Knowledge of hepatitis B virus infection, risk factors, vaccination, and barriers to vaccine acquisition among undergraduate accounting students

INTRODUCTION

The battle against hepatitis B (HB) has progressed over the decades, leading to the development of effective screening tools, prophylactic vaccinations, and antiviral drugs that significantly enhance patient outcomes. Despite these advancements, some populations around the world lack access to or awareness of these resources and the disease itself. The incidence of hepatitis B infection varies widely across the globe. Geographically, it can be divided into three groups: (i) high endemicity (>8%), predominantly found in developing nations (Southeast Asia, Far East Asia, and Sub-Saharan Africa); (ii) intermediate endemicity (2–7%), located in Latin America, the Mediterranean, and Eastern Europe; and (iii) low endemicity (<2%), present in North America, Western Europe, and Japan.^[1] Nigeria has one of the highest hyper-endemic rates (>8%) of HBV infection in Africa. Approximately 90% of Nigerians with chronic HBV are unaware of their infection status and are not included in international public health statistics due to a lack of funding, political will, and awareness to address the country's HBV issue. Consequently, Nigeria has one of the highest rates of hepatitis B virus (HBV)-related cancer in West Africa, with an age-standardised incidence estimate of 2.6 to <5.1 cases per 100,000 person-years^.[2]

The HB vector is the cause. Perinatal transmission, or the transfer from an infected mother to a newborn, unprotected sexual contact, sharing needles during injections, reusing contaminated needles, and coming into contact with an infected person's blood or bodily fluids are the main ways that it is spread. HBV infection is a major global health concern that can cause acute or chronic hepatitis in addition to major side effects like liver cirrhosis and liver cancer. According to the World Health Organisation, there are 1.5 million new cases of HB infections annually, and over 290 million people had chronic HB disease in 2019.^[3] This has resulted in over 820,000 deaths, mostly from cirrhosis and hepatocellular carcinoma (HCC).^[4]

Cultural practices and beliefs that vary from one community to another are the main source of risk factors for HBV infection. Several primary studies elsewhere have identified the following as the primary risk factors for Hepatitis B surface antigen seropositivity. A history of blood transfusions, low educational attainment, surgery, sexually transmitted infections, abortions, higher mean parity, early sexual activity, polygamy, maleness, rural birthplace and having sex with multiple partners.^[5]

Since 1980, there has been a vaccine that is both effective and safe. This vaccine is economical, reduces the risk of long-term HB-related morbidity and mortality, and prevents the HBV from spreading both vertically and horizontally. Moreover, especially in children, HB vaccination can shield against HCC and hepatitis D virus infection. Among the first anti-cancer drugs was the HBV vaccination. The HBV vaccine has thus been incorporated into national immunisation programs in 190 countries, according to relevant research studies.^[6] The death rate from complications caused by the HBV is thought to be reduced by increasing access to timely antiviral treatments for diagnosis, reducing the cost of vaccination, improving the institution's healthcare infrastructure, and educating the general public, including students, about the disease.^[7] Therefore, this study evaluated undergraduate accounting students' knowledge of HBV infection, risk factors, vaccination, and obstacles to vaccine acquisition, while keeping in mind that their program does not give them the basic information that could lead to misleading results.

MATERIAL AND METHODS

Nine hundred and thirty-one study participants from the 1^st to the 4^th year (final year) class levels of accounting classes participated in this cross-sectional descriptive survey. A proportionate sample size of 280 was established using the Taro Yamane Formula (1^st to 4^th year class levels). By dividing the students into levels and choosing 10% of the total population of students in each level at random, a stratified random sampling technique was used to select the sample for the study to improve the accuracy of estimates and guarantee that each subgroup is proportionately represented in the sample. To ascertain the sample size of accounting department students with their population size, the stratified random sampling method was utilised. The requirements for inclusion were that the student must be enrolled in the accounting program, be present when the study's purpose data were explained and data collection done, be willing to participate in the study, and sign a consent form.

To collect data, a self-structured questionnaire was created. It was developed using the research questions as a guide. It is divided into four sections: Section A comprises seven items (5–11 questions) that test students’ knowledge of the HBV; Section B comprises eight items (12–19 questions) that test students’ knowledge of hepatitis B risk factors; Section C comprises eight items (20–27 questions) that test students’ knowledge of HB vaccine immunisation; and Section D comprises eleven items (28–38 questions) that test students’ knowledge of the obstacles they face in acquiring the HB vaccine. The face and content validity were assessed by three senior lecturers from the University of Nigeria, Enugu Campus's Department of Nursing Sciences. Twenty-eight (28) students from the accounting department at Enugu State University of Science and Technology, who satisfied the inclusion requirements but were not study participants, participated in a test-retest pilot study of the instrument. The instrument's index of 0.81 indicates that it is a reliable tool.

The researcher's proposal, questionnaire, and letter of introduction from the head of the University of Nigeria's Enugu Campus's Nursing Sciences Department were submitted to the University of Nigeria Teaching Hospital's (UNTH) research committee for ethical approval to conduct the study (NHREC/05/01/2008B-FWWA00002458-1RB00002323). Before the surveys were distributed, the respondents' consent was also acquired. Everyone involved in the study was informed of its purpose. Numbering was used to identify each copy of the questionnaire. Every response was kept private and utilised exclusively for research. The respondents were not threatened by the study.

Data was collected over four weeks. In the data analysis, descriptive statistics such as means, standard deviations, frequencies, and percentages were used with SPSS. The chi-square test was used to examine the association between students' educational attainment and their knowledge of the risk factors for HBV infection and the vaccine.

RESULTS

A total of 280 questionnaires were sent out and gathered. With a mean and standard deviation of 21.21±2.37 and a modal age group of 21–25 (53.6%), the students' ages ranged from 17 to 34. The majority of them were females, 187 (66.8%), and most of them were single, 257 (95.7%). They were in 1^st year level 53 (18.9%), 2^nd year level 68 (24.3%), 3^rd year level 79 (28.2%), and 4^th (final) year level 80 (28.6%). The history of hepatitis among the students was 15 (5.4%), while the history in their family was 17 (6.1%) [Table 1].

One-half of the students, 141 (50.4%), knew HB. What they knew was that hepatitis B infection affects any age group, 168 (60.0%), and that it is caused by viruses, 161(57.5%), and not bacteria, 156 (55.7%) [Table 2].

Table 2: Knowledge of hepatitis B virus infection n = 280

Items	Yes (%)	No (%)	No idea (%)
Is hepatitis B caused by a virus?	161 (57.5)*	35 (12.5)	84 (30.0)
Is hepatitis B caused by bacteria?	38 (13.6)	156 (55.7) *	86 (30.7)
Can hepatitis B infection affect any age group?	168 (60.0) *	38 (13.6)	74 (26.4)
Are you aware of the first aid treatment in case of accidental exposure to hepatitis B?	81 (28.9) *	136 (48.6)	63 (22.5)
Most healthy adults infected with the hepatitis B virus can have no symptoms	103 (36.8) *	76 (27.1)	101 (36.1)
Is hepatitis B curable or treatable?	126 (45.0)	63 (22.5)	91 (32.5)
Will an infected person remain infected for life?	69 (24.6)	100 (35.7)	111 (39.6)
Overall knowledge of hepatitis B	Frequency	Percent
Good (knowledge score >50%)	141	50.4
Poor (knowledge score ≤ 50%)	139	49.6

Correct answers are asterisked (^*), Items with Yes and No as possible correct answers are double asterisked ().

One-third of the students, 184 (65.7%), accepted that they knew the risk factors of contracting the HBV. Their knowledge was mostly on the transmission of the virus through the use of contaminated unsterilised equipment e.g. syringe 210 (75.0%), through the transfusion of infected blood to an uninfected person 203 (72.5%), unsafe sex 191 (68.2%), contaminated tattoo equipment or barber’s blade 189 (67.5%) and from a carrier husband or sexual 175 (62.5%) [Table 3].

A majority of the participants, 177 (63.2%), confirmed that they are aware of the hepatitis B vaccine. Additionally, they believed that the vaccine was effective in preventing the infection (194; 69.3%), that both adults and children could be immunised 192 (68.6%), that there is a vaccine against the HBV 210 (71.8%), that there is a vaccine for prevention 202 (72.1%), and that the vaccine is available in Nigeria 175 (62.5%) [Table 4].

Table 4: Knowledge of hepatitis B virus vaccine. n = 280

Items	Yes (%)	No (%)	No idea (%)
Do you know that there is a vaccine against the hepatitis B virus?	201 (71.8) *	34 (12.1)	45 (16.1)
Is there a vaccine for preventing the hepatitis B virus?	202 (72.1) *	19 (6.8)	59 (21.1)
Does the hepatitis B vaccine have more than one dose?	117 (41.8) *	42 (15.0)	121 (43.2)
Can both children and adults be immunized against the virus?	192 (68.6) *	24 (8.6)	64 (22.9)
Is the vaccine available in Nigeria?	175 (62.5) *	16 (5.7)	89 (31.8)
Do you believe the vaccine is effective in preventing the infection?	194 (69.3) *	21 (7.5)	65 (23.2)
Is the hepatitis B virus curable?	119 (42.5)	68 (24.3)	93 (33.2)
Is there an effective treatment for hepatitis B virus infection?	157 (56.1)	43 (15.4)	80 (28.6)
Overall knowledge regarding the hepatitis B vaccine	Frequency	Percent
Good (knowledge score >50%)	177	63.2
Poor (knowledge score ≤ 50%)	103	36.8

Correct answers are asterisked (*); Items with Yes and No as possible correct answers are double asterisked ()

Out of 56 (20%) students who have received the HB vaccine, more than half completed the doses, 33 (58.9%). The barriers to not receiving the vaccine were mainly a lack of sufficient information about the disease and the vaccine 115 (59.0%), fear of side effects 105 (53.8%), and lack of knowledge of where to get vaccinated 99 (50.8%) [Table 5].

A significant correlation (p <.001) was found between the participants' level of study and their knowledge of risk factors for HBV infection; specifically, those at the 3rd and 2nd year levels were more likely to possess this knowledge. Age (p=.161) and sex (p=.172) did not significantly correlate [Table 6].

Furthermore, a significant correlation (p =.001) was found between knowledge of HBV infection and hepatitis vaccine immunisation. The vaccine immunisation was more closely linked to participants who knew more about the infection [Table 7].

DISCUSSION

The level of knowledge of HBV infection, risk factors, and vaccine immunisation against HB, and Obstacles to obtaining the vaccine were measured among undergraduate accounting students at the University of Nigeria, Enugu Campus.

The findings indicated that students had a fair level of knowledge about hepatitis B. They were primarily aware of its causes and that people of all ages are impacted. The absence of thorough coverage of infectious diseases in their curriculum might have resulted in gaps in knowledge regarding the crucial elements of HB. The knowledge gap may also result from a lack of campus-wide awareness campaigns. Even though the fair knowledge is somewhat admirable considering unrelated programs offered in the department of accountancy, targeted educational campaigns and initiatives that focus on infectious diseases like the HBV within the non-medical disciplines are desperately needed on campuses. This study found that although the level of knowledge was significantly higher than that found in other studies ^[8-10], students' knowledge of the HBV was slightly higher than that of a study in which only 47.2% of students had good knowledge of the virus. The demographics of the participants and the study's location could be the cause of these variations.^[11]

There was also an overall fair knowledge among students on the risk factors of contracting the HBV. The use of contaminated unsterilised equipment, such as a syringe, transfusion of infected blood to an unaffected person, unsafe sex, contaminated tattoo equipment or barber’s blade, and having a spouse who is a carrier were the known risk factors of contracting the virus. This is very commendable as knowledge of risk factors will help the students adopt safe health behaviours that can mitigate the contraction of the HBV, resulting in overall good health among the students. The findings of Odita et al., where blood transfusion, sexual activity, sharing of personal items, tattoo/scarification, and ear piercing were reported as the risk factors for HBV, corroborated this study.^[12] Similarly, preclinical year medical students in a study reported that blood transfusion and the use of contaminated needles and syringes were the major modes of transmission of the virus.^[13] Enhancing HB education across all student fields can help improve the comprehensive knowledge of this disease and its prevention among students.

The student’s level of knowledge regarding the HB vaccine was fair. They are aware that the vaccine, which is available in Nigeria, is effective in preventing the infection and can be given to both children and adults. The level of knowledge found in this study, though not high, is quite admirable, as knowledge of the existence of the hepatitis B vaccine may lead to improved levels of immunisation among the students. However, many still lacked detailed information about the vaccine’s dosage and administration schedule, which is essential for achieving full immunity. About 58.2% were not aware of the dosage of the vaccine in this study, although it was higher than the percentage of lack of awareness of the length of doses (43.60%) found in another study.^[14] In contrast to this study, a related study further reported that 72.7% of students were aware of HBV vaccination.^[13] Similarly, Abban et al., in disagreement with the result of the study, reported that only 32.9% of students were aware of the HB vaccination, showing poor awareness.^[10]

Very few of the students have received the vaccine, of which more than half have completed the doses. This is worrisome as the fair level of knowledge of vaccination did not translate to practice. This might be due to information gaps regarding the vaccination, as well as barriers that may hinder their ability to receive the vaccine. More so, some students may not know their vaccination status due to forgetfulness or any other reason. This is implicated in the results, where many students, including medical students, are not sure of their vaccination status.^[13] The percentage of students who have completed their vaccine doses in this study was more than the percentage (0.4%) found in a similar study.^[15] However, the percentage of students (22.5%) who have been vaccinated in the study of Adam and Fusheini was higher than the percentage found in this study.^[16] The barriers to receiving the vaccine were mainly due to a lack of information about the disease and the vaccine, fear of side effects, and a lack of knowledge of where to get vaccinated. Deficient knowledge about the disease and its vaccine can lead to confusion and uncertainty, making people hesitant to get vaccinated. This deficient knowledge may also fuel misconceptions and exaggerated concerns about the vaccine, exacerbating the fears of its side effects. The results of this study are consistent with those of related studies^.[9,15]

Participants' level of knowledge and their comprehension of risk factors were found to be strongly correlated by the study. Those in the 2nd and 3^rd year levels were more closely associated with knowledge. This may be because, as students advance in their education, they usually encounter more extensive material through coursework, extracurricular activities, and interactions with their peers. Additionally, students in these two levels have less coursework than those in their final year (4^th year), which enables them to use social media and the internet to research topics. This study supports the findings of Ibrahim and Adepoju, who discovered a significant correlation between educational attainment and HBV awareness.^[9]

Knowledge about HBV infection and vaccination was significantly correlated. The vaccine was better understood by those who knew more about the infection. Students are inspired to look for more information on risk factors and preventive measures after learning how serious an HBV infection can be. This is consistent with the study's findings, which showed that awareness of the HBV virus was a significant predictor of hepatitis B vaccine uptake.^[17]

CONCLUSION

The participants' knowledge of risk factors, vaccine immunisation, and HBV was moderate. The main barriers to the HBV vaccine's uptake were a lack of knowledge about the disease and the vaccine, fear of side effects, and confusion about where to get the shot. There was a significant correlation between the participants' knowledge of the risk factors for HBV infection and their study levels, and a correlation between their knowledge of immunisation and their knowledge of HBV infection.