Introduction

The hepatitis B virus (HBV) infection is an important cause of morbidity and mortality as it causes both acute-chronic viral hepatitis and complications such as cirrhosis and hepatocellular cancer (HCC). Chronic HBV infection is the cause of more than half of HCCs which represent approximately 75-90% of all primary liver cancers. Besides, the incidence of cirrhosis in patients with untreated chronic hepatitis B is at least 40% (1). In our country, more than half of the liver transplantation cases performed between 2012-2016 were associated with viral hepatitis, especially HBV (2).

The low awareness, especially in the at-risk population that was born before the adoption of vaccination programs, may increase disease burden and death due to transmission and HBV complications (2). In Turkey, one out of three people over the age of 18 are estimated to have been infected with HBV, and it is thought that there are more than 2 million adults with hepatitis B surface antigen (HBsAg) positivity. Only about 12% of these people were found to be aware of their condition (3). In our country, since HBV infection is the endemic and horizontal transmission is prominent, relatives who share the same house with the patients are at risk for transmission. It will be effective to reduce the prevalence of HBV by identifying missing and inaccurate information about HBV in society, especially in patients and their relatives, and increasing the level of knowledge among people, and organizing educational approaches to create attitude and behavior change (4). In our country, it is known that the vaccination rate of the high-risk population is around 5% (4).

This study aimed to evaluate the level of knowledge and attitudes of the first-degree relatives who share the same house with patients in terms of their knowledge regarding disease definition, modes of transmission, risk factors, prevention methods, and consequences of the disease.

Materials and Methods

Study Group

The study included 106 volunteers who were older than 18 years of age and shared the same house with an HBsAg-positive patient to which they were related (first-degree). Only one relative of patients was included in the study group. The patients were admitted to the Ankara Atatürk Training and Research Hospital between 01.06.2014-01.07.2014 and were followed up for a duration of at least one year at our center.

Ethical Issues

This study was approved by the Institutional Ethics Review Committee of Ankara Yıldırım Beyazıt University Faculty of Medicine. The relatives of the patients were informed, and verbal and written informed consent was obtained from them before they took the questionnaire.

Study Instrument

A self-explanatory questionnaire comprising of 24 questions was designed to evaluate and compare the knowledge, attitudes, and awareness of the participants regarding hepatitis B infection. The questionnaires were completed under observation without any intervention. The content of the questionnaire was created by scanning national and international publications and the disease-related questions we received from patients. The questions were open-ended, but in some questions, options were given to determine the views of the participants. The questionnaire was comprised of the following sections:

- Demographics: age, gender, education, socioeconomic status,

- Knowledge of HBV: sources, self-assessment, knowledge items,

- Attitudes and behaviors towards HBV,

- Disease concerns and difficulties.

Statistical Analysis

Statistical analyses were performed using SPSS version 15.0 (SPSS, Chicago, IL, USA). In the study, numerical data were shown with mean and standard deviation, and categorical data were shown with frequency and percentages. Chi-square tests were used for categorical data comparison between independent groups, and the Kruskal-Wallis test was used for multiple group analysis for ordinal data. The internal consistency of the questionnaires used in the study was evaluated with Cronbach’s alpha value. In all statistical analyses, obtaining a p-value <0.05 was considered statistically significant.

Results

Sociodemographic Characteristics

A total of 106 relatives, 63 (59.4%) females and 43 (40.6%) males were included in the study. The mean age of the participants was 40.6±11.8 years.

Awareness

The responses of the participants to the questions that measured their level of awareness are shown in Table 1.

In our study, women were more aware that hepatitis B was an infectious disease affecting the liver (p=0.001) and a contagious disease (p=0.039) than men.

Knowledge Level

The responses of the participants to the questions that measured their level of knowledge are shown in Table 2.

Women had more information about the risk of transmission to relatives (93.7%, p=0.012), protection methods (vaccination: 100%, p<0.001; separation of personal items with blood contact: 95.2% p=0.002), complications (death: 49.2%, p=0.015; liver transplantation 31.7%, p=0.023) and treatment purpose (stopping viral replication: 76.2%, p<0.001), while men had higher rate of the misinformation that hepatitis B could turn into hepatitis C spontaneously (93%, p<0.001). Participants under the age of 30 were more aware that hepatitis B was an infectious disease (86.4%, p=0.004) and could be transmitted through vertical (100%, p=0.001) and sexual transmission (72.7%, p<0.001).

The knowledge that inactive carriage was contagious and required follow-up was greater in those under 30 and over 50 years of age (100%, p=0.001). All participants over the age of 50 knew that treatment aimed to stop viral replication (p=0.003), and the disease could cause cirrhosis (p=0.007). Persons with higher education had more knowledge about the aim of reducing viral replication through treatment (69.1%, p=0.01) and stopping the progression of disease (81.8%, p=0.017). Also, they were more knowledgeable about the sexual transmission (using condoms: 56.4%, p=0.001; single partner sexual activity: 49.1%, p=0.012), when compared to those with lower education.

Sources of Information

Although the most common source of information was physicians for all groups, the rate of those who applied to the internet for information was higher in the group under 30 years of age (59.1%, p<0.001) and with a high level of education (38.2%, p=0.001) (Table 3).

Attitudes and Behaviors

The responses of the participants to the questions that measured their attitudes and behaviors are shown in Table 4. The rate of those who had HBV screening was lower in the group with higher education level (p=0.002).

Discussion

HBV infection is a global public health problem. In our country, vaccination and education studies in the prevention of infection are important since HBV infection is the endemic and horizontal transmission is prominent (5). This study aimed to measure the knowledge level of respondents concerning HBV infection and to determine their risk perceptions and attitudes. The patients in the study were followed by our clinic for more than a year. When the answers given to the questions measuring the level of knowledge about HBV were examined, 76.4% of the participants knew that hepatitis B was an infectious disease affecting the liver and 84.0% knew that inactive carriage could be seen. In a similar study conducted by Şenol (6) with the relatives of people with chronic hepatitis B in İstanbul, 90.4% of the participants stated that HBV was an infectious disease, 94.2% of them stated that inactive carriage could be seen, and 80.8% of them stated that the carriers could transmit the disease to others (6). In another study conducted by Poyrazoğlu et al. (7) in Kayseri, 41.1% of relatives stated that hepatitis was a liver disease and an infectious disease, while 61.6% of them stated that the carriers could transmit the disease to others.

It is known that 15-20% of chronic hepatitis B cases may progress to icterus and HCC (8,9). In our study, 90.6% of the participants knew that the complications could lead to icterus, 45.3% to HCC, 41.5% to liver transplantation, and 39.6% to death. In the study of Şenol (6), they found that 82.7% of the relatives knew that hepatitis B could cause icterus and HCC. In the study of Poyrazoğlu et al. (7), 93.8% of the relatives of patients (patients with hepatitis B and C) stated that hepatitis could cause icterus and 39.3% of them stated that the disease could cause cancer. In a study conducted by Cheung et al. (10) with Chinese and Southeast Asians living in Canada, 68% of the participants were aware of HBV while more than 60% did not know the relationship between HBV and icterus or cancer. Our study and other studies conducted with relatives of patients showed that the level of knowledge about complications was higher in relatives than in the general population. The reason for this can be that relatives of patients have more information about hepatitis B due to various concerns including their own health.

While 90.6% of the patients’ relatives had undergone screening tests, only 49.1% of them received the vaccination, even though 89.6% of the participants had knowledge about the protective effects of vaccination. Similar to our study, in the study of Şenol (6), it was found that 32.7% of the people who should be vaccinated against HBV had not applied for vaccinations. It is rather interesting to see that, even though the importance of vaccination is so well understood, a significant proportion of individuals choose not to get vaccinated-despite being at high risk for transmission. In the study conducted by Bulut et al. (11), the percentage of individuals completing the HBV vaccination schedule was 63.3%, and 12.1% of individuals did not even begin vaccination. In the same study, it was found that compliance with the vaccination schedule increased statistically with age (11). When the reasons for people not getting vaccinated were examined, the most common reasons were indifference, negligence, and lack of information (12). The vaccination rates of the risky population in our country are estimated to be around 5%-an alarming figure by any standard. Therefore, it is important to organize training and educational approaches that encourage vaccination in both health professionals and at-risk groups (4).

In Turkey, in studies investigating the level of HBV-related information, it has emerged that there is an insufficient level of knowledge. Gökmenoğlu et al.’s study of dentistry students, an important risk group, showed that the level of knowledge was insufficient (1). However, in the same study, it was shown that the level of knowledge is better in the advancing classes with awareness and education studies. Again, in a study conducted by Özen in our country, it was reported that the level of knowledge is not sufficient even in hepatitis carriers (2). In reports from various underdeveloped countries, it has been observed that the level of knowledge and awareness of HBV in dental healthcare professionals (3), pregnant women (4), and healthcare professionals (5) are not sufficient. However, it is seen that all these deficiencies can be increased with various training programs and awareness programs. In our study, even in a group that is expected to have a high level of awareness about the disease, the insufficient level of knowledge shows that it is important to keep people informed about the issue. 

Study Limitations

The limitations of our study are the relatively small number of patients, the fact that the questions were answered based on self-reporting, and the validity and reliability analysis of the questions asked were not performed. The other important limitation is that the data in the current study is relatively old and the statements and comments could be changed over time.

Conclusion

According to the findings of our study, the relatives of patients with HBV seem to have incomplete information about hepatitis B, while vaccination rates were found to be low. It is suggested that health professionals should give more importance to the education of patients and their relatives, especially during patient follow-up. In the fight against HBV infection, informing the whole society, especially patients with HBV and their relatives, about transmission routes and prevention of HBV transmission are vital. Our study is important because it is the first relatively large-scale study conducted with patient relatives in our country. However, multicenter studies with higher patient counts are needed to identify deficiencies in the society about hepatitis B, in order to address the lack of knowledge in the community and to provide education that will lead to behavioral changes.

Ethics

Ethics committee approval: This study was approved by the Institutional Ethics Review Committee of Ankara Yıldırım Beyazıt University Faculty of Medicine.

Informed Consent: Informed consent was obtained from them before they took the questionnaire.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: A.K.K., İ.H., M.A.T., Concept: A.K.K., R.G., M.A.T., Design: A.K.K., R.G., M.A.T., Data Collection or Processing: A.K.K., G.R.Y., R.G., Analysis or Interpretation: A.K.K., İ.H., M.A.T., Literature Search: A.K.K., İ.H., M.A.T., Writing: A.K.K., R.G., F.E., İ.H., G.R.Y., M.A.T., Final approval: A.K.K., R.G., F.E., İ.H., G.R.Y., M.A.T.

Conflict of Interest: The authors declare no conflict of interest.

Financial Disclosure: The authors declare that this study has not received any financial support.