1. Background
Hepatitis B virus (HBV) infection is a public health problem, especially in the developing countries. The prevalence of HBV infection varies from one country to another ranging from less than 1% in Western countries to up to 10% in some Asian countries (1). In Iraq, the prevalence of HBV is around 1% (2, 3). It is estimated that 400 million people are currently infected with the virus. The majority of them are asymptomatic and unaware of their disease (1). Chronic infection with HBV may predispose to liver cirrhosis, liver failure, and hepatocellular carcinoma (1). This puts extra burden on the thriving health systems in the developing countries such as Iraq. The risk factors associated with HBV infection are surgical operations and dental surgeries, history of blood and blood product transfusion, undergoing renal hemodialysis, drug abuse, and certain sexual behaviors (4-8). In Duhok city, Iraq, healthcare providers have set a plan to eradicate HBV by 2030. It is believed that health education programs can play an important role in eradicating the infection through educating the public about the modes of transmission, signs and symptoms, and prevention. Health education programs should be based upon a thorough study on the public’s knowledge, beliefs, and practices of HBV (9).
2. Objectives
No study has been conducted in Iraq on the public’s knowledge of HBV. Therefore, the current survey was conducted to examine the knowledge and beliefs of the people in this region on the modes of HBV transmission, sequelae of infection, and vaccination.
3. Methods
3.1. Data Collection
The data were collected by health workers using a questionnaire. The questionnaire was developed in English and translated into Kurdish. First, the questionnaire was explained to the participants, and then, they were asked to fill in the questionnaire. The questionnaire evaluated 3 parts of HBV infection: modes of transmission, symptomatology of HBV, and vaccination. The first part on the modes of transmission included 6 questions. The second part was about the symptomatology of HBV and included 3 questions. Finally, the last part was consisted of 2 questions about vaccination.
3.2. Research Ethics
The healthcare workers explained the aims of the project to the participants. Before data collection, the healthcare workers obtained oral consent from the participants. The project was approved by the ethics committee of the local hospital.
3.3. Data Analysis
All data were transferred into SPSS version 21 and a descriptive data analysis was performed. Simple 2 by 2 tables were created and participants’ answers to survey questions were summed and expressed as percentages. The difference between variables was studied by Chi-square test and the difference was considered significant at P ≥ 0.05.
4. Results
Totally, 168 persons were recruited in the current study with the age range of 17 to 49 years. Among them, 114 were male. All subjects were asked 11 questions. In total, 58.6% of the questions were answered correctly.
4.1. Knowledge of the Modes of Transmission
About 75% of the participants knew that HBV is transmitted more easily than HIV. About a half (51.2%) of the subjects thought that HBV can be transmitted by food. It was also found that only 33.9% of the subjects knew that HBV can be transmitted by toothbrush, while 72% of them gave the correct answer when they were asked that HBV asymptomatic patients can transmit the disease. The majority of the subjects (57.2%) thought that HBV can be transmitted by cough, whereas 60.7% of them gave the correct answer when they were asked about handshaking as a mode of transmission. Data were stratified according to gender, geographical region, and education levels; 35.2% of females thought that HIV is transmitted more easily than HBV, which was significantly higher than that of males (20.2%) (P = 0.03) (Table 1). The same trend was found among villagers who thought that HIV is transmitted more easily than HBV (29.5% versus 22.4% for urban residents; P = 0.02) (Table 2). In addition, the majority of illiterate subjects (75.9%) thought that HBV can be transmitted by food (P = 0.05) (Table 3).
Table 1.The Distribution of Knowledge about HBV According to the Gendera
| Questions | Male | Female | Total Correct | P Value | ||
|---|---|---|---|---|---|---|
| Correct | Wrong | Correct | Wrong | |||
| Easier transmission than HIV | 91 (79.8) | 23 (20.2) | 35 (64.8) | 19 (35.2) | 126 (75) | 0.030 |
| Transmitted by food | 57 (50) | 57 (50) | 25 (46.3) | 29 (53.7) | 82 (48.8) | 0.38 |
| Transmitter may be asymptomatic | 82 (71.9) | 32 (28.1) | 39 (72.2) | 15 (27.8) | 121 (72) | 0.56 |
| Transmission by toothbrush | 43 (37.7) | 71 (62.3) | 14 (25.9) | 40 (74.1) | 57 (33.9) | 0.90 |
| Transmission by air and cough | 54 (47.4) | 60 (52.6) | 18 (33.3) | 36 (66.7) | 72 (42.8) | 0.60 |
| Transmission by handshaking | 73 (64) | 41 (36) | 29 (53.7) | 25 (46.3) | 102 (60.7) | 0.113 |
| Acute HBV may heal spontaneously | 37 (32.5) | 77 (67.5) | 15 (27.8) | 39 (72.2) | 52 (30.9) | 0.335 |
| Patient may be asymptomatic | 64 (56.1) | 50 (44.9) | 33 (61.1) | 21 (38.9) | 97 (57.7) | 0.330 |
| HBV can cause liver cancer | 84 (73.7) | 30 (26.3) | 36 (66.7) | 18 (33.3) | 120 (71.4) | 0.223 |
| HBV is prevented through vaccination | 97 (85.1) | 17 (14.9) | 49 (90.7) | 5 (9.3) | 146 (86.9) | 0.224 |
| Vaccine is not available in Duhok | 73 (64) | 41 (36) | 35 (64.8) | 19 (35.2) | 108 (64.2) | 0.52 |
| Total | 1084 (58.6) | |||||
aValues are expressed as No. (%).
Table 2.The Distribution of Knowledge about HBV According to the Place of Residencea
| Questions | Urban | Rural | P Value | ||
|---|---|---|---|---|---|
| Correct | Wrong | Correct | Wrong | ||
| Easier transmission than HIV | 83 (77.6) | 24 (22.4) | 43 (70.5) | 18 (29.5) | 0.02 |
| Transmitted by food | 54 (50.5) | 53 (49.5) | 28 (45.9) | 33 (55.1) | 0.34 |
| Transmitter may be asymptomatic | 74 (69.2) | 33 (30.8) | 47 (77) | 14 (23) | 0.18 |
| Transmission by toothbrush | 40 (37.4) | 67 (62.6) | 17 (26.9) | 44 (72.1) | 0.13 |
| Transmission by air and cough | 49 (45.8) | 58 (54.2) | 23 (37.7) | 38 (62.3) | 0.19 |
| Transmission by handshaking | 67 (62.6) | 40 (37.4) | 35 (57.4) | 26 (42.6) | 0.30 |
| Acute HBV may heal spontaneously | 30 (28) | 77 (72) | 22 (36.1) | 39 (63.9) | 0.18 |
| Patient may be asymptomatic | 62 (57.9) | 45 (42.1) | 33 (57.4) | 26 (42.6) | 0.53 |
| HBV can cause liver cancer | 73 (68.2) | 34 (31.8) | 47 (77) | 14 (23) | 0.14 |
| HBV is prevented through vaccination | 94 (87.9) | 13 (12.1) | 52 (85.2) | 9 (14.8) | 0.38 |
| Vaccine is not available in Duhok | 66 (61.7) | 41 (38.3) | 42 (68.9) | 19 (31.1) | 0.22 |
aValues are expressed as No. (%).
Table 3.The Distribution of Knowledge About HBV According to the Level of Education
| Questions | Illiterate | Primary School | Secondary School | High School Diploma | Higher Education | P Value | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Correct | Wrong | Correct | Wrong | Correct | Wrong | Correct | Wrong | Correct | Wrong | ||
| Easier transmission than HIV | 19 (65.5) | 10 (34.5 | 20 (80) | 5 (20) | 48 (77.3 | 14 (22.6) | 8 (88.9) | 1 (11.1) | 31 (72.1) | 21 (27.9) | 0.55 |
| Transmitted by food | 7 (24.1) | 22 (75.9( | 15 (60) | 10 (40) | 33 (53.2) | 29 (46.8 | 5 (55.6 | 4 (44.4 | 22 (51.2 | 21 (49.8 | 0.05 |
| Transmitter may be asymptomatic | 20 (69) | 9 (31) | 18 (72) | 7 (28) | 49 (79) | 13 (21) | 6 (66.7) | 3 (33.3) | 28 (65.1) | 15 (34.9) | 0.59 |
| Transmission by toothbrush | 9 (31) | 20 (69) | 8 (32) | 17 (68) | 26 (41.9 | 36 (58.1 | 2 (22.2 | 7 (77.8 | 12 (27.9 | 3 (72.1 | 0.53 |
| Transmission by air and cough | 10 (34.5 | 19 (65.5 | 12 (48) | 13 (52) | 30 (48.4 | 32 (51.6 | 2 (22.2 | 7 (77.8 | 18 (41.9 | 2 5(58.1 | 0.49 |
| Transmission by handshaking | 17 (58.6 | 12 (41.4) | 19 (76) | 6 (24) | 33 (53.2 | 29 (46.8 | 4 (44.4) | 5 (55.6) | 29 (67.4 | 14 (32.6 | 0.21 |
| Acute HBV may heal spontaneously | 9 (31) | 20 (69) | 9 (36) | 16 (64) | 19 (30.6) | 43 (69.4) | 3 (33.3) | 6 (66.7) | 12 (27.9) | 31 (72.1 | 0.97 |
| Patient may be asymptomatic | 22(75.9 | 7 (24.1) | 12 (48) | 13 (52) | 35 (56.5) | 27 (43.5) | 7 (77.8) | 2 (22.2) | 21 (48.8) | 22 (51.2 | 0.95 |
| HBV can cause liver cancer | 18 (62.1 | 11 (37.9 | 19 (76) | 6 (24) | 43 (69.4 | 19 (30.6 | 6 (66.7 | 3 (33.3 | 34 (79.1 | 9 (20.9 | 0.57 |
| HBV is prevented through vaccination | 23 (79.3 | 6 (20.7) | 22 (88) | 3 (12) | 53 (85.5 | 9 (14.5 | 8 (88.9 | 1 (11.1) | 40 (93) | 3 (7) | 0.56 |
| Vaccine is not available in Duhok | 15 (51.7 | 14 (48.3) | 15 (60) | 10 (40) | 36 (58.1 | 26 (41.9 | 7 (77.8 | 2 (22.2 | 35 (81.4 | 8 (18.6 | 0.04 |
4.2. Knowledge of the Symptomatology and Disease Outcome
The majority of the studied participants (57.5%) knew that HBV infection can be asymptomatic and may cause liver cancer (71.4%). However, only a minority (30.9%) knew that acute infection can be resolved spontaneously (Table 1).
4.3. Knowledge of the Prevention
The majority of subjects (86.9%) knew that HBV is a vaccine-preventable disease and 64.2% of the recruited subjects knew that the vaccine was available in the city; 48.3% of the illiterate subjects thought that the vaccine was not available in the city (Table 3).
5. Discussion
The prevalence of HBV in Duhok was around 1% (2, 3, 10). Public healthcare providers have set an ambitious plan to eradicate HBV infection by 2030 (11, 12). Authors believed that the first step to achieve this goal should be evaluating the knowledge of the people living in the city. Such a survey may give an insight into the weak area that eradication programs should be emphasized. Therefore, the current survey aimed at testing the knowledge of people about 3 major areas in HBV infection: transmission, symptomatology, and prevention. HBV can be transmitted by sexual contact, receiving blood and blood products, and vertical transmission (1, 3). The transmission of the virus is also associated with certain behaviors such as homosexuality and drug abuse. It is noteworthy that the virus cannot be transmitted by handshaking, food, and cough (1, 3). The majority of the subjects knew that HBV is transmitted more easily than HIV. Also, 72% of the subjects knew that the HBV transmitter can be asymptomatic. However, the majority of the participants did not know that HBV can be transmitted through tooth brushing. Also, the majority thought that HBV can be transmitted by cough; 35.2% of females thought that HIV is transmitted more easily than HBV, which was significantly higher than that of males. The same trend was found among villagers who thought that HIV is transmitted more easily than HBV. In addition, the majority of illiterate subjects (75.9%) thought that HBV can be transmitted by food. It can be inferred that any educational programs about the modes of transmission of HBV should target females, illiterates, and villagers.
Approximately, 5% of the world's populations are infected with HBV. This infection is a public health problem, particularly in the developing countries such as Iraq. The majority of the patients with HBV are asymptomatic and unaware of their disease (1, 13). This might represent the major challenge in the eradication of HBV, as asymptomatic carriers can transmit the infection and also it may predispose to liver cancer or cirrhosis. In the current study, about a half of the subjects knew that HBV may be asymptomatic. Additionally, the majority of the subjects knew that HBV infection can predispose to liver cancer. Also, people should be urged to test for the infection and more efforts are needed to educate the people about the symptomatology of the disease.
HBV is a preventable disease, which can be prevented by receiving 3 doses of the vaccine (1, 13). This vaccine was introduced into the expanded program of vaccination in 2001. Since then, all newborn babies receive the vaccine and are regarded as protected. In addition, all at risk people are urged to receive the vaccine. The vaccine is also available for public in most of the primary healthcare centers. The majority of the subjects (86.9%) in the current study knew that HBV is a vaccine preventable disease. More than 40% of the current study participants did not know that the vaccine was available in the city. Data analysis revealed that 48.3% of the illiterate subjects thought that the vaccine was not available in the city. This might represent a failure to the previous educational programs. More efforts are needed to educate the public about HBV.
The current study results documented the average level of knowledge about the HBV modes of transmission. To achieve the eradication plan goals, efforts are needed to educate the public about the modes of transmission. More studies are needed to evaluate the level of knowledge after implementing educational programs.
