Introduction

Healthcare workers (HCWs) are susceptible to hepatitis B virus (HBV) infection from infected patients, and HBV-infected HCWs have the potential to infect patients (1). HCWs constitute one of the high-risk groups for this infection because of their repeated exposure, and contact with the body fluids of an infected person is one of the principal modes of transmission of HBV (2). HBV is highly infectious, can be transmitted without visible blood, and remains infectious on environmental surfaces for at least seven days (3). Acute HBV infection can result in chronic hepatitis, which can cause liver cancer, cirrhosis, liver failure, and even death. Guidelines for managing chronic HBV infection in children and adults, including disease monitoring and antiviral therapy, are available (1). In a study conducted by Kermode et al. (4) among 2 million HCWs worldwide, there was a 10-fold higher risk of contracting HBV due to occupational exposure. HCWs in developing countries are at serious risk of infection from blood-borne pathogens, especially in endemic areas such as Sub-Saharan Africa (5). The World Health Organization and the Centers for Disease Control and Prevention (CDC) advise that all HCWs receive an HBV vaccination before beginning their clinical attachments while in medical school as part of occupational safety measures (6). The low level of vaccination and high prevalence of hepatitis B surface antigen found in various studies may be explained by HCWs’ lack of knowledge about the transmission route of HBV (7). Several African studies have evaluated the knowledge, attitude, and practice (KAP) of HCWs toward HBV and their vaccination status, showing that KAP by HCWs toward HBV infection is generally inadequate in most developing countries (8). While health-related behaviors are affected by different aspects of KAP, few studies have examined the KAP level of HCWs toward HBV infection in Libya. A study was carried out by Elzouki et al. (9) to determine the prevalence of hepatitis B and hepatitis C among HCWs in five major hospitals in eastern Libya between July 2008 and June 2009. The samples of 601 HCWs were tested to analyze how the risk of HBV and HCV infections is affected by the type of occupation, place of work, working period, and vaccination status. Overall, 52% of HCWs reported receiving full vaccination doses (three doses) against HBV infection. The study explored that HBV vaccines could be provided to HCWs in Libya by scaling up the current vaccination program and implementing the policy of HBV immunization in every healthcare setting as recommended by the CDC.

Materials and Methods

The study was conducted at the Benghazi Medical Center (BMC). A descriptive case study with a self-administered questionnaire was conducted at BMC from August to November 2021. Only the medical and assistant medical staff were included (1029 medical staff and 940 assistant staff).

The sample size was calculated using Epi Information 7 with a 5% margin of error, 95% confidence interval, and 80% study power for the population (1,969). The sample size was 322 (168 medical staff and 154 assistant staff). The questionnaire was adapted from pretested questionnaires used in previous studies. This self-administered questionnaire comprised 44 closed-ended questions divided into four parts. The first part consists of five questions about demographic characteristics and vaccine state (q1-q5); the second part consists of twenty-two questions to assess knowledge regarding HBV infection (q6-q27); the third part consists of thirteen questions investigating the attitude toward HBV infection (q28-q40); and the last part consists of four questions examining the practices of HCWs (q41-q44). A pilot study was conducted on 15 HCWs in BMC to determine the reliability and internal consistency of the KAP questionnaire (10).

The study was approved by the Libyan Authority For Scientific Research (approval number: 2529/22). Permission was obtained from BMC management. Verbal consent was obtained from healthcare workers after the purpose of the study was explained.

Statistical Analysis

The data from the completed questionnaires were coded and analyzed using SPSS version 23. Using a five-point Likert scale, from strongly agree to strongly disagree. Responses that included “agree” and “strongly agree” were coded one if they were the correct answer; otherwise, they were coded 0. Likewise, responses of “disagree” or “strongly disagree” were coded one if it was the correct answer and else coded 0. Correct answers were added to give total KAP scores. A significance test, such as a One-Way ANOVA, was used to examine the difference in mean between the professional groups. The significance level was set at 5% (p≤0.05). A post-hoc least significant difference (LSD) test was used to examine the least significant difference among the types of professions that were compared between them. The reliability and internal consistency analysis was performed using Cronbach’s alpha coefficient, and the validation analysis was performed using the Content Validity Index (11). Pearson’s correlation analysis was used to find a relationship between KAP.

Results

Table 1 shows the respondents’ sociodemographic characteristics. Of the 322 questionnaires distributed, 317 were completely filled out and collected, for a response rate of (98.4%). Table 2 describes the correct responses to the knowledge questions about the prevention of HBV by HCWs. For the questions “HB can be prevented by avoiding food not well cooked”, and “HB can be prevented by avoiding drinking contaminated water” overall, correct responses to these questions from all HCWs were (41.3%) and (48.3%), respectively, which means poor knowledge. Table 3 provides details of the attitude questions and the positive responses by profession. For question “Do you avoid patients diagnosed with HB?” had 53.8% responded by medical doctors, 42.4% by lab technicians, 33.8 by pharmacists, 32.9% by nurses, and 21.7% by health attendants, which means they had a poor attitude about this point. Although the HBV vaccine is mandated for HCWs, 49% reported that they have received the vaccine, 33% not received and 18% are unsure if they have received the vaccine.

Table 4 provides details of the practice questions and the percentage of respondents with good practice responses by profession. In general, most HCWs had good practices for preventing HBV. Table 5 shows the descriptive statistics for the total KAP score with the type of profession. The overall mean knowledge score for all HCWs was 14.8 (95% CI: 14.4-15.3) which means poor knowledge, while the overall mean attitude score for all HCWs was 9.2 (95% CI: 8.9-9.5) which means a good positive attitude. The overall mean practice score for all HCWs was 3.5 (95% CI: 3.4-3.6) which means good practice.

The result of the P value from a One-Way ANOVA test in terms of KAP scores is described by a post-hoc (LSD) test in Table 6a, b, c.

In Table 7, the correlation between knowledge score and attitude score was moderately positive, with a statistically significant value of 0.000; this means that as knowledge score rises, so does attitude score, with moderate correlated power. While the correlation between knowledge score and practice score was positive with a statistical significance of 0.000, this means that as knowledge score increases, practice score increases with weakly correlated power. Moreover, the correlation between attitude score and practice score showed a weak positive relationship with a statistical significance of 0.000, which means that when attitude score increases, practice score also increases, with a weakly correlated power.

Discussion

Our study showed a gap in knowledge about HB infection among HCWs; the overall knowledge of HCWs about HB infection was 67.9%. Another study in Khartoum (12) showed that doctors have the highest KAP, which is very close to our study and lower than the 76.9% reported in Nigeria (10). However, the answers to some questions revealed a lack of knowledge, such as the fact that 44.5% of participants were unaware that HBV could not be transmitted feco-orally and 23.3% did not know that the virus is not transmitted through drinking contaminated water. In addition, 51.7% were unaware that the virus could not be prevented by avoiding drinking contaminated water, and 58.7% wrongly thought that HBV could be prevented by avoiding food that is not well cooked, which is less than the 63.2% reported by another study in Nigeria (10). On the other hand, 70.3% of the percentage is large compared to that reported by Samuel et al. (13), who showed that only 14.2% and 9.3% incorrectly identified the feco-oral route and drinking contaminated water as means of transmitting the virus, while 6.2% and 3.1% incorrectly thought that HBV can be prevented by avoiding contaminated water and food that is not well cooked. In our study, 80% of participants said that HBV can cause liver cancer and cirrhosis, which was inconsistent with other studies in Kabul, Afghanistan (8), where 88.24% of participants said it can. This study found that 73.8% of participants completed the HB vaccination schedule, which was lower than the 100% completion rate reported by Kumah et al. (14). Knowledge regarding preventive measures plays a role in the control of HBV. Overall, these results suggest that more knowledge is necessary when providing health education to HCWs, which is typically the first step toward risk reduction and an improvement in the quality of life. In our study, 33.8% of respondents were unsure about the safety of the HBV vaccine, which is lower than the study in Northern Vietnam (15), but higher than the 92.1% reported in Saudi Arabia for HBV vaccine safety. 27.1% of participants did not know the risk of contracting HBV by virtue of their work, unlike studies done in Saudi Arabia. 20.2% and 20.8% of respondents felt they did not need to be protected from hepatitis B infection (12). These HCWs were less likely to take HB infection control and prevention measures seriously because they thought they were not at risk of HB infection. 18.9% of participants were unaware of their HBV status, 20.8% had received the hepatitis vaccine, and 73.80% of HCWs were vaccinated, compared with 50.4% of respondents who did not know their HB status (14). Regarding practice toward HB preventive measures, 16.7% of respondents did not wear gloves when conducting procedures; this percentage was less than that in a study conducted in Kabul (62.55%) (8). Another study conducted in Sudan reported a much higher percentage of 92.8% (14). In our study, 90.5% of respondents said they properly disposed of sharps after use. However, overall correct responses to practice from all HCWs were 87.3% “good practice”, may be due to the data collected during the coronavirus disease-2019 (COVID-19) period, where HCWs underwent extensive infection control training. Regarding HBV vaccine status among HCWs, this study found that 49% of respondents among 317 participants had received an HBV vaccine, which is very similar to Japan’s rate of 48.20% (16). 18% of respondents are unsure if they have received the HBV vaccine, and 33% report that they have not received it. A study by Daw et al. (17) aimed to determine the prevalence of HBV markers among HCWs, investigate some risk factors for such prevalence, and outline specific policies to address these issues among HCWs. The study concludes that HBV vaccine, education, clinical advice, and health insurance should be available for HCWs who are at a higher risk of HBV infection (17).

Study Limitations

To prevent respondents from discussing their answers with others, the questionnaires were completed in the presence of the researcher. Only medical staff and medical assistant staff were involved in the study; other BMC staff such as security staff and administrative office staff were not involved.

Conclusion

This study found that the knowledge of HCWs at BMC about HBV is inadequate. The majority of the staff had poor knowledge responses, a positive attitude, and good practices for preventing HBV. The rate of vaccination indicates the risk, and the main reasons that led to its occurrence were that HCWs were not vaccinated because of a lack of knowledge about vaccination. HCWs who were not vaccinated needed to implement an HBV vaccination program.

Ethics

Ethics Committee Approval: The study was approved by the Libyan Authority For Scientific Research (approval number: 2529/22).

Informed Consent: Verbal consent was obtained from healthcare workers after the purpose of the study was explained.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: A.E., Design: A.E., R.G.O., Data Collection or Processing: R.G.O., Analysis or Interpretation: A.E., R.G.O., Literature Search: A.E., A.B.E., R.G.O., Writing: A.E., A.B.E., R.G.O.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declare no financial support.