Background
Globally, Africa has the second highest burden of hepatitis B virus (HBV) after Asia [
1]. While the risk of perinatal transmission of HBV is lower in Africa compared to Asia, it remains an important mode of transmission in Africa [
2]. Estimates indicate that nearly 370,000 newborns are perinatally infected with HBV, annually [
2]. Without interventions, 70–90% of infants born to HBV-infected mothers with high viral load and/or hepatitis B e antigen are at risk of being infected [
3,
4]. Prevention of mother-to-child transmission (PMTCT) of HBV is important, given that 80–90% of infections acquired in infancy lead to a chronic infection later in life, as opposed to 5% of infections acquired in adulthood [
5,
6].
The availability of effective preventive interventions, including active and passive infant immunization and peripartum antiviral maternal prophylaxis [
7], underpins the effort to eliminate HBV as a major public health threat in the African region, with impact targets of reducing incidence of chronic HBV and HBV-related deaths by 90% and 65%, respectively by 2030 [
8]. As part of the interventions for the PMTCT of HBV, the World Health Organization recommends early HBV screening for all pregnant women in settings with an HBV prevalence of ≥ 2% [
9]. However, as of 2021, only 17 (36%) of the 47 countries in the WHO African region had national policies for antenatal HBV screening [
10].
Nigeria has one of the largest burdens of HBV infection in the world [
1]. With a prevalence of > 5% among pregnant women [
11,
12], the country has adopted routine antenatal HBV screening in line with its plan to eliminate vertical transmission of HBV [
13,
14]. However, the screening rates remain suboptimal, particularly in primary healthcare centers (PHCs) [
15] where a significant proportion of women in rural areas access antenatal care. In a study that assessed the antenatal HBV screening rate among 2.8 million pregnant women who received antenatal care in health facilities providing PMTCT of HIV services in Nigeria, only 7% of the pregnant women were screened for HBV [
16]. Similarly, among 643 pregnant women in Oyo State, Nigeria, a study reported that 20% had ever been screened for HBV infection and 9% had received screening in the index pregnancy [
15].
Despite the burden of HBV among pregnant women in Nigeria, there is a paucity of data on the factors affecting antenatal HBV screening. Improving the HBV screening rate among pregnant women will require an understanding of the limiting factors, which are likely to operate at patient, providers, community, and/or the healthcare system levels [
17,
18]. The objective of this study was to identify the barriers affecting antenatal HBV screening in PHCs in Nigeria from the perspective of health workers.
Discussion
In this study, we assessed health workers’ perspective on the barriers to HBV screening of pregnant women accessing antenatal care in PHCs in Nigeria. The perceived barriers exist at patient, provider, and health system levels. They included: lack of test kits, unaffordability of HBV test, shortage of trained personnel, poor awareness and knowledge of HBV, and unavailability of treatment and prevention interventions for HBV. The recommended solutions to the identified barriers were: making test kits and vaccines available and free, creating awareness about HBV, and capacity-building interventions for health workers.
Antenatal care is an important entry point to identifying women with HBV and preventing perinatal transmission. However, among the few pregnant women receiving antenatal care in Nigeria, many are not screened for HBV. Our findings suggest that some of the missed opportunities for antenatal HBV screening in PHCs are health system related. The unavailability of basic equipment or health commodities that are needed for the provision of universal health services is a common occurrence in PHCs in Nigeria [
20‐
22]. For example, in a survey of 2480 PHCs from 12 states in Nigeria’s six geopolitical zones, a study reported that only 10.4% of the facilities had HBV vaccine. Moreover, most PHCs, particularly in rural areas, do not have the minimum recommended number of staff and cadre [
22‐
24], thus limiting the scope of work and impacting the quality of services rendered. Although primary healthcare is described as the bedrock of the Nigerian healthcare system, underfunding and poor governance have affected its optimal functionality [
20,
25,
26].
The respondents also identified the high costs of the HBV screening test and treatment as limiting factors to providing screening services to pregnant women. As in many African countries [
27], HBV screening of pregnant women is not freely available in many health facilities in Nigeria as a result of the limited donor and government support for HBV prevention and control [
28]. Even where antenatal care services are free, such screening tests may not be covered, if the kits are not provided by the government. Depending on the location, the HBV screening test in PHCs may cost $3 to $5. In a country where many people live below the poverty line, such amounts may be unaffordable to some individuals [
28]. Although the national health insurance scheme covers HBV screening test for pregnant women [
29], the health insurance coverage remains very low at 3% [
30] and many women still pay out-of-pocket for antenatal services. Similarly, in the absence of a national program for free or subsidized antiviral drugs, the cost of treatment of HBV has remained prohibitive [
31].
A common view also expressed by the respondents was the HBV knowledge gap. Indeed studies have reported poor knowledge of HBV among pregnant women [
15,
32] and health workers [
33‐
35] in Nigeria. Notwithstanding the high burden, HBV has received limited awareness campaigns compared with an infectious disease such as HIV. This may be responsible for the ignorance among pregnant women noted by the respondents. Myths and misconceptions from lack of knowledge may affect the demand and uptake of HBV screening test. Poor awareness may also be associated with low-risk perception and the perceived need for screening by pregnant women and health workers. While there is a need for a mass campaign about HBV screening, incorporating it into routine antenatal counselling may improve knowledge and facilitate the uptake of screening among pregnant women. This will also require strengthening the capacity of the health workers to provide such services.
Our findings, although limited to health workers, are consistent with previous studies in low-income countries that have identified lack of test kits, high cost of testing and treatment, limited public awareness, and a paucity of skilled health providers as barriers to HBV screening among pregnant women and other populations [
17,
18,
36‐
38].This suggests that these challenges are not unique to Nigeria, and it calls for a regional effort to ensuring access to low-cost testing and treatment. Governments should also begin to prioritize HBV testing and allocate more resources to address the burden. In maximizing resources, the HIV programs in many countries can be leveraged for the prevention and control of vertical transmission of HBV [
39].
To the best of our knowledge, our study will be among the first to present the barriers to HBV screening of pregnant women from the perspective of health workers in Nigeria. Nonetheless, the representativeness of our findings is limited by the number of included states. The survey was self-administered and the health workers’ responses in our study might have been affected by their ability to express their views in writing and personal biases. While the views of the respondents might truly reflect barriers at provider and health system levels, they might not fully reflect the patient-level barriers for the pregnant women. We recommend further qualitative studies on the barriers to HBV screening tests, particularly from the perspectives of pregnant women. Implementation science research is also needed to test and identify effective strategies for improving HBV screening rates. Finally, our findings highlight the need for a national service availability and readiness assessment survey for HBV prevention and treatment services.
Conclusions
The findings from this study suggest that HBV screening of pregnant women attending PHCs in Nigeria is affected by multilevel barriers. To eliminate perinatal transmission of HBV in Nigeria, the highlighted factors at the patient, provider and health system levels must be addressed through effective and sustainable interventions. These should include interventions targeted at improving the availability of HBV test kits and other essential commodities, strengthening the capacity of health providers, making the HBV vaccine and treatment more affordable, and improving HBV awareness.
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