Knowledge, Health Practices and Policies for Hepatitis for Midwifery and Nurses in Allied and District Hospital Faisalabad

Background: Hepatitis B Virus (HBV) is a critical global health concern with significant morbidity and mortality. Nurses and midwives, as frontline healthcare professionals, are particularly vulnerable to HBV infection. This study focuses on evaluating the knowledge, attitudes, and practices (KAP) related to HBV among these groups in Faisalabad, Pakistan, a region with limited existing research on this topic.


INTRODUCTION
The hepatitis B virus (HBV) is a significant global health concern, leading to acute and chronic infections, including cirrhosis, hepatocellular cancer, and chronic hepatitis, all contributing to substantial morbidity and mortality (1).Worldwide, the prevalence of HBV has been notable, with 240 million individuals identified with hepatitis B surface antigen (HBsAg) in 2005, an increase from 223 million in 1990 (2)(3)(4)(5).In Pakistan, various studies have reported differing rates of HBV prevalence across different groups (6).A comprehensive systematic review and metaanalysis highlighted a significant variation in HBV seroprevalence in Pakistan, ranging from 5.1% to 26.8%, with an average prevalence of 12.1% based on 14 studies encompassing 5848 individuals.Notably, Punjab State exhibited the highest incidence of HBV in Pakistan at 12.7% (7), surpassing rates observed in countries like Nigeria (5%) and Ethiopia (7%).Key risk factors for HBV infection include mother-to-child transmission (MTCT) and transfusion of contaminated blood (8).Pregnant women with chronic hepatitis B can manage their pregnancies effectively, though there are risks associated with active hepatitis and elevated liver enzymes, particularly concerning postpartum immunological reconstitution (9).HBV MTCT can occur during any of the three pregnancy stages:  (10).Currently, preventing MTCT of HBV involves both active and passive immunoprophylaxis, typically including HBV immunoglobulin and vaccination for newborns of HBsAg-positive mothers immediately after birth, coupled with maternal referral to hepatology clinics for ongoing evaluation and monitoring (9,(11)(12)(13)(14)(15).For healthcare workers (HCWs), such as nurses and midwives, the risk of contracting HBV is heightened if appropriate personal protective measures are not diligently followed (7,10,16).A lack of awareness regarding HBV prevalence and workplace safety protocols, including post-exposure prophylaxis (PEP), HBV vaccination, training, and the adoption of safer workplace practices, can contribute to the spread of HBV.Particularly for unvaccinated HCWs, handling sharps and needle stick injuries (NSI) poses a significant risk for infection from various pathogens, including HBV (17)(18)(19).In this context, nurses and midwives play a crucial role in caring for HBVinfected patients.They provide support throughout the treatment process and offer critical information regarding the nature of the disease, diagnosis, prevention, and timely administration of immunoglobulins.A comprehensive understanding of the disease and its various implications for patients is essential for nurses and midwives to devise effective management strategies.Research indicates that knowledge, attitude, and practice (KAP) significantly influence health-related behaviors (6).However, there has been limited research on the KAP levels of HCWs in relation to HBV infection in Pakistan.KAP surveys are a widely utilized tool in health-seeking behavior research, extensively applied in public health studies.These surveys gather data on participants' knowledge, attitudes, and behaviors concerning specific topics.Knowledge refers to the understanding of a particular subject, attitudes encompass feelings, preconceived notions, behavioral inclinations, and reactions towards a subject, while practice represents how individuals act based on their knowledge and feelings (20)(21)(22)(23).Given this backdrop, the objective of this study was to examine the knowledge, attitudes, and practices of nurses and midwives in Faisalabad, Pakistan, regarding HBV infection.This investigation aims to identify gaps in understanding and areas for improvement, which can inform the development of targeted preventive and control strategies for HBV infection in this region.By enhancing the KAP levels among these healthcare professionals, the study seeks to contribute to reducing HBV transmission and improving patient outcomes.

MATERIAL AND METHODS
A cross-sectional study using a descriptive design, between August 18 and September 2, 2021, was conducted in District and Allied Hospitals in Faisalabad, Pakistan.These hospitals were chosen for their status as public health tertiary care facilities, serving a significant portion of the Faisalabad state population (6,10,24,25).They offer specialized clinical inpatient and outpatient services, with a focus on obstetrics and gynaecology, making them primary referral centers in the region.Faisalabad, with over 5 million inhabitants according to the 2008 census, is the most populous state in Pakistan, characterized by rapid urbanization and diverse demographics (12).The study encompassed 55 nurses and 30 midwives from District Hospital and 57 nurses and 10 midwives from Allied Hospital.All employed nurses and midwives at these institutions were eligible, except those who chose not to participate.Data were collected using a 31-item structured questionnaire divided into four sections.The questionnaire, designed to assess knowledge, attitudes, and practices regarding HBV infection, comprised six demographic questions, fifteen knowledge-related questions, four on attitudes, and six on practices (3,26).It included specific questions on HBV etiology, natural history, transmission routes, complications, and post-exposure prophylaxis (PEP).The responses were binary (yes/no), with positive attitudes identified by responses acknowledging the importance of vaccination, glove use, tool sterilization, and suggesting PEP for HBV exposure.Practice-related questions focused on vaccination status, tool sterilization, glove usage, and, for those with a history of non-surgical wound infection (NSI), practices like handwashing, wound sterilization, and PEP administration (26-28).A scoring system was implemented where each correct answer was awarded one point, leading to an overall Knowledge, Attitude, and Practice (KAP) score derived from the sum of correct responses across the 15 knowledge, higher for average knowledge, 3 or higher for positive attitude, and 5 or higher (or 3 for no NSI history) for safe practice (14).The questionnaire underwent a rigorous development process, including expert consultations and a pilot study with 14 respondents to ensure clarity and acceptability.However, data from the pilot study were excluded from the final analysis.Statistical Package for Social Sciences (SPSS) version 21 was employed for data analysis, using descriptive statistics for variable distribution and frequency tables, and a Chi-square test to explore associations between categorical variables and the primary outcomes (knowledge, attitude, and practice regarding HBV infection).The significance threshold was set at a p-value of ≤.05 (13).Ethical considerations were meticulously addressed.Prior to commencement, approvals were obtained from the general directors of the District and Allied hospitals, the institutional board of the University of Agriculture Faisalabad's Faculty of Medicine, and the State Ministry of Health of Pakistan's Faisalabad state.Informed written consent was secured from each participant after a detailed explanation of the study, with stringent measures taken to ensure confidentiality.

RESULTS
The first table shows demographic and professional characteristics of the respondents.Age-wise, the majority (62.72%) were between 20-30 years, followed by 31-40 years (13.64%),41-50 years (11.82%), and above 51 years (11.82%).In terms of hospital employment, 59.1% were from District Hospital Faisalabad and 40.9% from Allied Hospital Faisalabad.Regarding occupation, 75.46% were nurses and 24.55% were midwives.For education level, 70% had education above university level, while 30% had education below or equal to university level.Experiencewise, 53.64% had below 2 years of experience, and 46.37% had above 2 years.
ISSN 2791-156X Journal of Health and Rehabilitation Research (JHRR) This work is licensed under a Creative Commons Attribution 4.0 International License | www.jhrlmc.com| Vol. 3, Issue 2 intrauterine, intrapartum, or postpartum.High maternal viral load, HBeAg positivity, preterm labor, prolonged labor, and failed immunoprophylaxis in siblings are key contributors to this risk et al., 2023 | Hepatitis Guidelines for Midwives and Nurses in Faisalabad Hospitals This work is licensed under a Creative Commons Attribution 4.0 International License | www.jhrlmc.com| Vol. 3, Issue 2

Table 1
Demographic and Professional Characteristics The second table examines correlations between different variables and HBV-related knowledge, attitude, and practice (KAP) scores.In District Hospital, 30 participants had high KAP scores compared to 35 with low KAP scores (p-value: 0.043).Allied Hospital showed 25 with high and 20 with low KAP scores.Among nurses, 50 completed vaccination versus 33 who did not (p-value: 0.034), while among midwives, 15 completed it versus 12 who did not.Regarding education, those with education below or equal to university level had 15 with good knowledge and 18 with poor knowledge (p-value: 0.056).

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Those above university level had 40 with good and 37 with poor knowledge.For experience, among those with below 2 years, 35 experienced a needlestick injury (NSI) and 24 did not (p-value: 0.039); above 2 years had 20 with NSI and 31 without.
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Table 3
Washing hands with water & soap after NSI 88 (80.00%)Sterilized the wound site after NSI 74 (67.27%)Check if the patient has a blood-borne disease after NSI 67 (60.91%)