SUBMITTED 20 SEPT 22 1 REVISION REQ. 31 OCT 22; REVISION RECD. 24 NOV 22 2 ACCEPTED 29 DEC 22 3 ONLINE-FIRST: JANUARY 2023 4 DOI: https://doi.org/10.18295/squmj.1.2023.004 5 6 Knowledge, Attitude, and Practice among Palestinian Healthcare Workers in 7 the Gaza Strip towards Hepatitis B 8 A cross-sectional survey 9 Abd Al-Karim Sammour, Younis Elijla, Muath Alsarafandi, *Belal 10 Aldabbour, Loay Kanou, Fahmy Almaidana, Moataz El egla, Samah Harara, 11 Seham Oda, Nour Albardaweel, Adnan Skaik 12 13 Faculty of Medicine, Islamic University of Gaza, Gaza, State of Palestine. 14 *Corresponding Author’s e-mail: belal90md@gmail.com 15 16 Abstract 17 Objectives: Healthcare workers are at a high potential risk of Hepatitis B virus infection (HBV). 18 This survey aims to identify gaps and strengths in the knowledge, cultural perceptions, and 19 practices of healthcare workers towards HBV in order to drive appropriate health interventions. 20 Methods: This cross-sectional study was conducted between March and April 2022. We 21 surveyed a convenience sample of three at-risk healthcare providers from the major health 22 facilities in Gaza. A 40-item, self-administered questionnaire was used. Statistical data analysis 23 was conducted using SPSS version 25 to obtain descriptive and inferential statistics via various 24 nonparametric, correlation, and regression tests (with p<0.05). Results: 447 healthcare workers 25 participated in the study. Overall, 105 (23.5%) demonstrated poor knowledge (under 14\20 26 points), 284 (63.5%) had moderate knowledge (14-17 points), and 58 (13%) showed good 27 knowledge about HBV. The majority (367, 82.1%) expressed an excellent attitude. Finally, 287 28 (64.2%) demonstrated a good level of practice toward HBV infection. A history of needle stick 29 injury was reported by 233 (52.1%) participants, of whom 170 (73.3%) reported taking 30 appropriate preventive actions after exposure. Conclusion: The majority of participants 31 demonstrated overall good knowledge regarding HBV infection. Nonetheless, significant gaps 32 remain in the different aspects of the KAP construct, which require appropriate awareness 33 campaigns to further limit the spread of this preventable viral infection. 34 Keywords: Health Knowledge, Attitudes, Practice; Attitude of Health Personnel; Hepatitis B; 35 Epidemiology; prevention and control; Health Personnel; Cross-Sectional Studies. 36 37 Advances in Knowledge: 38  The overall knowledge about HBV infection among HCWs in Gaza Strip is good. 39  There were significant gaps in knowledge, such as modes of transmission and HBV 40 therapy. 41 Application to Patient Care: 42  Assessing the knowledge, attitude, and practice among HCWs will help pinpoint gaps in 43 the HBV prevention protocols and practices, ultimately helping health policy-makers 44 protect both at-risk HCWs and their patients. 45 46 Introduction 47 Hepatitis B virus (HBV) is a vaccine-preventable viral infection of the liver with serious potential 48 complications such as liver cirrhosis and hepatocellular carcinoma. It is bloodborne and may be 49 transmitted through blood transfusion, sexual activity, or perinatally from the infected mother.1 50 The global burden of HBV was estimated at 316 million cases in 2019 (all-age prevalence of 51 4.1%), with more than half a million HBV-related deaths globally during the same year.2 52 53 The Middle East is an area of low-intermediate HBV endemicity (2% - 4.9%).3 Palestine is 54 considered a moderately endemic area for HBV infection.4 The HBV incidence and carrier rates 55 in the country were 0.37 and 7.9/100,000 population, respectively, in 2020. In the Gaza Strip, the 56 rates were 0.15 and 5.6/100,000 populations, respectively, during the same year.5 This represented 57 a significant decline from an incidence rate of 11-15/100,000 between 1990–1994 in Palestine, 58 which has been attributed to adapting the HBV vaccine into the national vaccination schedule since 59 1992.6 The HBV vaccine is a reliable and cost-effective preventive tool with over 90% 60 effectiveness against chronic HBV infection and nearly 70% protection against HBV-related 61 hepatocellular carcinoma (HCC).7,8 62 63 Risk factors for HBV transmission in Palestine include undergoing blood transfusion or dental 64 procedures, sharing contaminated sharp objects such as shaving blades and Hejamat tools, and 65 intravenous drug use.4 Hemodialysis patients and patients who receive treatment in neighboring 66 countries also are at increased risk.9 HCWs are at a several-fold higher risk of contracting HBV 67 infection compared to the general population,10-12 and the hazard is higher for professions that 68 include performing invasive procedures or handling human blood and specimens (e.g., surgeons, 69 nurses, dentists).13,14 Therefore, besides HBV vaccination, additional preventive measures are 70 necessary to protect HCWs against HBV infection, including the use of personal protective 71 equipment (PPE), proper sterilization of medical equipment, disinfection of health facilities, and 72 post-exposure prophylaxis after accidental exposure to contaminated blood or body fluids.15 73 74 Needle stick injuries (NSIs) represent a particularly preventable hazard that can be avoided with 75 appropriate staff training and safety protocols.16 A study in 2004 found a 2.8% prevalence of 76 Hepatitis B surface antigen (HBsAg) among 399 tested healthcare workers, and needle stick 77 injuries demonstrated a highly significant association as the leading risk factor for infection. Also, 78 unvaccinated healthcare workers showed higher rates of infection with approximately twice the 79 rate among vaccinated participants (4.1% vs. 2.0%).17 Another study in 2021 demonstrated that 80 289 of 538 healthcare workers in Gaza (54%) had had at least one NSI, with nurses and cleaners 81 at the highest risk.18 82 83 Implementing effective preventive plans for HBV infection necessitates that HCWs demonstrate 84 an adequate understanding of the disease, reflected in their knowledge, attitude, and practice 85 (KAP). KAP studies have been used widely in measuring public health levels, assessing the 86 fundamental understanding, perspectives, and activities commonly shared by a certain population 87 on a particular topic. This is the first study to examine the KAP of HCWs in the Gaza Strip towards 88 HBV infection. 89 Methods 90 Study design, settings, and population 91 This descriptive, institution-based, cross-sectional study was conducted at seven governmental 92 hospitals (Al-Shifa Medical Complex, Nasser Medical Complex, European Gaza Hospital, 93 Indonesian hospital, Rantissi Pediatric Complex, Al Durra Pediatric Hospital, Palestinian-Turkish 94 Friendship hospital), one major governmental primary health center (Sabha Al Harazin Primary 95 Healthcare Center), and two private hospitals (Al-Quds Specialized Hospital and Al-Sahaba 96 Medical Complex). These institutions represented the major hospitals and health centers providing 97 healthcare services across the Gaza Strip from north to south. The study was conducted between 98 March and April 2022. The convenience sampling method was used to survey 447 medical doctors, 99 nurses, and laboratory technicians who worked in the above-mentioned facilities, as those 100 professions were considered to be at the highest risk for exposure to patients and their blood 101 products. The study included HCWs from the three professions who worked in these hospitals 102 during the study period and consented to fill out the questionnaire. We excluded HCWs from other 103 disciplines, those who were absent during the data collection period, and those who refused to 104 participate. 105 106 Data Collection 107 The study team constructed a questionnaire based on a literature review of previous similar 108 studies.19-23 The final version of the questionnaire included 40 items divided into four sections; the 109 first section included the sociodemographic data of participants, the second section (20 questions) 110 assessed participants’ knowledge, the third section (9 questions) assessed participants’ attitudes, 111 and the fourth section (11 questions) assessed participants’ practice towards HBV. The validity 112 and reliability of the referenced questionnaires were established by the referenced studies. Experts 113 from the Public Health Department at the Islamic University of Gaza evaluated our questionnaire's 114 face, substance, and convergent validity and ensured that the questionnaire appropriately covered 115 the relevant questions pertaining to the study within the local context. The questionnaire was then 116 piloted for acceptability and consistency with 20 respondents who shared similar demographic 117 characteristics with the actual study population. Only a few linguistic modifications were required 118 after the pilot testing, and data from the pilot study were not included in the final analysis. 119 Scoring System 120 HCWs who scored 18 or more correct answers out of 20 questions in the second section were 121 considered to have high knowledge about HBV; scores between 14 and 17 were regarded as 122 moderate knowledge, while scores below 14 were regarded as having insufficient knowledge. In 123 terms of attitude, scores of six and above reflected a good attitude. Meanwhile, scoring six or seven 124 out of seven items reflected a good level of practice. These measurements resulted from the 125 normality characteristics of data distribution, either 25-75 quartiles or the median. 126 127 Data Analysis 128 Data were analyzed using the statistical package for social sciences (SPSS) version 25 (SPSS Inc., 129 Chicago, IL, USA). Data analysis provided frequency tables for variables. The Kolmogorov-130 Smirnov test was used to assess the sample distribution's normality. Kruskal-Wallis and Mann-131 Whitney tests were used to determine the relationship between the dependent variables 132 (knowledge, attitude, and practice) and the independent categorical variables of the 133 sociodemographic data. The multinomial logistic regression was used to predict the relationship 134 between the cohort characteristics and KAP domains. Statistical significance was set at p-values 135 of less than 0.05. 136 137 Ethical Consideration 138 Before conducting the study, written ethical approval was obtained from the Human Resource at 139 the Ministry of Health, and administrative approvals were obtained from the directorate of each 140 facility. Verbal consent was obtained from participants upon answering the questionnaire. Each 141 questionnaire was deidentified and assigned a code number throughout data entry and data analysis 142 in order to maintain anonymity and confidentiality for all participants. 143 144 Results 145 Sociodemographic characteristics of the cohort 146 A total of 447 HCWs working in ten governmental and private health centers participated in our 147 study (Table 1). The response rate was 100%. Most participants were recruited from governmental 148 hospitals (95.3%). The largest age group was 24-30 years (41.4%), and the majority had more than 149 two years of work experience (Table 1). 150 Knowledge about HBV and its associated factors 151 The majority of participants in our study demonstrated a moderate level of knowledge about HBV 152 infection (284 HCWs; 63.5%). On the other hand, ten participants (2.2%) denied that HBV 153 infection is caused by a virus, and 125 (28%) failed to acknowledge sexual transmission as a 154 common HBV transmission mode. Also, 179 (40%) participants believed that sharing dishes with 155 HBV-positive patients can transmit the disease, while 110 (24.6%) participants did not recognize 156 the association between HBV infection and liver cancer. Meanwhile, 278 (56.2%) of participants 157 believed that the human body could not spontaneously cure an HBV infection, while 32 (7.2%) 158 were oblivious to the presence of a vaccine against HBV (Table 2). The Kruskal-Wallis test 159 demonstrated a significant difference in knowledge levels among the different professions (p < 160 .001). Still, no significant associations were found between knowledge levels and age, affiliation, 161 or experience years (Table 5). 162 163 Attitude about HBV and its relations 164 Most participants demonstrated a good attitude (367 participants, 82.1%) (Table 3). Fear and 165 sadness were the most common expected reactions to receiving a diagnosis of HBV infection, 166 reported by 202 (45.2%) and 150 (33.6%) participants, respectively. The majority (344, 77%) said 167 they would first inform the physician about their illness, while friends came last. Most participants 168 (365, 81.7%) would visit a health facility if they had symptoms of HBV infection as soon as they 169 realized them, while 35 (7.8%) said they would seek traditional healers. The majority believed that 170 instrument sterilization, wearing gloves, and vaccination could prevent transmission, but 86 171 (19.2%) did not recommend post-exposure prophylaxis for those exposed to HBV. There was a 172 statistically significant difference in attitude depending on affiliation (p < 0.001), specialty (p < 173 0.001), and experience years (p = 0.02) but not age (Table 5). 174 175 Practical measures for HBV and needle stick injuries 176 Of 447 participants, 296 (66.2%) have been screened previously for HBV infection. There was a 177 statistically significant difference in screening for HBV among health specialties, with the highest 178 screening rate among medical laboratory technicians (P = 0.005). Of the sample, 45 (11.1%) said 179 they would not ask for blood screening for HBV before receiving a potential blood transfusion. 180 Most, however, ask for a new syringe before use (405, 90.6%) and apply safety equipment for ear 181 or nose piercing (376, 84.1%) (Table 4). Nearly half (233, 52.1%) the participants reported having 182 needle stick injuries before. Of those, most followed preventive and health guidelines to prevent 183 infection with HBV (Table 4). Practical measures were statistically different according to age 184 groups (p < 0.001), affiliation (p = 0.006), and years of experience (p < 0.001), but not specialty 185 (Table 5). 186 187 Predictors of KAP performance among participants 188 The multinomial logistic regression revealed that nurses were more susceptible to having lower 189 knowledge levels with an odds ratio of 0.161 (P= 0.000) (Table 6). Also, being a governmental 190 employee or a medical doctor was associated with having higher levels of good attitude, with an 191 odds ratio of 8.505 and 8.599 (P= 0.000) (Table 6). Additionally, having less than two years of 192 work experience was associated with low levels of both attitude and practice, with an odds ratio 193 of 0.292 and 0.485, respectively (P= 0.001 and 0.011) (Tables 6). Finally, the three domains 194 (knowledge, attitude, and practice) demonstrated a positive correlation with each other, with the 195 knowledge-attitude correlation coefficient (.275), knowledge-practice correlation coefficient 196 (.202), attitude-practice correlation coefficient (.295), (P<0.01). 197 198 Discussion 199 This study evaluated the KAP of Palestinian HCWs in the Gaza Strip towards HBV. There is a 200 dearth of literature on this topic in Palestine. Our literature review did not identify previous similar 201 local studies. The Ministry of Health (MoH) is the major provider of primary and secondary 202 healthcare services in Palestine.24 Also, due to poor economic conditions in Gaza, many private-203 sector HCWs are also government employees working two jobs. Therefore, government-employed 204 HCWs represented the majority of our cohort. 205 206 We found that 76.5% of participants demonstrated moderate or excellent knowledge regarding 207 HBV. This result falls within the range revealed by other recent studies done between 2013-2019 208 from Ethiopia, Afghanistan, and Nigeria, where 73% to 86% of surveyed HCWs demonstrated 209 good knowledge about HBV. It is also higher than other studies from Cameroon and Sudan, where 210 only 47% and 58% of participants, respectively, had an adequate knowledge.20,21,25-27 The different 211 results reflect variations in knowledge among the HCWs in these countries, but they may also be 212 partly attributed to variations in the professions representing each study’s population. Knowledge 213 levels among nurses were lower than doctors and laboratory technicians in our study, and similar 214 observations were made in the studies from Afghanistan and Ethiopia.20,26 Overall, HCWs 215 surveyed in our study fall closer to the better-educated end of the knowledge spectrum revealed in 216 those studies and other studies in the literature. 217 218 Also, in terms of knowledge, 94%, 96.6%, and 82.8% of participants answered correctly that HBV 219 could be transmitted via contaminated sharps, blood transfusion, and from mother to fetus (i.e., 220 vertical transmission), which approximately correlates with the results of the Afghanistan study.20 221 However, the results diverge where it concerns the transmission of HBV through unprotected sex 222 (72.0% vs. 89.64) and whether HBV has a definitive cure (43.8% vs. 82.86%). Additionally, the 223 fact that nearly one-third of participants in our study wrongfully answered other questions related 224 to HBV modes of transmission (questions 3, 4, 8, and 10) reveals a significant gap in knowledge 225 and cultural beliefs about HBV and indicates the need for more awareness campaigns regarding 226 primary prevention of HBV in the Gaza Strip. 227 228 About 82.1% of the participants showed an overall favorable attitude toward HBV, which is 229 similar to the Sudanese study in which 86.4% of participants had a favorable attitude, and higher 230 than the Afghan and Cameroonian studies (44% and 46%, respectively).20,21,25 The authors of the 231 latter study attributed the inadequate attitude to the insufficient knowledge of the participants, 232 which further stresses the importance of disease awareness among HCWs. Meanwhile, medical 233 doctors in the Afghan study had more unfavorable attitudes toward HBV compared to the other 234 professions. In contrast, doctors in our cohort performed much better in terms of healthy attitudes 235 (OR 8.599) compared to the remaining participants. Doctors receive longer and more extensive 236 education compared to the other health professions, which could explain this observation, 237 especially in the context of the correlation between knowledge and attitude that was demonstrated 238 in our analysis (Table 7). 239 240 The finding that 77% of participants chose the physician as the first go-to person to inform about 241 their illness and 88.6% would visit a health facility if they had symptoms of HBV infection reflects 242 a positive cultural behavior shared among the different HCWs in our study. We also found that 243 93.3%, 97.8%, and 80.8% of participants acknowledge the importance of wearing gloves, 244 instrument sterilization, and post-exposure prophylaxis. These results are better than those in 245 the Sudanese study (72.7%, 64.5%, and 52.7%, respectively). Again, this difference may be partly 246 related to the different representations of healthcare professions among the cohorts. It may also be 247 explained by the better knowledge scores of our study. 248 249 The prevalence of NSIs among HCWs was 52.1%, which replicates the findings of another recent 250 local study where the prevalence was 54%.18 The numbers are also similar to those reported in the 251 Sudanese study (51.8%) (21). These alarming results warrant advocating for the widespread 252 application of well-established safety and needlestick prevention guidelines.28 Of the HCWs who 253 suffered NSIs, 91.0%, 88,8%, and 82.4% showed appropriate practice responses after the injury, 254 such as washing hands with water and soap, sterilizing the wound site, and checking if the patient 255 has a blood-borne disease. 256 257 Overall, 85.2% of participants in our cohort reported being vaccinated against HBV. In a recent 258 study from the West Bank, the prevalence of HBV vaccination among 265 dentists was 74.5%.29 259 In contrast, the prevalence of HBV vaccination was 56.37% in the Afghan study, under 50% in 260 the Sudanese study, and even lower in the Cameroon (19%).20,21,25 It is estimated that HBV 261 vaccines saved an estimated $130 billion in direct and indirect costs between 2001 and 2020 in 73 262 low- and-middle income countries.30 Adopting the HBV vaccine in the Palestinian national 263 vaccination schedule is also credited for the declining incidence of HBV in the country.6 HBV 264 vaccine is available to the population free of charge. Also, HBV screening is a mandatory part of 265 the pre-employment health examination, which may play a role in enhancing the percentage of 266 vaccinated people in Palestine. 267 268 In our study, we demonstrated a positive correlation between the different study domains 269 (knowledge, attitude, and practice), which has also been reported in studies from Ghana and 270 Pakistan.31,23 This finding emphasizes that having good knowledge is essential in order to modify 271 false beliefs and preconceptions and help HCWs develop healthy attitudes and practices. 272 Stigmatization of HBV is an important barrier to appropriate practices and it has been shown to 273 exert substantial influence on the health behavior of individuals with or at risk for HBV.33 Future 274 research is invited to assess public perceptions and prejudices toward people living with HBV 275 infection. This study has several limitations, including the use of the convenience sampling method 276 and the relative underrepresentation of private-sector employees. The study was also limited to 277 HCWs in the Gaza Strip due to the political and geographical separation from the West Bank. 278 These limitations might limit the generalization of the results, so further studies are still needed. 279 Finally, KAP surveys are inherently reliant on self-reported responses, therefore the results might 280 partly reflect participant assumptions rather than reality. 281 282 Conclusion 283 The overall knowledge about HBV infection among HCWs in Gaza Strip is good. However, 284 significant gaps remain, such as regarding modes of transmission and HBV therapy, requiring the 285 attention of health prevention authorities. These gaps may be addressed through awareness lectures 286 and campaigns. Most HCWs' attitudes and practices are within a reasonable range, and knowledge, 287 attitude, and practice demonstrated a positive correlation. The study showed a high prevalence of 288 NSIs among HCWs in the Gaza Strip, which could be minimized by providing targeted 289 interventions and training to improve risk awareness. Fortunately, though, the vaccination 290 coverage among HCWs is high, which should help averse against some of the risks and maintain 291 the trend of the declining incidence of HBV in Palestine. 292 293 Authors’ contribution 294 AKS, YE, MA and BA contributed to the literature review, study design, data analysis and drafting 295 of the manuscript. All authors contributed to data collection, data entry and data curation. All 296 authors revised and approved the final version of the manuscript. 297 298 Conflict of Interest 299 The authors declare no conflicts of interest. 300 301 Funding 302 No funding was received for this study. 303 304 References 305 1. 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Can J Gastroenterol. 407 2012;26(9):597-602. https://doi.org/10.1155/2012/705094 408 409 Table 1: Demographic characteristics of the participants. 410 Demographic characteristics N Percent Age 24-30 185 41.4% 31-40 142 31.8% 41-50 75 16.8% Older than 50 45 10.0% Experience years Less than 2 years 111 24.8% More than 2 years 336 75.2% Affiliation Governmental Hospitals Medical Doctor 143 32% Nurse 195 43.6% Laboratory Technician 88 19.7%) Private Hospitals Medical Doctor 3 0.7% Nurse 18 4% Laboratory Technician 0 0% Total 447 100.0% 411 https://dx.doi.org/10.18203/2394-6040.ijcmph20150477 https://doi.org/10.1186/1471-2458-12-692 https://doi.org/10.1155/2012/705094 Table 2: Participant’s responses to knowledge on HBV infection. 412 HBV Knowledge Items ‡ Total Medical Doctor† Nurse† Laboratory Technician† P-value * HBV infection is caused by a virus organism 437 (97.8%) 143 (97.9%) 206 (96.7%) 88 (100.0%) .211 HBV infection can be transmitted from mother to fetus 370 (82.8%) 134 (91.8%) 159 (74.6%) 77 (87.5%) .000 HBV infection cannot be transmitted to the infants through breast milk 309 (69.1%) 97 (66.4%) 152 (71.4%) 60 (68.2%) .598 HBV infection cannot be spread through close contact (such as kissing) 281 (62.9%) 101 (69.2%) 126 (59.2%) 54 (61.4%) .147 Sexual transmission is a common way through which HBV infection can be transmitted 322 (72.0%) 104 (71.2%) 156 (73.2%) 62 (70.5%) .857 HBV infection can spread through blood transfusion 432 (96.6%) 144 (98.6%) 201 (94.4%) 87 (98.9%) .038 HBV infection can spread through sharps such as needles, blades and operation tools 420 (94.0%) 142 (97.3%) 194 (91.1%) 84 (95.5%) .044 HBV infection can spread by using shared blades at the barber, or shared ear and nose piercing tools 291 (65.1%) 107 (73.3%) 131 (61.5%) 53 (60.2%) .040 Undergoing medical and/or surgical procedures increases the chance of HBV infection 411 (91.9%) 134 (91.8%) 192 (90.1%) 85 (96.6%) .173 HBV infection cannot spread through sharing dishes with an HBV positive patient 268 (60.0%) 100 (68.5%) 101 (47.4%) 67 (76.1%) .000 Symptoms of HBV infection do not appear immediately after the entrance of HVB into the body 368 (82.3%) 127 (87.0%) 161 (75.6%) 80 (90.9%) .001 HBV infection can lead to liver cirrhosis 380 (85.0%) 123 (84.2%) 182 (85.4%) 75 (85.2%) .950 HBV infection is associated with an increased risk of liver cancer 337 (75.4%) 117 (80.1%) 149 (70.0%) 71 (80.7%) .039 An infected individual can have HBV infection without symptoms 359 (80.3%) 126 (86.3%) 159 (74.6%) 74 (84.1%) .015 Jaundice is one of the common symptoms of HBV infection 349 (78.1%) 105 (71.9%) 172 (80.8%) 72 (81.8%) .089 Nausea, vomiting, and loss of appetite are common symptoms of HBV infection 338 (75.6%) 115 (78.8%) 169 (79.3%) 54 (61.4%) .002 413 414 HBV infection is not curable 241 (53.9%) 80 (54.8%) 129 (60.6%) 32 (36.4%) .001 HBV infection can be self-cured by the body 196 (43.8%) 64 (43.8%) 80 (37.6%) 52 (59.1%) .003 There is vaccine available for HBV infection 415 (92.8%) 137 (93.8%) 195 (91.5%) 83 (94.3%) .594 No specific diet is required during the treatment of HBV infection 215 (48.1%) 79 (54.1%) 79 (37.1%) 57 (64.8%) .000 * Chi-Square Tests, † Percentage from each specialty, ‡ Correct answers Table 3: participant’s responses on attitude towards HBV infection. 415 HBV Attitude items Total Medical Doctor† Nurse† Laboratory Technician† P-value * What would be your reaction if you found out that you have HBV infection? ‡ Fear 202 (45.2%) 75 (51.4%) 103 (48.4%) 24 (27.3%) .001 Shame 40 (8.9%) 3 )2.1%) 30 )14.1%) 7 )8.0%) .000 Surprise 70 (15.7%) 20 )13.7%) 36 )16.9%) 14 )15.9%) .713 Sadness 150 (33.6%) 54 )37.0%) 50 )23.5%) 46 )52.3%) .000 Whom would you inform about your illness? ‡ Physician 344 (77.0%) 116 )79.5%) 158 )74.2%) 70 )79.5%) .412 Spouse 54 (12.1%) 21 )14.4%) 24 )11.3%) 9 )10.2%) .564 Children 26 (5.8%) 5 )3.4%) 14 )6.6%) 7 )8.0%) .289 Other relatives 39 (8.7%) 9 )6.2%) 23 )10.8%) 7 )8.0%) .299 Friends 29 (6.5%) 13 )8.9%) 15 )7.0%) 1 )1.1%) .059 When do you think you will visit health facility if you have symptoms of HBV infection? Own treatment fails 45 (10.1% 8 )5.5%) 26 )12.2%) 11 )12.5%) .007 Soon as I realized the symptoms§ 365 (81.7%) 133 )91.1%) 162 )76.1%) 70 )79.5%) .007 Will not go to the health facility 37 (8.3%) 5 )3.4%) 25 )11.7%) 7 )8.0%) .007 What would worry you the most if you are diagnosed with HBV infection? ‡ Fear of death 97 (21.7%) 37 )25.3%) 45 )21.1%) 15 )17.0%) .316 Fear of disease spread to family 277 (62.0%) 95 )65.1%) 120 )56.3%) 62 )70.5%) .046 Cost of treatment 36 (8.1%) 9 )6.2%) 17 )8.0%) 10 )11.4%) .367 416 417 Isolation from community 60 (13.4%) 11 )7.5%) 39 )18.3%) 10 )11.4%) .011 What would you do if you think you have symptoms of HBV infection? Go to pharmacy 16 (3.6%) 1 )0.7%) 13 )6.1%) 2 )2.3%) .000 Go to traditional healers 35 (7.8%) 3 )2.1%) 25 )11.7%) 7 )8.0%) .000 Go to health facility§ 396(88.6%) 142 )97.3%) 175 )82.2%) 79 )89.8%) .000 Do you believe that instrument sterilization is important to prevent transmission? Yes§ 437 (97.8%) 142 )97.3%) 210 )98.6%) 85 )96.6%) .499 No 10 (2.2%) 4 )2.7%) 3 )1.4%) 3 )3.4%) .499 Do you believe that wearing gloves is important to prevent transmission? Yes§ 417 (93.3%) 139 )95.2%) 201 )94.4%) 77 )87.5%) .051 No 30 (6.7%) 7 )4.8%) 12 )5.6%) 11 )12.5%) .051 Do you believe that vaccination could prevent transmission? Yes§ 404 (90.4%) 134 )91.8%) 192 )90.1%) 78 )88.6%) .722 No 43 (9.6%) 12 )8.2%) 21 )9.9%) 10 )11.4%) .722 Do you recommend Post exposure prophylaxis for those who had been exposed to HBV? Yes§ 361 (80.8%) 132 )90.4%) 168 )78.9%) 61 )69.3%) .000 No 86 (19.2%) 14 )9.6%) 45 )21.1%) 27 )30.7%) .000 * Chi-Square Tests, † Percentage from each specialty, ‡can apply more than one, § Favorable attitude Table 4: Participant’s responses on practice toward HBV infection. 418 419 HBV practice items Total Medical Doctor† Nurse† Laboratory Technician† P-value * Have you been screened for HBV infection? 296 (66.2) 86 (58.9%) 140 (65.7%) 70 (79.5%) .005 Have you got yourself vaccinated? 381 (85.2) 119 (81.5%) 183 (85.9%) 79 (89.8%) .209 Do you ask for new syringe before use? 405 (90.6) 132 (90.4%) 191 (89.7%) 82 (93.2%) .634 Do you ask your barber to change blade/or safe equipment for ear or nose piercing? 376 (84.1) 128 (87.7%) 181 (85.0%) 67 (76.1%) .058 Do you ask for blood screening before transfusion? 402 (89.9) 118 (80.8%) 203 (95.3%) 81 (92.0%) .000 In case you are diagnosed with HBV infection, would you go for further investigation? 401 (89.7) 137 (93.8%) 188 (88.3%) 76 (86.4%) .120 Do you avoid meeting a patient with HBV infection? 302 (67.6) 110 (75.3%) 129 (60.6%) 63 (71.6%) .009 Have you had a needle stick injury before? 233 (52.1) 66 (45.2%) 124 (58.2%) 43 (48.9%) .042 Washing hands with water and soap after a needle stick injury‡ 212 (91.0) 56 (84.8%) 117 (94.4%) 39 (90.7%) .093 Clean the wound site after a needle stick injury‡ 207 (88.8) 57 (86.4%) 112 (90.3%) 38 (88.4%) .707 Check if the patient has a blood-borne disease after a needle stick injury‡ 192 (82.4) 44 (66.7%) 110 (88.7%) 38 (88.4%) .000 * Chi-Square Tests, † Percentage from each specialty, ‡ From HCWs who had a history of needle stick injury Table 5: Interaction between cohort characteristics and KAP domains. 420 Demographic characteristics N Knowledge score Mean (SD) P-value Attitude score Mean (SD) P-value Practice score Mean (SD) P-value Age * 0.166 0.113 0.00 24-30 185 15.10 (2.041) 5.22 (.955) 5.42 (1.244) 31-40 142 14.86 (1.915) 5.33 (.928) 5.95 (1.163) 41-50 75 15.15 (2.276) 5.49 (.844) 6.12 (1.026) More than 50 45 15.56 (2.292) 5.44 (.785) 5.71 (1.160) Affiliation ** 0.463 0.00 0.006 Governmental 426 15.09 (2.071) 5.36 (.906) 5.77 (1.198) Private 21 14.81 (14.81) 4.52 (.750) 5.05 (1.203) Specialty * 0.00 0.00 0.503 Medical Doctor 146 15.61 (2.141) 5.63 (.654) 5.68 (1.219) Nurse 213 14.52 (1.985) 5.20 (.967) 5.70 (1.241) Laboratory Technician 88 15.15 (1.825) 5.11 (1.033) 5.89 (1.098) Experience years ** .866 0.02 0.00 Less than 2 years 111 15.10 (2.013) 5.07 (1.042) 5.23 (1.291) More than 2 years 336 15.07 (2.094) 5.41 (.855) 5.90 (1.130) * Kruskal Wallis Test, ** Mann-Whitney Test, P<0.05 421 422 Table 6: Predictors of demonstrating a good knowledge, attitude and practice levels about HBV. 423 424 Item Demographic characteristics N p value Odds ratio CI 95 (Lowe Bond) CI 95 (Upper Bond) P re d ic to rs o f d e m o n st ra ti n g a g o o d k n o w le d g e l e v e l a b o u t H B V Age 24-30 185 .056 .292 .082 1.034 31-40 142 .102 .369 .112 1.219 41-50 75 .154 .408 .119 1.398 More than 50 45 REF REF REF REF Affiliation Governmental 426 .959 .955 .160 5.691 Private 21 REF REF REF REF Specialty Medical Doctor 146 .600 1.283 .505 3.260 Nurse 213 000 .161 .058 .445 Laboratory Technician 88 REF REF REF REF Experience years Less than 2 years 111 .483 1.434 .523 3.932 More than 2 years 336 REF REF REF REF P re d ic to rs o f d e m o n st ra ti n g a g o o d a tt it u d e l e v e l a b o u t H B V Age 24-30 185 .508 .662 .196 2.240 31-40 142 .158 .441 .141 1.374 41-50 75 .667 .750 .202 2.788 More than 50 45 REF REF REF REF Affiliation Governmental 426 .000 8.505 2.912 24.840 Private 21 REF REF REF REF Specialty Medical Doctor 146 .000 8.599 3.493 21.168 Nurse 213 .130 1.619 .868 3.018 Laboratory Technician 88 REF REF REF REF Experience years Less than 2 years 111 .001 .292 .138 .617 More than 2 years 336 REF REF REF REF P re d ic to rs o f d e m o n st ra ti n g a g o o d p ra c ti c e l e v e l a b o u t H B V Age 24-30 185 .918 1.041 .487 2.222 31-40 142 .382 1.381 .670 2.846 41-50 75 .248 1.612 .717 3.624 More than 50 45 REF REF REF REF Affiliation Governmental 426 .055 2.544 .978 6.616 Private 21 REF REF REF REF Specialty Medical Doctor 146 .561 .844 .476 1.496 Nurse 213 .826 1.064 .612 1.850 Laboratory Technician 88 REF REF REF REF Experience years Less than 2 years 111 .011 .485 .277 .849 More than 2 years 336 REF REF REF REF