Attitudes of Health Workers Towards Management of Hepatitis B Infection in General Hospitals in Kwara State, Nigeria

Hepatitis B is one of the most dangerous diseases in the world and it has become a serious threat to public health. Health workers are mostly at risk of contracting the disease as they remain the first point of call to the victims. This study examined the attitudes of health workers towards management of HBV infection and the difference in attitudes of health workers based on area of specialization . An ex-post facto research design sampling 412 health workers across different areas of specialization which include doctors, nurses, laboratory scientists and laboratory technicians . Majority of the health workers had negative attitudes towards HBV patients. However, doctors (mean score=3.72) and nurses (mean score=3.54) had mild negative attitudes towards HBV patients, while laboratory scientists (mean score=3.02) and laboratory technicians (mean score=3.04) had the poorest attitudes towards HBV patients . There is need to improve the attitudes of the different cadres of health workers in the state, in order to improve the quality of life of HBV patients and reduce stigma which may impact negatively on patients’ mental health.


INTRODUCTION
The burden of exposure to blood-borne pathogens such as Hepatitis B Virus, (HBV) cannot be overemphasized among health workers.Percutaneous exposure to blood-borne infections from infected needles, scalpels, broken glasses, ends of dental wires, or other sharps is relatively high among health care workers.Health workers (HWs) are faced with the unique challenge of protecting themselves and the general population from these blood-borne infections.According to [1] HBV transmission requires a non-immune host, a contaminated source and skin or mucous membrane injury.These three aspects are the main fields for prevention interventions against the infection.Transmission of HBV from patients to HWs has been known for many years.However, the roots of transmission have not been recognized completely [4].Findings from case studies conducted in several European countries including France, Italy, Spain, United Kingdom and Switzerland showed that HBV transmission among HCWs was significantly correlated with factors such as the type of procedure, severity of injury and the gender of the HWs.Contact with patients whose viral loads were high also increased the transmission risk 11 folds compared to a lesser viral load [11].
It is worthy of note that discriminatory behaviour and attitude is common towards patients with hepatitis B infection due to the highly infectious nature of the infection.Attitudes are directly under the influence of knowledge levels; therefore, it is necessary to increase the level of understanding of the disease management strategies in order to bring about positive attitudes among the healthcare workers to prevent discrimination and prejudice towards the infection and the patients [10].A study found that attitude and self-reported behaviour scores were similar among the professional groups except dentists who were more negative overall [9].Self-reported compliance with infection control guidelines indicated that HWs often treated patients with hepatitis differently from other patients to prevent hepatitis transmission.For example, 79 per cent believed people with hepatitis should be identified for safety reasons.Several participants indicated that they identified patients with hepatitis by placing alert notes in their medical files.Forty-eight per cent of participants indicated that they used additional infection control precautions when they knew patients had hepatitis.For example, 60 per cent of them double gloved when they treated a bleeding person with hepatitis.Responses to the open questions suggested that HPs used additional precautions to reduce their risk of exposure to infectious blood.Another study regarding hepatitis B and C revealed that HWs who were weak in knowledge were more Attitudes of the clinician play a key role in prevention of spread of infection [8].A study on assessment of knowledge, attitudes and practices of HWs including, dental interns, medical interns, and nursing interns in Odisha revealed negative attitudes of HWs, however, those who were knowledgeable were more likely to show positive attitudes [12].Regarding attitude statements it was found that, 95.8 per cent of the HWs surveyed believed that hepatitis patients should be identified for infection control purposes, 82.8 per cent of the participants indicated that they used additional infection control precautions when they knew patients had hepatitis, 74.4 per cent double-gloved when they treated a bleeding person with hepatitis.48.5 per cent of the participants indicated that patients with hepatitis C should be given the last appointment of the day.Among the HCWs, 92.1 per cent felt compassion when hepatitis was acquired through a blood transfusion, compared with 55.6 per cent when it was contracted through injection drug use.Participants' willingness to care for people with hepatitis was identified by responses to three questions [3].Among HWs, 82.8 per cent believed that they liked to treat these patients and 15.5 per cent said that they did not like treating these patients.Regarding attitudes toward intravenous (IV)-drug users, 78.7 per cent showed fear toward IV-drug users, while 77 per cent said that they were worried they might contract a disease from the patients.35.6 per cent agreed that IV-drug users deserved the disease and 40.2 per cent indicated that they did not want to treat IV-drug users [3].Studies on occupational exposure and infection control among healthcare workers in Nigeria have been conducted predominantly among dental professionals in south-western Nigeria and also among dental students [6].The physiological and psychological differences between the sexes reflect in their health behavior and are also characterized by gender differences in the prevalence of certain kinds of occupational hazards [8].In a study on attitudes towards hepatitis B infection among healthcare students in a private medical college in Odisha, it was revealed that attitude toward hepatitis B infection were higher in MBBS students than in dental and nursing students, whereas behavior of dental students toward the disease was quite satisfactory than MBBS and nursing students [7].Much work has been carried out to assess occupational exposure and compliance with infection control practices among the healthcare professionals.However, there is paucity of data on the assessment of attitudes of HWs in Kwara State towards HBV infection in the literature [2].
There is paucity of literature on attitude towards Hepatitis B management among HCWs in Kwara State, so there is no evidence to show that HCWs in the state have positive attitudes to the management of the infection.Some of the HCWs may also not be abiding by the guidelines for prevention of hepatitis B transmission which is directed towards prevention of transmission of the infection from patients to HWs in order that HWs may have positive attitude towards their patients.Since attitude of HWs will go a long way in the prevention of hepatitis B virus transmission and reducing stigmatization of patients suffering from the infection, the researcher carried out a study on assessment of HCWs' attitudes toward management of hepatitis B infection in general hospitals in Kwara State.The study answered the following questions; i) What is the attitude of health workers towards the management of hepatitis B infection in general hospitals in Kwara State?ii) Is there any difference in the attitude towards HBV infection among health workers in Kwara State, Nigeria based on cadre?The study also tested the following hypothesis; there is no significant difference in the attitude of healthcare workers towards the management of hepatitis B infection based on cadre in general hospitals in Kwara State?

METHODS
The design for this study is an ex-post facto research design.All healthcare workers in general hospitals in Kwara State, Nigeria was the target population for this study.Specifically, doctors, nurses, laboratory scientists, and laboratory technicians were used for the study.According to Kwara State Ministry of Health (2019), there were eight hundred and twenty-four (824) health personnel in general hospitals in Kwara State, Nigeria as at the time of this study.Four hundred and twelve (412) respondents which amounts to 50% were used for the study.The sample was selected using a multi-stage sampling technique.The study area was stratified into the three existing senatorial districts of Kwara Central, Kwara North, and Kwara South.Simple random sampling was used to select two general hospitals from each senatorial district with the use of simple random sampling technique, while doctors, nurses, laboratory scientists, and laboratory technicians were randomly selected using systematic sampling to select every 3rd personnel as they were arriving at the hospitals.A researchers structured questionnaire tagged Questionnaire on Attitude Towards Hepatitis B infection among Health Workers (QATHBIHW) was used for the study.Three experts in the field of Health Education validated the instrument.The instrument was administered on the respondents at the selected hospitals on daily basis.Consent of the respondents was sought at an appropriate section of the instrument.Respondents who declined were exempted from the study.The data was analysed using a descriptive statistical tool of bar chart, frequency counts and percentages to analyse the demographic characteristics of the respondents and answer the research questions raised for the study.While ANOVA was used to test the hypothesis se for the study at 0.05 alpha level of significance.

RESULTS
This is because, 400 (97.1%) of the respondents believed that every patient that comes to the hospital should be tested for HBV before they receive health care, 398(96.6%)felt that patients with HBV infection should always be given the last appointment for the day, 412(100%) believed that healthcare workers who are HBV positive should not be allowed to give health care services to patients.350 (85.0%) will be willing to manage HBV patient any time they seek for treatment.Again, 375 (91.0%) always felt worried that they might contract the disease from HBV patients any time they are around them.412 (100%) agreed that, more occupational diseases prevention programme should be organized in order to reduce HBV infection among healthcare worker, 250 (60.7%) always feel that HBV vaccines are not potent enough to prevent them from contracting the infection.403 (97.8%) have more sympathy for people suffering from HBV infection, 412(100%) expressed that an alert note should be placed in the case file of an HBV patient so that they will quickly know how to be extra careful when treating such patient.However, only 40(9.7%) often have some kind of hatred towards HBV patients, 4(1.0%) of the respondents think stigma should be attached to HBV patients.Furthermore, 395(95.9%) of the respondents do not find it difficult to hug HBV patients, while 405(98.3%%)would like to get their patients tested before giving any serious attention to them.However, 390 (94.7%) disagreed that testing outpatients for HBV is not necessary.Table 2 show that doctors have better attitudes (3.72±0.427)towards HBV infection compared to their nurses' counterparts (3.54±0.403).Poor attitudes are reflected among laboratory scientists (3.02±0.403)while the poorest attitude (3.04±0.387)was found among the laboratory technicians.This implies that the health workers differ in their attitudes towards Hepatitis B infections based on area of specialization.This may be as a result of doctors being at the highest level of health workers and they seem to be the first point of call for hepatitis B patients.Table 3 shows that the calculated value is 752 while the critical F-value is 0.99.The significant F-value is 0.10 which is greater than 0.05 alpha level.This implies that the attitude of health workers towards HBV infection is significant.

DISCUSSION
Health workers in Kwara State Nigeria were found to have significantly poor attitude towards HBV infection at the general hospital in the State.
It is important to note that, attitudes of health workers play a key role in prevention of spread of infection and mental health of patients.This finding is in line with a study on assessment of knowledge, attitudes and practices of HWs in Odisha, which revealed that, dental interns, medical interns, and nursing interns are likely to show negative attitudes and those who were knowledgeable were more likely to show positive attitudes [10].Regarding attitude statements, another study found that 95.8 per cent of the HWs surveyed believed that hepatitis patients should be identified for infection control purposes, 82.8 per cent of the participants indicated that they used additional infection control precautions when they knew patients had hepatitis, 74.4 per cent double-gloved when they treated a bleeding person with hepatitis.48.5 per cent of the participants indicated that patients with hepatitis C should be given the last appointment of the day [10].Among the HWs, 92.1 per cent felt compassion when hepatitis was acquired through a blood transfusion, compared with 55.6 per cent when it was contracted through injection drug use.Participants' willingness to care for people with hepatitis was identified by responses to three questions.Among HWs, 82.8 per cent believed that they liked to treat these patients and 15.5 per cent said that they did not like treating these patients.Regarding attitudes toward intravenous (IV)-drug users, 78.7 per cent showed fear toward IV-drug users, while 77 per cent said that they were worried they might contract a disease from the patients.35.6 per cent agreed that IVdrug users deserved the disease and 40.2 per cent indicated that they did not want to treat IV-drug users by [13].Doctors were also found to have better attitudes towards HBV infection compared to their nurses' counterparts.This shows that, a negative attitude was reflected among laboratory scientists and laboratory technicians.This implies that the health workers differ in their attitudes towards Hepatitis B infection based on area of specialization.This finding is further explained by the findings of a study which revealed that in Pakistan, doctors had experienced the most injuries, while blood collection was the activity that accounted for most of their exposure to blood-borne microorganisms.In addition, majority of HCWs had been exposed to blood at least once.Needle recapping after administering intravenous injections and line was responsible for most of the finger injuries among them [12].Previous study opined that it is worthy of note that discriminatory behaviour and attitude is common towards patients with hepatitis B infection due to the highly infectious nature of the infection.Attitudes and practices are directly under the influence of knowledge levels; therefore, it is necessary to increase the level of understanding of the disease management strategies in order to bring about positive attitudes among the healthcare workers to prevent discrimination and prejudice towards the infection and the patients [10].However, another study found that attitude and self-reported behaviour scores were similar among the professional groups except dentists who were more negative overall.Selfreported compliance with infection control guidelines indicated that HWs often treated patients with hepatitis differently from other patients to prevent hepatitis transmission.For example, 79 per cent believed people with hepatitis should be identified for safety reasons [9].Several participants indicated that they identified patients with hepatitis by placing alert notes in their medical files.Forty-eight per cent of participants indicated that they used additional infection control precautions when they knew patients had hepatitis.For example, 60 per cent of them double gloved when they treated a bleeding person with hepatitis.
Responses to the open questions suggested that HWs used additional precautions to reduce their risk of exposure to infectious blood.The findings of this study are a little bit surprising because, health workers are generally assumed to have better attitudes towards the management of HBV as they have more knowledge of how to prevent its transmission without prejudice or stigmatization of the victims.

CONCLUSION
It was concluded based on the findings that, health workers in Kwara State, Nigeria generally have negative attitudes towards the management of hepatitis B infection.Moreso, doctors have better attitudes towards the management of HBV infection, followed by nurses, laboratory scientists and laboratory technicians respectively in Kwara State, Nigeria.Hence, there is need to improve the attitudes of the different cadres of health workers in the state, in order to improve the quality of life of HBV patients and reduce stigma which may impact negatively on patients' mental health.

Recommendations
Based on the conclusions drawn from this study, the following recommendations were made; health workers in Kwara State, Nigeria should try as much as possible to prevent themselves from being infected by getting vaccinated against the virus by using surgical gloves while dealing with patients, avoiding needle-stick injuries and take all other preventive measures available so as to make them have better attitudes towards HBV infections.Moreso, health workers in Kwara State, Nigeria should be trained and retrained by health educators, superior officers, and non-governmental organizations, in form of workshop and seminars on transmission of HBV infection and importance of not stigmatizing their patients while managing HBV infections.They should be able to prevent themselves from getting infected while giving quality services and support to HBV patients.

Limitations
The data retrieved did not include years of experience of the clients and as such, limited the researcher's ability to determine if health professional with higher years of experience would have better attitudes towards HBV management.

Conflict of interest
There is no conflict of interest on this study.

Author Contributions
Q.O.Abdulrasaq, is the lead author, who was involved in planning, execution, and data collection.A.M. Abdulraheem is the corresponding author and assisted in the data collection and editorial.J.O. Abdulqudus played a role key role in writing significant portions of the paper and served as research assistant.T.K. Ijaodola assisted data collection.K.A. Jidda also assisted in editorial and data collection.While, M. Onobumeh implemented, and edited a significant section of the paper.All the authors individually contributed to the article and gave their approval to the submitted version.