Evaluation of the General Population's Knowledge Concerning Liver Health: A Cross-Sectional Study

Introduction: Liver disease is among the leading causes of global mortality and morbidity. Given their substantial impact on public health, raising awareness about liver diseases is paramount for their prevention and effective management. This study aimed to evaluate the knowledge, awareness, attitudes, and behaviors of Syrians regarding liver health, chronic liver disorders, and their associated serious and irreversible complications. Methods: We conducted a cross-sectional study encompassing the adult Syrian population between August 25 and September 29, 2023, excluding non-Syrians and individuals below the age of 18 years. A validated questionnaire, adapted from a previous study, was employed, consisting of 31 questions that covered topics related to knowledge and awareness of liver health and diseases (3-point Likert scale), attitudes towards liver screening, diagnosis, and treatment, and awareness of treatment options and vaccination. Statistical analysis including logistic regression was conducted using Statistical Product and Service Solutions (SPSS, version 28; IBM SPSS Statistics for Windows, Armonk, NY), with statistical significance set established at pp-values below 0.05. Results: This study included 941 participants, with an average age of 26.5 years. While two-thirds of respondents demonstrated awareness of hepatitis B and C as viral diseases (663 (70.4%) and 612 (65.4%), respectively), approximately 66 (7%) were unaware of the potential for hepatitis to induce chronic liver inflammation or lead to liver failure. Over half of the participants were knowledgeable about the non-genetic nature of hepatitis B and C, and 579 (61.7%) were informed about the transmission risks associated with these infections. The most common reason cited for not participating in health screening tests was the perception of being in good health (219, 77.4%), and prescription medication was the most frequently sought treatment for hepatitis (543, 83.9%). Bivariate analysis revealed correlations between participant knowledge and sex, socioeconomic status, educational level, and occupation (P < 0.05). Similarly, the study identified significant associations between participant attitudes and age, gender, economic status, job, and educational level (P < 0.05). Moreover, the multivariate analysis demonstrated that gender, occupation, and educational level significantly influenced both participants’ knowledge and attitudes. Specifically, males exhibited lower knowledge and less favorable attitudes than females (P = 0.041 and P < 0.001, respectively). Conclusion: The Syrian population possessed moderate knowledge of liver health and liver disorders. To bridge this knowledge gap and enhance preventive measures, it is recommended that additional health programs and awareness initiatives be implemented, involving healthcare providers and leveraging their expertise.


Introduction
The liver, a crucial organ responsible for various physiological functions such as nutrient metabolism, detoxification, and bile production, plays a vital role in maintaining overall health [1].
Globally, liver diseases contribute significantly to mortality and morbidity, resulting in approximately two million deaths annually.This includes one million deaths from cirrhosis complications and another million deaths from viral hepatitis and hepatocellular carcinoma (HCC) [2,3].Cirrhosis, representing the advanced stage of liver scarring due to persistent inflammation, is associated with severe complications, such as portal hypertension, liver failure, and increased mortality [4][5][6].Notably, a considerable number of patients or individuals with cirrhosis may remain asymptomatic during the compensated stage [7].
Regionally, the prevalence of liver diseases that lead to cirrhosis varies.In developed countries, common causes include the hepatitis C virus (HCV), alcoholic liver disease, and nonalcoholic steatohepatitis, whereas, in developing countries, hepatitis B and C are the primary contributors to cirrhosis [8].
NASH, a liver condition characterized by lipid accumulation in hepatocytes, results in lipotoxicity and cellular damage.It predominantly affects individuals with obesity or metabolic disorders such as diabetes, insulin resistance, or lipid dysregulation.The uncontrolled inflammation in NASH can progress into fibrosis and cirrhosis [9].
Among the hepatitis viruses, hepatitis B, C, and D are associated with chronic liver diseases, cirrhosis, and liver cancer.Globally, hepatitis B and C had a prevalence of 3.9% (292 million) and 1% (71 million), respectively, in 2015-2016.Notably, half of all hepatitis B cases occur in Nigeria, China, India, and Indonesia.Chronic hepatitis C infection may lead to cirrhosis in 10%-20% of cases and HCC in 1-5%.
The New England Journal of Medicine suggested crucial steps upon the cirrhosis diagnosis.These include discontinuing harmful substances such as medications, alcohol, and certain drugs.Blood pressure monitoring, esophageal varices screening, and biannual HCC screenings are essential.With a mean arterial pressure of 82 mm Hg, antihypertensive drugs should be discontinued.If deemed appropriate, liver transplantation evaluation should be initiated [12].
Decompensated cirrhosis poses a 9.7-fold higher mortality risk than that of the general population.Those with compensated cirrhosis have an average life expectancy of 10-13 years, while individuals with decompensated cirrhosis are expected to survive for only two years [12].
Given the often-asymptomatic progression of liver diseases to advanced stages, creating awareness becomes crucial for effective prevention and management [13].Strategies such as promoting healthy habits, encouraging hepatitis virus vaccination, and avoiding risky behaviors are proven effective in preventing liver diseases [14].Early detection through screening is equally vital for preventing disease progression and reducing the risk of complications [15].
Despite advances in the understanding of liver function and the pathophysiology of chronic liver disorders globally, liver diseases continue to significantly impact public health [1].Recognizing this ongoing challenge, further research and the implementation of preventive measures are imperative to improve patient prognosis and enhance their quality of life.This research specifically aims to evaluate the knowledge, awareness, attitudes, and behaviors of Syrians concerning liver health, chronic liver disorders, and related irreversible complications.This study is poised to serve as a valuable reference for future research and prospective public health initiatives, focusing on screening and safeguarding the population.

Study design and setting
This cross-sectional study was conducted among the adult Syrian population from August 25 to September 29, 2023.The participants were restricted to Syrian nationals aged 18 years and above.The primary objective was to assess the knowledge, attitudes, and practices related to liver health, chronic liver diseases, their impact on human health, and preventive measures.The study utilized a questionnaire adapted from a previously validated scale [16], with our analysis relying on the same cut-off points.The questionnaire was meticulously translated into Arabic by healthcare professionals proficient in multiple languages to ensure accessibility to the target population.Data collection employed a combination of convenience and snowball sampling methods, distributing the questionnaire both online via Google Forms on various social media platforms and in print for in-person distribution.

Sample size calculation
To determine the appropriate sample size, we referred to World Bank statistics indicating an expected Syrian population of 18,275,704 people in 2021 [17].Assuming a percentage of 50%, a margin of error of 5%, and a confidence level of 95%, we calculated a minimum sample size of 385 using Calculator.net(www.calculator.net/)[18].

Statistical analysis
Descriptive statistics were employed to summarize participants' demographic profiles, with categorical data presented as frequencies and percentages, and continuous data represented as means and standard deviations.Relevant statistical tests, including chi-square tests and t-tests, were used to evaluate and compare knowledge, attitudes, and confidence scores, when applicable.The analysis was conducted using Statistical Product and Service Solutions (SPSS, version 28; IBM SPSS Statistics for Windows, Armonk, NY), with statistical significance set established at pp-values below 0.05.Multivariate logistic regression analysis was also conducted to explore the combined influence of multiple independent variables on binary or categorical outcome variables related to knowledge and attitudes concerning liver health management, allowing for a more comprehensive understanding of the relationships between the predictor variables and the final outcomes.

Demographic profile of the study participants
The study included 941 participants between the ages of 17 and 78 years, with a mean age of 26.5 (SD = 10.2).More than half of the participants (546, 58%) were female, and 590 (62.7 %) were students.
Approximately three-fourths of respondents (727, 77.3%) were city dwellers.Regarding social status, 729 (77.5%) of the study population were single, while 196 (20.8%) of them were married.The majority of the participants had a university degree (737, 78.3%), whereas 14 (1.5%) of them had attained middle school, and six (0.6%) had no education.The vast majority of them (845, 89.8%) did not report having any chronic conditions.Additionally, 825 (87.7%) reported good or average economic status, whereas 48 (5.1%) reported low financial status.One hundred seventy-five (18.6%) of them were privately employed, and 74 (7.9%) were unemployed (Table 1).The majority of respondents reported that hepatitis B and C could be transmitted through various means, including sexual intercourse (581, 61.7%), contact with blood such as through an open wound (679, 72.2%), and by sharing non-sterile needles or experiencing needlestick injuries (770, 81.8%).A notable 587 (62.4%) believed that these diseases cannot be transmitted by touching an infected person.Additionally, almost half of the study population agreed that transmission through the fecal-oral route was unlikely.Regarding the transmission of hepatitis B and C from a pregnant mother to her baby during birth, 185 (19.7%) of participants were uncertain.Meanwhile, 119 (12.6%) and 406 (43.1%) of respondents rejected the idea that hepatitis B and C can be transmitted via sharing razors or toothbrushes and by receiving tattoos or body piercing from settings with poor infection control standards, respectively.On the other hand, 339 (36%) reported that transmission could occur by dining together with an infected person.Three-quarters of the participants concurred that hepatitis B and C cannot be transferred by eating contaminated or raw seafood, such as shellfish (714, 75.9%;Table 3).

Barriers to health screening and treatment seeking among participants: insights from a Syrian population
The most common reasons given for not attending health screening tests were the lack of need for health screening tests and feeling healthy, with 219 (77.4%) of participants citing this reason, followed by 105 (37%) reported that their doctor did not recommend screening tests, and 99 (35%) reported that screening tests are expensive.Among individuals who had previously been diagnosed with a liver problem, the majority (36, 67.9%) received therapy shortly after diagnosis, whereas a significant proportion (8, 15.1%) never received treatment.The most common answers for not obtaining treatment were "doctor did not prescribe any treatment" (452, 50%), "doctor was not able to clearly explain the treatment plan" (404, 44.7%), and "prescription medicine was not available in our area" (380, 42%).In addition, the respondents indicated that they were uncertain of doctors recommending observation and follow-up without initiating treatments or unable to receive treatment due to a lack of insurance or being underinsured (156 (17.3%) and 127 (14%), respectively).The additional details are provided in Table 4.As shown in Figure 1, the most common therapy for hepatitis sought by respondents (83.9%) was a prescription medicine; otherwise, 32.6%, 15.1%, and 7.5% relied on functional food, herbal remedies, and over-the-counter items, respectively.

FIGURE 1: Treatment sought for hepatitis by the respondents (N= 905).
Only 18.9% of people afflicted with hepatitis said that their physicians informed them that viral hepatitis infection may develop into live cancer, and 13.2% of them reported their doctors provided educational materials to help understand the association between viral hepatitis and liver cancer (Figure 2).

Demographic correlation of knowledgeability and attitudes towards liver health in the Syrian population
Bivariate analysis revealed a relationship between participant knowledge and gender, social status, educational level, age, and job (P < 0.05).As shown in Table 5, the knowledgeable group had a higher proportion of females (327, 61.9%) compared to the non-knowledgeable group (219, 53.0%).Knowledgeable individuals were more likely to be single (447, 84.7%) compared to non-knowledgeable individuals (282, 68.3%).On the other hand, non-knowledgeable individuals were more likely to be married (121, 29.3%) compared to knowledgeable individuals (75, 14.2%).The participants with a university education showed a higher rate of knowledge than the non-knowledgeable group (282, 68.3%).In contrast, the participants with postgraduate demonstrated lower knowledge than the non-knowledgeable group (1, 0.2%).Approximately, on the knowledgeable group, half of the participants showed a higher proportion to be students compared to the non-knowledgeable group (220, 53%).Additionally, the mean age of the people demonstrated a higher proportion of knowledge than the non-knowledgeable people (49, 11.9%).Participants' attitudes were strongly related to their age, gender, economic status, job, and educational level (P < 0.05).There were significant differences in the distribution of educational levels between the two groups (good and low attitudes).For example, the proportion of individuals with a diploma was higher in the group with a good attitude (543, 83.8%) compared to the other groups (194, 66.2%).The proportion of individuals with a high school education was higher in the group with a low attitude (62, 21  Table 7 illustrates the results of the multivariate analysis, indicating a significant association between gender and the participants' knowledge and attitudes.Specifically, males demonstrated lower knowledge and a less positive attitude compared to females (OR = 0.74, 95% CI (0.56-0.99),P = 0.041; OR = 0.53, 95% CI (0.39-0.71),P < 0.001, respectively).Additionally, married individuals exhibited lower knowledge levels than their single counterparts (OR = 0.42, 95% CI (0.25-0.68);P < 0.001).Job type also emerged as a significant factor associated with both knowledge and attitudes.Unemployed individuals and those working in private jobs demonstrated lower knowledge and attitude levels compared to students, who were used as the reference category (OR = 0.48, 95%CI (0.27-0.87);P = 0.015; OR = 0.52, 95%CI (0.34-0.78);P = 0.002), (OR = 0.91, 95%CI (0.49-1.71);P = 0.77; OR = 0.6, 95%CI (0.4-0.92); P = 0.01).

Discussion
Hepatitis is a viral infection that causes liver injury and inflammation, leading to a weakened immune system, increased susceptibility to infection, impaired blood filtration, and nutrient processing.It poses a significant global challenge, impacting both morbidity and mortality, and has the potential for outbreaks [19].
This study aimed to assess the knowledge, awareness, attitudes, and understanding of liver health and diseases among the Syrian population.The goal is to establish clear reference points for future public health screening and protection initiatives, as well as for further studies.It is important to note that this research was conducted online, which may have introduced bias toward individuals with higher education and socioeconomic status [20].
The data revealed a reasonably good level of public awareness regarding fundamental aspects of liver virus infections, especially hepatitis B and C. Approximately two-thirds of the respondents correctly identified hepatitis B and C as viral infections rather than bacteria.Additionally, over (50%) of participants demonstrated a clear understanding of how hepatitis can progress to chronic liver inflammation and liver cancer.
However, 362 (38.5%) of the respondents believed that hepatitis C cannot be prevented through vaccination, whereas 685 (72.8%) recognized that vaccination could prevent hepatitis B. Additionally, a small percentage of the study population does not know that hepatitis B and C can increase the risk of developing cancer and liver cirrhosis, with 58 (6.2%) for hepatitis B and 62 (6.6%) for hepatitis C.These findings align with a published study in Thailand, where over (80%) of the participants agreed that hepatitis B and C could lead to liver failure, liver cirrhosis, and cancer.In contrast to our study, almost half of the participants in that study mistakenly considered hepatitis B and C bacterial infections [16].Another study similar to ours found that more than three-quarters of the participants believed vaccinations could prevent hepatitis B, but 280 (28.9%) mistakenly believed there was a vaccine for hepatitis C [21].
Our results revealed that most participants correctly knew that hepatitis B and C could be transmitted through sexual intercourse, blood, and by sharing non-sterile needles or through needlestick injuries, with percentages of 61.7%, 72.2%, and 81.8%, respectively.In contrast, previous research found low awareness of the transmission of hepatitis B and C, where only 28.3%, 16.3%, and 29.3% of individuals reported that hepatitis B and C could be transferred via contaminated blood, razor blades or nail clippers, and unprotected sex, respectively [22].
Our data revealed prevalent misconceptions about hepatitis transmission, such as the mistaken belief that hepatitis viruses can spread through the fecal-oral route or by consuming contaminated or raw seafood.These findings align with those of prior research from different regions, emphasizing persistent myths regarding hepatitis transmission [23].
Our study found that respondents with an average age of 26.5 years exhibited varying levels of awareness.
Younger participants tended to have higher knowledge levels, possibly due to increased access to healthrelated information on the Internet among this demographic [24].Similar research in India also identified a correlation between younger age and higher knowledge levels, which was attributed to improved information accessibility for younger individuals [25].
Our bivariate analysis indicated that 327 (61.9%) of females, 447 (84.7%) of single individuals, 75 (14.2%) of married individuals, and 455 (86.2%) with a university education had higher knowledge proportions.This aligns with our study's overall findings, showing that lower educational attainment is associated with lower knowledge of viral hepatitis and its consequences.As education levels increased, knowledge scores also increased.However, in contrast to our study, no association with knowledge was observed based on economic status [26].A separate cross-sectional study of the Jordanian population revealed a strong correlation between educational level, monthly income, and knowledge about hepatitis B [27].
Notably, individuals who were unemployed or employed in the private sector exhibited lower knowledge levels.This observation may be attributed to European regulations mandating HBV vaccination and proof of immunization for specific job positions [28].
This study identified barriers to participating in health-screening examinations.These barriers include a lack of perceived urgency, infrequent physician recommendations for liver screening, financial constraints, and social stigma and discrimination faced by individuals diagnosed with hepatitis.The stigma surrounding viral hepatitis is a widespread issue and has been linked to low uptake of hepatitis B and C screening.Despite the existence of anti-discrimination laws in many countries, workplace discrimination against individuals with viral hepatitis remains a concern, especially in Southeast and Southern Asia [29].These outcomes align with prior research, which revealed that obstacles to treatment include disrespect and a lack of consideration from some physicians and nurses, as well as not receiving equal healthcare [30].
Almost two-thirds of the respondents reported seeking treatment upon receiving a diagnosis of hepatitis.However, financial constraints and unavailability of medications in their area were cited as reasons for not seeking treatment.Effective doctor-patient communication and the prescription of appropriate treatment have emerged as critical factors in ensuring treatment adherence.Physicians were identified as the primary source of information for patients, underscoring the importance of education for healthcare providers.A qualitative study in Ireland found that connections with healthcare providers increase their engagement with care [31].
In terms of attitudes and knowledge, married individuals demonstrated higher scores than their single counterparts, while female participants exhibited superior attitudes and knowledge compared to male participants.These observations may be linked to the influence of marital status on health-related awareness and attitude.Married individuals may be more likely to engage in health-related discussions within their households, fostering a shared understanding of diseases and preventive measures.In addition, cultural and societal expectations of family responsibilities may contribute to increased health awareness among married individuals.The observed gender disparity, with females showing higher knowledge and attitudes, could be attributed to the targeted awareness campaigns.Ongoing efforts to educate and empower women on health matters, especially those focusing on women's health, seem to positively impact knowledge levels among females.These findings align with previous research [32] on women's knowledge and health behavior regarding hepatitis B and C, suggesting that continued campaigns to educate and empower women on health matters have a positive impact.Furthermore, awareness campaigns targeting pregnant women and women of reproductive age likely contribute to these results, as they are considered high-risk demographics for mother-to-child disease transmission.The implementation of these strategies holds the promise of facilitating early detection, alleviating the burden of liver diseases in the Syrian community, and enhancing knowledge of liver health among the Syrian population.Ultimately, this leads to a positive attitude and improved behaviors that prevent hepatitis in the population [33].
Initiating public awareness campaigns focused on liver health and chronic liver diseases, and the significance of early detection is paramount.These campaigns encompass the creation of informative brochures, posters, and online resources, all aimed at educating the population about risk factors, symptoms, and available preventative measures.
Conducting community workshops and seminars led by healthcare professionals is another pivotal approach.These events delve into a range of topics, including the vital functions of the liver, the consequences of lifestyle choices on liver health, and the imperative nature of regular check-ups.Interactive sessions play a pivotal role in facilitating a deeper understanding.
Incorporating liver health education into school curricula is a proactive measure.This educational approach not only reaches a younger audience but also instills healthy habits from an early age, ensuring that future generations possess a more comprehensive understanding of liver health.
Collaboration with local healthcare providers, clinics, and hospitals is instrumental in offering liver health screening and consultation.The objective is to motivate individuals to pursue regular check-ups while

TABLE 1 : Participants' socioeconomic characteristics. Awareness of hepatitis B and C: a mixed understanding
prevented through vaccination.Furthermore, 511 (54.3%) and 573 (60.9%) of the respondents acknowledged that hepatitis B and C are not genetic illnesses, respectively.Approximately 6% of the participants did not recognize that hepatitis B and C increased the risk of developing liver cirrhosis and cancer.At a similar rate, the participants had responded unsure that these diseases were not airborne (hepatitis B: 244 (25.9%); hepatitis C: 269 (28.6%);Table2).Frequency (Percentage, %

) Hepatitis B Hepatitis C Question (correct response) Is a bacterial infection (disagree)
Can be prevented by vaccination (agree for hepatitis B; disagree for hepatitis C)

TABLE 2 :
Knowledge of the features of hepatitis B and hepatitis C.Knowledge about transmission risks of hepatitis B and C2024 Alibrahim et al.Cureus 16(2): e54162.DOI 10.7759/cureus.54162

TABLE 5 : Factors associated with participants' knowledge.
1: Chi-square test, 2: Mann-Whitney U test .2%) compared to the other group (60, 9.3%).Females had the highest proportion of positive attitudes towards hepatitis (415, 64%) compared to males, who appeared to have the lowest good attitudes towards hepatitis (233, 36%).The study population's mean age proportion in the group with a low attitude towards hepatitis was higher (34, 11.5%) than the group with a good attitude towards hepatitis despite having the same mean age.The individuals with good income status demonstrated good attitudes (314, 48.5%) more than other low-income groups with low attitudes.Retired appeared the lowest good attitude than other job categories with low attitudes (10, 1.5%; Table6).