Sociodemographic Determinants of Knowledge, Attitudes, and Practices Toward Hepatitis B Infection Among Pregnant Women: A Cross-National Study in Jordan

Background Mother-to-child transmission (MTCT) of the hepatitis B virus (HBV) is significant, as most infants infected at birth go on to develop chronic hepatitis B. Vaccination and antiviral treatment during pregnancy could primarily prevent vertical transmission. Therefore, the purpose of this study is to assess pregnant Jordanian females’ knowledge, attitude, and practices (KAP) toward HBV. In addition, to explore the relationship between the level of KAP toward HBV infection and its predictors. Methods Our cross-sectional study was conducted among pregnant women in Jordan. We enrolled 621 participants between January and April 2023. Our survey was derived from a previously validated tool that was used to investigate a similar aim as our study. The survey was done via Google Forms (Google LLC, Mountain View, California, United States) and it contained questions divided into four main sections: participants’ demographics, knowledge section, attitudes section, and practices section. Results The majority of participants have neither a personal nor family history of HBV, and only 91 (14.7%) of the participants had a medical degree. The overall knowledge, attitude, and practice (KAP) scores were low, as only 176 (28.3%), 315 (50.7%), and 244 (39.3%) of participants achieved high levels of knowledge, attitude, and practice scores, respectively. A significant association was found between knowledge level, practice assessment, and the following variables: age, educational level, job, study field, history of HBV in the family, and source of knowledge. Regarding attitude, a significant association was found with the job, study field, and source of knowledge. Conclusion This study found that pregnant women in Jordan had a low level of awareness of HBV infection. Thus, more efforts should be made to raise awareness about HBV among high-risk groups, especially pregnant women.


Introduction
Globally, the hepatitis B virus (HBV) is a serious health problem, with 1.5 million new cases of chronic hepatitis B infection occurring annually, impacting 296 million people worldwide [1].The global epidemiology of HBV is demonstrated in Middle Eastern countries, with intermediate (2-5%) to high endemicity (>5%) chronic carriers in many countries [1].The majority of the cases are transmitted from mother to child during pregnancy or after birth [2].Mother-to-child transmission (MTCT) of HBV is significant, as most infants infected at birth go on to develop chronic hepatitis B [3].The chronicity depends mainly on age, as the risk of infants becoming chronic carriers if infected at birth is 70-90%, whereas the chance of becoming a chronic carrier is only 5% in adult-infected individuals [3].On the other hand, adult infection usually causes an acute, self-limiting illness followed by viral clearance or, in rare cases, fulminant liver failure [4].In contrast, infants' infection with the virus results in a life-long chronic infection and virus carriage [5].The hepatitis B surface antigen (HBsAg) can be carried without causing any symptoms, or the condition can progress to severe, active variants that cause fibrosis, liver cirrhosis, and hepatocellular carcinoma (HCC) [4].In Jordan, the prevalence of HBV among pregnant women is around 5% [6], which is less than in China and some African countries (6-11.7%)[7][8][9], but quite higher than in other Middle Eastern countries (1.5-4%) [10,11].As vertical transmission is the main route for HBV infection among pregnant women, it could be prevented mainly by vaccination and antiviral treatment during pregnancy [12].The first step in prevention is to screen all pregnant women in their first trimester to identify the best management step for the mother and to prevent vertical transmission to her baby [13].The HBV vaccine is safe and effective even during pregnancy, and all infected or non-immune (anti-HB levels lower than 10 mIU/mL) pregnant women should be vaccinated against HBV, whether they are at high risk for the virus or not [14].However, 10% of infants of HBV-infected mothers still develop HBV infection despite vaccination and administration of hepatitis B immune globulin (HBIG) [13].Additional measures should be taken for the prevention of MTCT, such as the use of antiviral therapy (lamivudine, telbivudine, or tenofovir) with HBeAgpositive mothers, in addition to the standard infant immune prophylaxis (the first dose of HBV vaccine and HBIG) at birth [15].This will effectively reduce the vertical transmission of HBV and avoid many of its significant future consequences [15].In light of the WHO's effort to achieve the elimination of hepatitis infection by 2030, promoting awareness among the general population as well as high-risk groups such as pregnant women is crucial.Numerous studies have been conducted among pregnant women [6,10,[16][17][18].They found the awareness among pregnant women to be unsatisfactory.Thus, there is a need to take immediate action to control the increase in the prevalence of HBV among pregnant women, provide welfare for the infant, and prevent sequelae of HBV infection.Therefore, this study aims to investigate pregnant Jordanian females' knowledge, attitudes, and practices toward HBV.In addition, to explore the relationship between the level of knowledge, attitudes, and practices toward HBV infection and its predictors.

Materials And Methods
Our cross-sectional study was conducted among pregnant women in Jordan.We enrolled 621 participants between January and April 2023.The target population was reached through Jordan University Hospital, Al-Zarqa Governmental Hospital, Prince Hamza Hospital, Al Bashir Hospital, Princess Rahma Hospital, As-Salt Hospital, and Nadim Hospital.The selection process for the participants was a stratified, cluster sampling technique, ensuring representation from the population that is visiting the health facility in Jordan.Jordan is usually divided into three regions: North, Central, and South, with a high population density in the Central.We selected the main health facility in each region to recruit an equal number of representatives from each health facility to include an equal population from all sociodemographic levels in every region.
After getting ethical permission, we contacted administrators from each institution to help disseminate the questionnaire to eligible individuals.Pregnant women who were attending the gynecology/obstetric clinic were invited to participate in the study.The questionnaire was distributed to all participants via text message, and those who had difficulty accessing the Internet or could not read were invited to in-person interviews.The minimum sample size needed for the study is 385, which was calculated based on 5% marginal error and 50% prevalence.

Questionnaire administration
Eligible participants were invited to participate voluntarily by filling out the questionnaire.The questionnaire was sent to the participants through an online survey link.Informed consent was obtained from all participants.It was explicitly mentioned that participants could withdraw their responses freely at any time.Participants were requested to submit the necessary information to obtain reliable results, but no personal information was gathered.

Measurement tool
Our survey was derived from a previously validated tool that was used to investigate a similar aim as our study [19].The survey was done via Google Forms (Google LLC, Mountain View, California, United States), and it contained questions divided into four main sections.The first section assessed participants' demographics, followed by a knowledge section with 20 items, an attitudes section with seven items, and a practices section with eight items.A pilot test was done on the questionnaire to make sure the questions were clear and comprehensible before being distributed and used.Participants should achieve a score of more than 75% to be considered to have an appropriate level of knowledge, attitudes, or practices.The questionnaire is shown in Appendix 1, 2, and 3.

Ethical considerations
The protocol was established in accordance with the Helsinki Declaration's ethical principles, and it had been reviewed and accepted by the Institutional Review Board (IRB) at the University of Jordan under reference number 0/2022/2506 in meeting no.2022/24.Before completing the questionnaire, all individuals gave written informed consent.The data was collected and processed in an anonymous form before being stored on a personal computer that only the authors have access to.

Statistical analysis
Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, United States) was used to enter the data, which was then imported into IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States) for analysis.For each numerical and categorical variable, descriptive statistics were calculated and reported as frequency and percentage, or mean and standard deviation, respectively.The Chi-square test was used to assess the relationship between demographic factors, knowledge, attitudes, and practices.Multivariate regression analysis was used to evaluate each independent variable after controlling for possible confounders.Each correct response received one point.If a participant correctly responded to 75% of the questions or more in each KAP section, the score was deemed to be good.
If less than 75% of the questions in each section were correctly answered, the participant's score was deemed poor.

Demographics of survey participants
The demographics of the participants are presented in Table 1.Of the total 621 women, N = 299 (48.1%) were between 28-37 years of age, and nearly N = 477 (76.8%) of the participants live in the city; N = 564 (90.8%) of them were of high education.Of the participants, N = 91 (14.7%) had a medical study field.There were nearly equal numbers of employed and unemployed participants.Almost all participants, N = 616 (99.2%), don't have a history of HBV, and N = 537 (86.5%) of them don't have a history of HBV in their family.Their source of knowledge varies between medical N = 126 (20.3%), non-medical N = 311 (50.1%), and never heard of it N = 184 (29.6%).

Associated factors toward knowledge, attitude, and practices toward HBV infection
As shown in Table 4, a significant association was found between knowledge level, practice assessment, and the following variables: age, educational level, job, study field, history of HBV in the family, and source of knowledge.Regarding attitude, a significant association was found with the job, study field, and source of knowledge.

TABLE 5: Logistic regression analysis between demographic characteristics of knowledge, attitudes, and practices toward HBV
OR: odds ratio; CI: confidence interval; P: P-value; NA: not applicable; not included in the logistic regression analysis; * denotes significance

Discussion
This cross-national, multicenter study in Jordan aimed to assess knowledge, attitudes, and practices toward HBV among pregnant women and its predictors.Overall, two-thirds of pregnant women had a low level of knowledge about HBV, especially among those who don't work, have no medical study background, live in a rural area, and have no family history of HBV.This unsatisfactory level of knowledge is consistent with other studies [6,10,17,18,20,21].The majority of respondents were aware of the terms hepatitis and hepatitis B and acknowledged it's a viral disease, which was similar to a study conducted in Saudi Arabia [10], in contrast to another study conducted in Jordan [6].This result could be due to the high socioeconomic status of our participants.Also, we noticed the major gaps in certain areas of knowledge; as reported, in the era of disease presentation, only one-third were aware that it can present with flu-like symptoms or no symptoms at all.In addition, less than half of respondents believe that HBV can cause liver cancer as a long-term complication.Obtaining sufficient disease-related knowledge may allow people to make proper decisions by visiting a doctor immediately when symptoms start and before a complication occurs.Moreover, improving illness awareness would minimize patient worry, increase treatment compliance and satisfaction, and lower treatment costs [22][23][24].
In terms of awareness about the mode of transmission, participants showed average results, in which more than half of them were aware that HBV can be transmitted by unsterilized syringes, contaminated blood products, and the reuse of blades and nose-piercing needles.On the other hand, less than half of them were aware that it can be transmitted vertically from mother to child and through unsafe sex.Surprisingly, only one-fourth of women asserted that HBV can't be transmitted by food or water prepared by a person infected with HBV.This major defect in knowledge of transmission routes was also observed in other studies [10,17,18,20,21].As reported by a study conducted in Turkey, increased knowledge of the disease's transmission is associated with a lower risk of getting hepatitis B. Furthermore, high levels of awareness about the prevention and spread of hepatitis B are important for encouraging testing and identifying people who are affected.
[25] In addition, the majority of the participants claimed that there is a cure for HBV or that it can be cured by itself; this false belief was also reported in a study conducted in China [20].Moreover, 40% of participants underestimated treatment costs.The level of attitudes among the participants is considered moderate, as N = 315 (50.7%) of women had a good attitude towards HBV.This finding is similar to a study conducted in Saudi Arabia [10], however, the attitude was reported to be low in countries like Ethiopia and Vietnam [17,21].
Our study disclosed that most participants would go first to a doctor as soon as symptoms of HBV infection appear, and around three-quarters would like to talk about their illness with their doctors, while the remaining would like to talk with a family member (spouse, parents, or other relatives).In addition, more than half of the participants would feel some sort of stigma if they were diagnosed with HBV, as they would feel shame, surprise, or sadness.Similarly, a study in Vietnam revealed high levels of stigma among pregnant women [17].This level of stigma was reflected in the attitudes of the respondents, as they were worried about being in contact with HBV-infected patients; in fact, around 90% of the participants would go to a healthcare facility as soon as they realized the symptoms of hepatitis B, and a small proportion of them had the fear of being isolated if the diagnosis was confirmed.It is commonly acknowledged that HBV-associated stigma can significantly impact health-seeking behaviors, including screening, prevention, diagnosis, and treatment of HBV [26].Regarding practice assessment, the majority of the participants expressed poor practice measures towards HBV infection.Surprisingly, less than half got vaccinated against HBV, and only one-quarter had done screening for it.Vaccination plays an important role in providing protection and decreasing complications of HBV, as can be seen in Libya and Jordan in a practical sense, where implementing the vaccine decreased the prevalence of the disease from 2.8 to 1.5% [27] and from 9.9% to 2.4%, respectively [28].In our study, only 40% of participants had gotten the vaccine, which was similar to other population groups in Jordan [16].Regarding HBV prevention, participants showed better practices, as they would ask for new equipment during medical procedures, during their visit to the barbershop, or while getting an ear/nose piercing.Around ten percent of the pregnant women had attended an educational program about HBV infection; hence, we need more participation in such programs directed at childbearing age women, as they would be future mothers.
As we noticed, having a high degree of education and employment, as well as getting their information from medical sources, were all associated with higher levels of knowledge and practice.Furthermore, higher education levels may help them land a better job.Thus, the respondent will be able to get information from medical sources by scheduling routine checkups with their doctor.This suggests that there is a complicated link between a person's work situation, education level, and capacity to get reliable medical information about hepatitis B. Unlike what was reported by a Chinese study [20], participants with a family history of HBV infection were noted to have higher levels of knowledge and practice.On the other hand, living in a rural area is a predictor of lower knowledge levels, as found in Ethiopia [21].Also, only those who have a medical background tend to have a high level of attitude.Future public health measures are required to prevent mother-to-child transmission by implementing hepatitis B screening programs.Moreover, it is important to increase the knowledge of HBV among all females of reproductive age, regardless of their socio-economic status, to increase the rate of hepatitis B birth dosage immunization.Raising awareness through programs and interventions could be done accordingly by government officials and pharmaceutical companies.In addition to that, screening programs, free of charge or for a minute fee, should be put in place for all those at risk.This research faces a few drawbacks.As the survey was designed to recruit participants from pregnant women in the general population, whether they are hepatitis B patients or not, it assessed knowledge, attitudes, and practices toward hepatitis B in pregnant women from the general population, with only a small percentage of them having a history of hepatitis B. Secondly, the survey may have a selection bias; this comes from the method of its distribution using mainly online methods, which limited our selection to a population with certain demographics that have access to the internet; furthermore, recall bias was inventible in self-reported questions.Despite the few drawbacks, the importance of our research lies in its targeted population, as it explored the knowledge, attitudes, and practices towards hepatitis B in pregnant females, who are the most important population of hepatitis B patients, as the prevention of its transmission to newborns and developing chronicity with its disastrous outcomes starts with them.

FIGURE 1 :
FIGURE 1: Practice assessment at the University of Jordan, Amman, the Hashemite Kingdom of Jordan reference number: 0/ 2022/ 2506 in meeting no.2022/24.Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

TABLE 1 : Demographics of survey participants
HBV: hepatitis B virus

Table 3
shows the attitudes among participants.Most of the participants, N = 374 (60.2%), denied they could get the disease, and almost half, N = 300 (48.3%), would experience fear if that happened.Almost two-thirds of respondents (N = 473, 76.2%) chose to talk to a physician about their illness, and 516 (83%) would refer to him if they had symptoms.Around N = 561 (90.3%) were willing to go to a health facility as soon as they realized such symptoms.When asked how expensive the treatment is, N = 248 (39.9%) didn't know, N = 75 (12.1%)thought it would be free, and only N = 98 (15.8%) believed it was expensive.Around N = 338 (54.4%) of the participants feared it would spread to their families.

TABLE 3 : Attitude assessment Practice toward hepatitis B virus
asked for a new syringe before use, N = 422 (68%) asked for screening of blood before transfusion, and N = 478 (77%) asked a barber to change equipment.Almost all participants, N = 587 (94.5%), would undergo further investigations in the event of the diagnosis of the disease.Around N = 378 (60.9%) responded to avoiding meeting hepatitis B patients.Only N = 59 (9.5%) participated in health education programs related to hepatitis.

TABLE 4 : Association between demographic characteristics and knowledge, attitudes, and practices toward HBV
* Denotes significance; HBV: hepatitis B virus