Background
Globally, chronic infection with hepatitis B virus (HBV) is a public health challenge, affecting more than 350 million individuals [
1‐
3]. Chronic HBV infection results in high mortality from cirrhosis and liver cancer [
4]. Recent analysis from the global burden of disease data reveals that HBV and its complications of liver cirrhosis and primary liver cancer are not only among the leading 20 causes of death, but are on the rise [
5]. The two regions of Africa and south East Asia collectively contribute to the highest HBV prevalence [
6] and 70% of liver cancer prevalence worldwide. In accordance with the current global viral hepatitis strategy 2016–2021, elimination goals are to be formulated for identified special sub-populations (micro-elimination), considering both epidemiologic and socio-cultural contexts [
7]. Hepatitis B is mostly transmitted horizontally via contact with infected body fluids including blood transfusions and contaminated medical injections, through unprotected sex and from mother to child (vertical transmission) through child birth. In highly endemic regions of SSA, mother to child transmission is recognized as a major route for HBV transmission [
8].
With Uganda’s high HBV national prevalence [
9], pregnant women need to be considered a focal sub-population for possible viral hepatitis B micro-elimination [
7,
10]. Timely antenatal HBV detection, treatment and vaccination to prevent mother to child HBV transmission should result in reduced disease incidence and consequently, prevalence [
11]. Yet little has been done to strengthen hepatitis B testing and treatment among Ugandan pregnant women. In most SSA countries including Uganda, specific HBV prevention efforts among pregnant women are hampered by several barriers which include among others, (i) low awareness and knowledge about HBV and its prevention [
12,
13] which makes the disease less palpable within communities (ii) health systems that are ill-prepared to offer antenatal screening, treatment and prevention services. Where HBV services exist, they are a private health service, in a few urban healthcare settings and the costs are not affordable. In addition, studies have reported lack of community and peer support as important impediments to HBV prevention [
14,
15]. Such structural and financial barriers significantly make uptake of HBV prevention a challenge. (iii) Insufficient information about pregnant women’s, beliefs, perceptions and behavioral intentions in relation to HBV risk and prevention. If inaccurate HBV disease perceptions are not rectified, this negatively affects behavioral response geared towards HBV prevention in this population [
16]. Since pregnant women are at risk of transmitting HBV via sexual, vertical and horizontal routes when infected, it remains vital to understand their perceptions of HBV risk, to inform targeted education and risk communication which may enhance HBV prevention behaviors.
Self-perceived health is defined as “an individual’s evaluation of his or her own health” [
17]. Theories of health behavior [
18,
19] and scientific studies [
20‐
22] have shown that personal perceived threat of disease not only influences one’s personal rating of their health, but also whether they engage in preventive health behaviors. To better understand pregnant women’s HBV and liver cancer-related perceptions, we utilized the health belief model (HBM) [
18]. The HBM was selected primarily because of its central attention to disease-preventive health behaviors, and the psychosocial and cognitive determinants of these behaviors, which this study evaluated. The model supposes that individual perceptions of risk of acquiring a given disease and how severe this disease is likely to be, merge to shape overall perceived threat of a given disease. This threat, is further influenced by one’s age, gender and general knowledge about the disease and its causes as individually unique characteristics. It is then weighed against one’s beliefs about the likelihood of receiving care, benefits or barriers to care and ability to seek for and obtain care, to then stimulate care-seeking, treatment and preventive behavior.
Behavioral intentions
Intention to prevent HBV was hinged on the theory of planned behavior [
19], which interprets perceived self-efficacy and individual behavioral control, as predictors of behavioral intention. Behavioral intention, (BI) defined as “
a person’s perceived likelihood or “subjective probability that he or she will engage in a given behavior” [
23], has been shown to be a good proxy measure for actual prevention behaviors in several settings [
24‐
26]
. The theory of planned behavior has been utilized in disease prevention studies including liver cancer prevention research [
27,
28]. Although interventions have been done to elevate population awareness and knowledge of HBV, [
29‐
31] which consequently improves population perceptions about HBV risk and prevention, less work has been done to assess the relationship between HBV perceptions and actual uptake of HBV prevention behaviors particularly in SSA. Continued limited understanding of this relationship may hinder effectiveness of education programs in addressing negative perceptions, which have been identified as barriers to seeking and utilizing prevention services [
32]. Applying these two theories of health behavior, we developed and measured constructs for perceptions and behavioral intentions.
In this study, we aimed to measure pregnant women’s perceptions about risk and prevention of HBV and liver cancer; perceived disease severity, barriers, benefits and self-efficacy for hepatitis B and liver cancer, and also determined the relationship between perception variables, socio-demographic characteristics and intention to test, treat and vaccinate against hepatitis B, as proxy measures for actual behaviors.
Discussion
HBV education triggers formulation of decisions to seek HBV care and prevention services, but is more effective if it is rooted in a clear understanding of existing population perceptions regarding disease risks and prevention. In this study, we have assessed perceptions and behavioral intentions related to HBV risk and prevention among pregnant women in two regions of Uganda, a country of moderate to high HBV prevalence with inadequate programs for preventing mother to child HBV transmission. We identified that high perceived self-efficacy was associated with intention to screen, vaccinate and seek treatment for hepatitis B. Further assessment also showed that individuals residing in the north, compared to the central region, plus those belonging to Christian religious following compared to Muslims, were more likely to have high perceived self-efficacy for participating in HBV prevention actions.
Few pregnant women, all-inclusive, had high perceived risk of acquiring HBV and liver cancer during their lifetime, and a significant proportion still believed they were at low risk of liver cancer, even if they were to contract HBV. Our results also showed regional differences in risk perceptions, where a higher fraction of women from the central region tended to have high perceived risk of acquiring HBV and liver cancer, for themselves, their children and their spouses, compared to those from the northern region. This finding is similar to a study by Kue and colleagues among Chinese immigrants in the USA [
35], where perceptions about HBV and liver cancer were low in a population at increased HBV risk. There is sufficient evidence linking HBV to liver cancer [
36], including evidence that HBV exerts a direct carcinogenic effect on the liver [
37‐
39] and that HBV vaccination [
40,
41] and treatment for chronic HBV infection [
42] has reduced liver cancer rates in some territories. Moreover, recent findings from SSA showed that liver cancer occurs at a much younger age among HBV-infected individuals [
43]. It is therefore important that HBV prevention interventions are based on an understanding of population perceptions regarding HBV and liver cancer risk, to incorporate appropriate risk communication and risk reduction strategies.
Perceived self-efficacy in this study was independently related to hepatitis B prevention behavioral intentions, including intention to screen for hepatitis B, to seek treatment, and to receive a hepatitis B vaccination. In this, our data stand with the theory of planned behaviour, indicating that if individuals are self-assured in their ability to prevent HBV, they are more likely to participate in preventive actions. A recent study among Iranian patients with non-alcoholic fatty liver disease also found that both perceived duration of illness and self-efficacy were predictive of adopting healthy nutritional habits [
44]. Similar findings to these have been reported among immigrant minority populations in Europe [
45,
46]. However, due to limited number of studies examining this relationship among African populations, more research to uncover other possible factors that explain this relationship would be useful.
Although perceived risk and severity have been reported in several studies to positively influence disease screening behaviors [
35,
47‐
50], and both the health belief model and theory of planned behaviour so stipulate, observations from our study did not support this relationship. Perceived severity was not associated with intention to test, vaccinate or treat HBV, and perceived risk was inversely related to intention to screen for HBV, though the magnitude of association was not strong and was not statistically significant. Pregnant women might care more about consequences of not screening, to their unborn baby, other than to themselves, such that irrespective of the level of perceived risk, they would seek care. The theoretical models therefore might be more applicable to individuals who only consider their own risk, in deciding whether to seek care. In a US study among high risk men, lack of HBV vaccination was found among at-risk men with low perceived risk of HBV [
51]. Conversely, another study found perceived severity of HBV disease to be negatively associated with HBV testing [
52]. A possible explanation for our findings might be the multiple measures we used to estimate perceived risk, which might have masked the magnitude of risk perception as a construct. Equally, our investigation of risk perceptions and behavioral intentions occurred in a context where HBV services for pregnant women to consider accessing are non-existing [
53], whereas in the USA, services are available, at a cost. These differences might influence how individuals perceive risk and how they make decisions on intention to take preventive action.
Links between HBV-related perception constructs and socio-demographic characteristics have been barely evaluated, particularly in SSA pregnant populations, or in developed countries among migrants from Africa. In our study, both region and religion influenced perceived self-efficacy, a socio-cognitive construct shown to positively influence uptake of HBV preventive behaviors. Pregnant women who resided in the central, compared to the northern region were more likely to have low perceived self-efficacy for taking up HBV prevention measures. In addition, individuals who self-identified as Muslims were also more likely to have low self-efficacy for participating in HBV prevention services, compared to those who self-identified as Christians, in adjusted models. These findings mirror those in a study among Moroccan immigrants in Europe [
45], where authors reported that influence from Islamic leaders in this minority, mostly Muslim community, negatively influenced intention to participate in HBV screening. It is nonetheless, less clear which factors underlie this finding, and more research might uncover issues not investigated in this study. The finding however, suggests that HBV prevention programs may benefit from being culturally adapted to suit the environments in which they plan to be implemented.
We note that this study had important limitations. Assessment of behavioral intentions relied on participants’ self-reports and HBV-related perceptions were gauged in a setting without a national program for HBV testing or vaccination for pregnant women. This might have influenced how respondents perceived their risk and how they might have reported their intent to participate in HBV prevention services, which may limit comparability to other research. Moreover, we did not include assessment of cues to action. Nonetheless, our study is among very few investigations to evaluate hepatitis B related perceptions and preventive intentions among indigenous African pregnant women. As such, it contributes to filling an existing gap on available evidence to inform programs that aim to reinforce hepatitis B prevention behaviors among pregnant women within the SSA region. In addition, we performed a rigorous assessment of HBV-related perceptions and preventive behavioral intentions, followed by further analysis to specifically identify correlates of perceived self-efficacy in this pregnant population, given that perceived efficacy was directly related to positive HBV preventive behavioral intentions. This work, in line with the current global health sector strategy on viral hepatitis elimination by 2030 [
7], has significant implications for national programming and policy. HBV prevention programs should aim to provide accurate risk communication that will enable individuals to correct erroneous perceptions of HBV and liver cancer risk. They should equally purpose to improve self-efficacy in sections of the community with low efficacy, in order to improve uptake of HBV prevention behaviors. Given our findings, national policy may consider transcending traditional prevention approaches to reach out to communities through alternative forums, such as places of worship and leaders of religious groups, for a more sustained and end user-centered response to HBV.
Conclusion
In an obstetric population of a SSA setting without antenatal HBV services, we systematically evaluated perceptions of hepatitis B and liver cancer risk and attendant benefits, barriers and self-efficacy in relation to prevention behaviors. We found low perceptions of risk of both HBV and liver cancer. We identified that high perceived self-efficacy, of which region and religion were significant determinants, was associated with intention to screen, to vaccinate and to seek treatment for hepatitis B. In environments like this one, where specific evidence needed to refine HBV risk and prevention communication is insufficient, these findings may be relied on to lay a foundation for strengthening HBV and liver cancer risk communication and prevention programming, in order to maximize their impact on national HBV elimination strategies.
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