Dynamics of Hepatitis B infection prevention practices among pregnant women attending antenatal care at Lubaga Hospital Kampala, Uganda using the constructs of information-motivation-behavioural skills model

The study is a cross sectional descriptive study that employed quantitative data approach to capture data on the study variables among the pregnant women using Lubaga health facility for antenatal care between the period of September 2020 and October 2020, since antenatal clinic settings would be appropriate to collect pertinent information related to hepatitis B virus infectivity.

This study took place at Lubaga hospital, which was formerly known as Uganda Martyrs hospital. It is a private not-for-profit health facility owned by Kampala Roman Catholic Archdiocese. Over the years, the hospital, which is relatively a high-volume 237 bed-capacity facility has established a name as a highly as an affordable health care provider. Consequently, it is seen as having persistency allures and a center that manages treatment of individuals from both the low and middle socio-economic status. Millions of people have been reported to have benefited from its health care services during its long history of existence. This hospital is also known to have built a very strong anecdotal reputation for treatment/ management of liver diseases ever since the 1970s where anybody with liver problems in Uganda was often referred to. Antenatal clinics operate from Mondays through Saturdays in the Public Health Department of the hospital that has more than 400 antenatal clinic attendees per week.

Eligible participants were expectant mothers of not less than 18 years, who were on routine antenatal care in Lubaga hospital and who gave their written consents to be part of the procedures of the study. Participants who were severely indisposed (i.e. those who were extremely exhausted) to embark on the study-specific procedures were excluded.

The study involved a total of 385 respondents from Lubaga Hospital, calculated employing Kish Leslie (1965) formula on the basis of the previously reported prevalence of 47% awareness of HBV infection by Nankya-Mutyoba et al., [15], 0.05 precision level and 5% (α) or type 1 error.

where N denotes the estimate of the sample size for the pregnant women

The pregnant women were sampled using systematic-sampling approach where every registered 2^nd pregnant woman waiting to be attended to was selected to participate in the study following a random start. Recruitment of the participants was based on the daily patronage level and available population at the ANC unit of the Public Health Department. As the expectant mothers arrived to the facility, they were registered before being recruited using the periodic interval. Therefore, approximately 30 expectant mothers were recruited per day from Mondays through Fridays for a period of 3 weeks.

The study captured data from 385 respondents. It was observed that more than half of the participants (59%) were between the age of 18 and 28 and the least age group (2.1%) lies between the age of 40 and above. Majority (272/385 (70.6%)) were from the central region while nearly half of the respondents 163 (42.3%) had secondary education. More than two-thirds (296/385(76.9%)) of them reported to be in monogamous affair while majority (140/385, 36.4%) were also reported to be Catholics with most of them, 158 (41.0%) being self-employed. Upon the assessment of the mean scores on HBV infection prevention practices among the respondents, younger women (14.9), respondents from other regions (14.7), women with non-formal education (14.4), single/divorced women (14.1), and traders (14.4) demonstrated the poorest scores for HBV prevention practices (see Table 1).

The study sought to assess knowledge of the participants regarding HBV infection, their perceptions of consequences of an infection, and behavioural skills as predictors of HBV infection prevention practices considering the potential inherent in vertical transmission during pregnancy. This study captured data from three hundred and eighty-five (385) expectant mothers attending Lubaga Hospital for antenatal care and the findings revealed that majority of them demonstrated high awareness of HBV infection. Predominantly, they heard about the infection before pregnancy from places like hospitals, the community and from the public. Regarding the disease-specific knowledge, they demonstrated a fairly average knowledge level with a prevalence of 52.4% reported from a mean knowledge score of 6.29 (5.97 ± 6.61) as measured on a maximum score reference scale of 12. This fairly average knowledge level on hepatitis B infection is not in line with the unacceptable low level of knowledge displayed by pregnant women in a recently conducted study in Uganda by Nankya-Mutyoba et al., [15] and with others conducted within sub-Saharan Africa like that of Ali Abdulai and others [22]; Elsheik et al., [23]; Frambo et al., [24] and Dun-Dery et al., [25]. However, nearly similar to this average knowledge score is the report from the study conducted in Limbe Health District, Cameroon by Mbouamba-Yankam et al., [26]. In line with this finding, is the good knowledge level reported previously in a different geographical setting in Cameroon by Talla Paul et al., [27].

Due to the above-average level of knowledge of the respondents in this study, and in view of their awareness prior to this study, majority were still unable to identify some of the basic features of the mode of transmission including sexual transmission. Also, almost all the respondents did not know that fever could be an important sign of HBV infection and more than half of them did not also know that liver cancer risk is linked with being infected with hepatitis B virus infection. Knowledge gaps however, exist regarding reasons why at-risk population such as pregnant women and infants need to be protected from getting infected. Some (53%) of them in response felt that they can pass the infection to the baby through drinking water. Similarly, 3 out of every 4 pregnant women believed that it is because she may likely not be able to carry the pregnancy to term. Further, the role of vaccination in breaking the transmission of the infection vertically from mother to child as well as reducing the risk of chronicity could be hampered if the doses are not completed. Approximately half of the respondents did not know the number of doses required to complete the series of vaccination against hepatitis B thereby responding that just one or two doses are required whereas knowledge of vaccination has been previously reported to be a significant predictor of vaccination uptake [28]. This means that people who are adequately informed about vaccination are likely to uptake vaccine compared to those who are not knowledgeable about HBV vaccine. Health education in this setting still has a lot of gap to fill regarding the population of pregnant women’s knowledge of vertical transmission and the adequacy of the general awareness of HBV infection.

Information-adequacy about HBV infection in pregnant women population is a significant aspect of the strategies involved in micro-elimination of HBV towards elimination of the vertical transmission of HBV infection by 2030. The findings from this current study imply a control policy for hepatitis B in Uganda and similar regions within Sub-Saharan Africa where HBV infection education during antenatal visits, testing or vaccine uptake by pregnant women as well as administration of vaccination dose at birth for neonates are missing.

The average but inadequate knowledge about hepatitis B infection demonstrated by the respondents in this study is a missed chance to adequately inform expectant mothers on the consequences of hepatitis B infection complications on an expectant mother as well as the developing foetus. The issue might be due to the nature of the contacts expectant mothers have during antenatal clinic visits with the health facility which implies a need for health promotion intervention to target the observed knowledge deficiencies and improve the information-adequacy of the seriousness of HBV infection in order for the effective HBV infection prevention and control not to be hampered in Uganda. Similar studies by Ali Abdulai et al., [22] and Nankya-Mutyoba et al., [15] called for the same approach.

Additionally, to the knowledge level, this study reported an averagely positive perception towards the prevention practices of hepatitis B infection among the respondents, displaying a prevalence of 53.7% (\(\overline{X }=\) 17.71, 95% CI = 17.10 ± 18.31) on a rating scale of 33. This finding happens to be strongly concurring with the reports from previously conducted studies like that of France population by Brouard et al., [29], Nigeria by Chingle et al., [30] and Iran [31]. Contrary to the report of perception from this finding, is the low and incorrect perception towards HBV infection and liver carcinoma among similar population within central and northern Uganda reported in the study conducted by Nankya-Mutyoba et al., [32]. This present study’s results prove beneficial for interventions targeted at pregnant women’s perception.

Many of the respondents have a low perception towards the likelihood of contracting HBV infection and being predisposed to the risk of liver carcinoma, in spite of knowledge of the known link between liver carcinoma and hepatitis B. Despite the fact that 77% of the 385 study participants believe that vaccination of their baby at birth can offer protection against HBV infection and lower the risk of liver cancer, approximately half of them are motivated and willing to go for hepatitis B screening and vaccination simply due to recommendation by a health worker. Only a third of the respondents had a very high likelihood of taking their child for up taking HBV vaccine as a part of scheduled routine immunization for infant. This is a proportion a bit lesser than the 60.1% of respondents willing to do such in a report from the previous conducted study in obstetric population in Vietnam [33]. However, this study boasts of a less than 2% higher sample size than the 380 of Hang pham and others. This implies the need for prioritizing expectant mothers and mothers’ education in subsequent health campaigns with the aim of reducing wrong perceptions and improving the coverage of vaccine uptake at birth in Central Uganda.

The low likelihood of vaccinating themselves and their babies could be linked to their perception that vaccines circulating in Kampala are fake; as noted from some respondents. However, the 20% low proportion of the total respondents willing to get screened for HBV over the next 365 days is another issue reported in this study. It could be related to the misperception of the respondents that could be linked to their notion of the cost of screening and vaccination. Since they do not perceive themselves to being predisposed to hepatitis B infection or liver cancer risk, then their low likelihood of screening and vaccinating themselves might be justified. Hence, there is a need that the interventions directed towards HBV prevention focus on the perception of this population sub-group to initiate risk communication and strategies aimed at reducing this risk. It has been evidently shown in this study that there could be some other forms of motivation towards HBV prevention regardless of their low perception of risk which generally influenced the average score level of motivation recorded in this study. This has implications for health workers’ impacts and involvement toward shaping the perception of pregnant women and motivating them to seek testing services for HBV infection, uptake vaccine for their babies and initiate prevention practices of HBV infection.

The findings regarding the level of behavioural skills towards HBV infection prevention practices among our respondents showed high behavioural skills with a prevalence rate of 63.1%. This is an indication that the respondents displayed good behavioural skills necessary for adopting a health-promoting behaviour. In terms of perceived severity, relatively half of them strongly agreed that hepatitis B is a serious infection that can be fatal. Also, should they develop cancer of liver, it will be critical more than any other complications that endangers career and deteriorate financial status. This report is almost in concord with the high perceived severity reported by Nankya-Mutyoba et al., [32] and a more higher perceived severity reported in the study conducted by Balegha et al., [34], although the discrepancy in the findings might be as a result of the differences in the population of study since Balegha et al., [34] focused their study on nursing students in contrast to pregnant women as employed in this study.

Regarding the outcome expectancy, roughly half of the respondents agreed that they were confident that getting screened for hepatitis B infection will help them discover and treat the infection quickly before it leads to liver carcinoma. Despite the all-inclusive high behavioural skills score level, just one-third of the respondents strongly agreed that they confidently believed that vaccinating their child against HBV infection will get them no worries about the baby developing carcinoma of the liver during adulthood. This report may be as a result of the gaps in their knowledge about liver cancer and the relationship with HBV infection as well as the efficiency of vaccination in preventing the infection. While a third of the total respondents did not perceive not experiencing liver infection symptoms as a barrier to testing themselves for hepatitis B and going for vaccination, 4 out of every 10 pregnant women strongly believed that miscarriage will result from getting vaccinated for HBV during pregnancy. This could be linked to the fact that some are of the perception that available vaccines in Kampala are fake and they do not want to put themselves and their unborn babies at risk. This implies that hepatitis B prevention education policy should direct communication on effective vaccination and information on location and availability of vaccination services to the public and the vulnerable group in order to improve the uptake of vaccination among the obstetric populations.

Furthermore, an overwhelming majority of the respondents displayed an encouraging self-efficacy by strongly agreeing to the item inquiring about their certainty of taking their child for all the required vaccinations regardless of the distance of the immunization centre from their places of residence. This is due to the fact that most of them who seem to be adequately informed about HBV infection rejected their high likelihood of not going for vaccination because the clinic is far from where they live and this knowledge could have reformed their perception giving them the confidence in preventing themselves and their unborn babies come what may. Simultaneously, most of them (due to the mentioned fact) strongly agreed that they were certain of going for HBV screening irrespective of the payment the screening required, although the perceived self-efficacy is not as high compared to the one reported by Nankya-Mutyoba et al., [32]. However, it has together with their high outcome expectancy, low perceived barrier and high severity influenced the total high score of 63.1% generated for their behavioural skills. This implies that if the benefit of vaccination is clearly perceived by people the same way they perceive the severity of the infection if they are not protected and without having any hindrance towards prevention, they are likely going to initiate prevention practices. Attention of HBV prevention education policy should however be paid to communicating the complications of HBV infection, the need and benefit of vaccination to the pregnant women as this will influence their self-efficacy and in turn have impact in their uptake of HBV prevention services. Therefore, awareness of the pregnant women must be raised and necessary HBV vaccine-related important information must be provided to them as a significant approach in order for vaccination to be scaled up among this high-risk population group.

Reported findings from this study show that the respondents in the study demonstrated an average score level for prevention practices towards HBV infection with a prevalence of 52.1% (\(\overline{X }\)=15.62, 95% CI = 15.03 ± 16.20) when measured on a 30-points rating scale. This result contradicts poor practices that numerous studies have previously reported within Sub-Saharan Africa like that of Elsheik et al., [23]; Mbouamba-Yankam et al., [26] and Balegha et al., [34]. Almost in line with this finding, is the relatively better or safe prevention practices reported by Talla Paul et al., [27] and Mursy and Mohamed [35]. However, the latter [35] focused on nurses and midwives in contrast to expectant mothers employed in our study. The general average level of prevention practices reported in this study leaves no much concern. However, the frequency of some of the respondents hepatitis B prevention practices do leave a lot to worry about considering the fact that less than 4 out of every 10 respondents avoid unprotected sex with the use of barrier protective measure very often which might be due to their religious belief. This is based on the fact that majority of the respondents were reported to be Catholics followed by Muslims and the idea of using such protective wears might not be too welcoming. However, it will contribute less to their risks of being infected since majority of them reported to practice safer sex often and avoid having more than one sexual partner.

This finding implies that the national prevention policy may alternatively intensify approaches regarding the prevention, complications, and risk factors by reaching out to individuals within the grassroots. Suggested places include sensitization in worship centres through leaders of religious groups. This would enhance the continuous dissemination of information through person-focused approach regarding the prevention and control of hepatitis B infection.

While 7 out of every 10 respondents avoid having tattoos on their body just around one-third of the respondents do not always share and reuse needle. The poor practice of reusing needles is a reflection of their lack of knowledge concerning the predisposing risk factors of HBV infection. Amazingly, half of them claimed to avoid casual contact with HBV infected person very often and 42.6% of the respondents often avoided sharing food with infected person in order to prevent the infection. Both practices however, are not associated with the transmission of the infection and they do not know because their knowledge of the transmission of HBV is not adequate. Regarding routine screening for HBV detection, more than half of the respondents do not undergo regular routine screening. Similarly, nearly three-quarter of the total respondents do not often complete recommended HBV infection vaccinations for their children as part of scheduled routine immunization required for infants. This self-reported practice might be due to their perception towards vaccination. Also, just 12.7% of the 385 pregnant women claimed to have derived information from the clinic about HBV infection as well as ways of protecting themselves and their children. This is indeed, a gap that is needed to be filled at the health facility for majority showed from their perceptions that they can be motivated to initiate prevention practices like screening and vaccination should they be recommended by a health worker. This implies a need for more personalized HBV health education by the health workers who have been directed to cater for expectant mothers during antenatal visits in order to adequately inform them about the infection dynamics and how to prevent themselves and their unborn babies. Evidently from our present study, it was observed that the overwhelming majority of the expectant mothers had not been vaccinated for HBV prior to the study denoting a very low uptake of HBV vaccination. This low uptake of vaccination is comparable to the report from a study previously conducted by [36] in Northern Uganda. This suggests the need for public health interventions informing pregnant women adequately on HBV education as well vaccination.

Findings reported on the study variables relationship demonstrated a statistical significant predicting-association between the disease-specific knowledge, motivation, behavioural skills and HBV infection prevention practices among the study respondents. Numerous previously conducted studies have reported significant relationships between knowledge of HBV as well as prevention practices, which is in agreement with this study like that of [26, 37], while a study by [27] reported a non-significant relationship between knowledge and practice. Regarding perception predicting prevention practices, Chingle et al., [30] reported such in a study conducted in West Africa. However, the study only measured perception of risks unlike this present study that had some other constructs of motivation such as reinforcement by health worker among others, measured with perception. In addition to behavioural intentions that included self-efficacy, one of the major constructs in the behavioural skills measured in this study, perception was reported to be associated significantly with it in the studies conducted in Iran [31] and that of [32] conducted in Uganda. The all-inclusive significant predicting relationship observed in our study obeys the theoretical model that guided this study [13] which postulates that information-adequacy, motivation and behavioural skills are the leading predictors of health behaviours’ performance as well as adoption. Similarly, it states that when people become adequately informed; motivated towards performing an action and possess the necessary skills shaping behaviours, an enabling environment will be created vis-à-vis adopting or initiating practices that would positively promote their health. Contrarily, when individuals demonstrate poor information on health problems and performing action, they do not tend to be motivated and are also short of the required skills for shaping behaviours to perform effectively. Consequently, they will end up adopting and engaging in health risk practices that could bring about negative health outcomes. These findings have significant implications for HBV prevention policy and will contribute to filling a gap already known regarding usable facts like the inadequate knowledge and misperceptions including the focused areas of intervention that will help to inform programs aimed at reinforcing HBV infection prevention behaviours among pregnant women.

This study will be the first of its kind hitherto as there are no studies in Uganda and across literature search that has reported to use this theoretical model (IMB) combining the explored variables to predict HBV infection prevention practices displayed by pregnant women.

Globally, human infection transmissions are effectively prevented when adequately vaccinated with the most appropriate vaccines, especially, among pregnant women and infants who are most vulnerable. The concerns about HBV infection is a global threat among at-risk populations and the lesson learned in this study has implications throughout the African continent, in the first instance, where the psycho-cognitive dispositions and behavioural responses are like the population studied in Uganda at the health facility. No doubt, a multi-country study may need to be conducted or, at best, a systematic review and meta-analysis of the subject of consideration in the study to ascertain the true profile of HBV vaccine coverage and antecedent factors associated with identified outcomes.