion

Awareness and risk perception on HBV infection was high among the University of Jos students; however, uptake of HBV vaccine is low which was worse for nonmedical students. Hence, we strongly recommend targeted health education and screening for university students and HBV vaccination; especially for health-care students by making the vaccine available at entry into the university and periodically.

Limitations

The research is self-funded. Being a very dangerous and highly infective condition, we will have loved to explore further possible individual behaviors that could expose the students to HBV and to assess and compare the prevalence of the disease among the different groups. This could be a scope for further research in a resource-poor setting like Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.