A cross-sectional assessment of knowledge, attitude and practice among Hepatitis-B patients in Quetta, Pakistan

Hepatitis-B (HB) is a serious infectious disease of the liver, infecting 2 billion people around the globe; of these, 350 million will develop lifelong chronic infection [1]. An estimated 15–40% of chronic HB carriers are susceptible to develop liver cirrhosis and hepatocellular carcinoma [2, 3]. HB is a life threatening infection resulting in 0.6 million deaths annually [4, 5]. In Asia, 10 to 15 million individuals suffer from HB [6‐8]. Similarly to what is reported worldwide, the prevalence of HB in Pakistan ranges between 7 to 20% based on different regions [6, 9‐14]. In urban areas of Pakistan, the prevalence of HB is reportedly lower (2-5%) than rural areas, where the prevalence is reported to range between 30-35% [11, 13, 14].

Knowledge, attitude, and practice (KAP) studies are representative of a specific population to collect information on what is known, believed and performed in relation to a particular topic. Knowledge, attitude, and practice are the most frequently used study tools in health-seeking behaviour research [15, 16]. Knowledge is usually assessed to evaluate how patients’ knowledge corresponds to biomedical concepts [17]. Questions included in knowledge assessment are related to causes, symptoms, transmission and treatment and the management of the disease or infection condition under investigation [18]. Attitude is “a learned predisposition to think, feel and act in a particular way towards a given object or class of objects” [19]. Practices in KAP surveys usually inquire about the use of preventive measures or different healthcare options. In certain cases, it permits statements about actual practices as well as yielding information on people’s behaviours or on what they know should be done in a hypothetical scenario [20]. Therefore, measuring KAP is consequently critical to prevent the spread of infection.

Within this context, the health system in Pakistan consists of traditional public and private sectors. The public sector encompasses a wide network of dispensaries, basic health units, rural health centres and hospitals [21]. However, in the private sector, apart from some accredited outlets and hospitals, there is mushrooming growth of medical general practitioners and other complementary and alternative medicine (CAM) options (homoeopathic practitioners, traditional and spiritual healers, Greco-Arab healers, herbalists, bonesetters and hakims) [21]. Since CAM options provide easy and cheap treatment options with an easy access, the majority of patients, regardless of their disease or illness, seek CAM therapies as their primary choice of treatment. This leads to inappropriate or delayed healthcare, resulting in undesirable outcomes [22]. In addition, such practices also lead to the spread of infection among healthy societal members. At present, the prevalence of HB is rising in Pakistan and furthermore, there is paucity of information about KAP among HB patients. Therefore, the purpose of the present study was to assess KAP among HB patients in order to use the data in developing information, education and communication activities for the patients as well as community. Such activities will be helpful in the prevention and control of HB in a developing country like Pakistan.

The results of the current study reveal that HB patients have poor KAP towards their disease. A small percentage of patients actually know about the transmission of HB; this lack of knowledge about HB transmission can be attributed to a rise in the frequency of HB. This finding is in line with that which was reported earlier, where poor knowledge levels of different populations from different regions were reported [21, 32‐37]. However, such studies were concerned with the knowledge of the general or healthy population and there are no data on the knowledge of HB patients.

The results of the present study revealed that, although all the patients had access to healthcare professionals, the primary source of information regarding HB was through family, friends and neighbours. Therefore, we can conclude that poor KAP scores are correlated with advice taken from an unreliable source. A primary reason of this attitude is linked to the lack of communication between the healthcare professional and the patient, meaning that the patient may not receive adequate information. Healthcare professionals should disseminate information regarding HB and present themselves as a primary source of information for HB patients. This will provide evidence-based knowledge to HB patients, which will improve HB patients’ compliance towards their treatment and prevent the further spread of infection.

The mean attitude score was found to be in the negative range. Before being diagnosed with HB, the majority of patients believed that they could never get the infection. Perceived susceptibility or a viewpoint of how vulnerable a person considers himself/herself to getting a disease can influence one’s attitude in taking certain actions [38]. In addition, the majority of patients revealed the use of complementary and alternative medicines after they became infected with HB before consulting a physician. Homoeopaths and traditional/spiritual healers were the treatment of choice until there was no improvement in the signs and symptoms of HB. Consulting physicians was sought as the last resort, when all other healing systems had failed to provide a cure. This is in line with that which was reported earlier in Pakistan [39]. The delay in seeking medical treatment results in the further deterioration of the condition and can cause the spread of infections to other healthy individuals as well. Nearly half of the patients perceived HB treatment as expensive, which could be one reason for using alternative treatments. Within this context, poverty, cultural beliefs and perceived severity of illness could be additional reasons for seeking alternative methods of treatment. In developing countries like Pakistan, access to traditional healers is more economical than seeking treatment at medical healthcare facilities [39].

Isolation from society was the biggest fear after being diagnosed with HB in patients in the current study. Isolation describes the absence of social interactions in society and results in several behavioural changes. The phenomenon of isolation has been widely studied among patients with mental health problems [38]; however, this phenomenon is not well explored among HB patients from conservative societies like Pakistan. Such behavioural changes may also affect patients’ health-related quality of life which is evident from literature [40]. It is interesting to note that the majority of patients also reported that they avoid meeting people; this is bad practice as it could lead them to become self-isolated. Therefore, their fear that they will be isolated could be because they themselves avoid meeting with people rather than society making them isolated.

Patients in the current study also showed poor practice towards HB. Only a small number of patients appeared for HB screening before they were diagnosed with infection. The majority of the patients were not concerned about the safety measures which exposed them to the danger of spreading HB infection within their social circle. Poor practices were also evident from practicing unsafe sex and not taking safety measures while seeking services at barber shops. These poor practices impose a danger to other healthy individuals in society. Thus, all HB diagnosed patients should be informed regarding the importance of safe practice and the dangers of spreading the infection to healthy individuals. Only a very small number of the patients had attended a health education program, and they reported a lack of information about educational campaigns in their areas. Educational programs are strongly recommended for healthy individuals, as well as for HB patients. Mass media should be recognised and introduced as an effective educational tool for HB patients with an aim of a better understating of HB.

In the current study, the education level, occupation and area of residence (locality) were the significant demographic factors associated with the mean KAP scores. Although education level was reported to be significantly associated with KAP scores in other studies from different parts of the world [34, 41], the literature do not report a relationship between occupation or residence and KAP of HB patients.

The positive correlations between knowledge-attitude, knowledge-practice and attitude-practice in this study reaffirm the relationship between knowledge attitude and practice with infection control measures. It is concluded that adequate knowledge can lead to a positive attitude, resulting in good practices. The findings are in line with the results of some previous studies; however, such results were a representation of a healthy population and no data are reported from the perspective of HB patients [21, 42].

The reported positive correlations are explainable by the theory of Reasoned Action. A person’s intention to a specific behaviour is a function of their attitude towards that behaviour. Furthermore, the attitude toward the behaviour is determined by the person’s belief that a given outcome will occur if he/she will perform the behaviour [43]. Within this context, in the current study, the practices related to HB as a performed behaviour were dependent on the attitude of the patients towards their disease condition. In addition, the attitude was shaped because of the knowledge that the patient possesses regarding HB infection. Hence, it is concluded that correct knowledge brings about a positive attitude and this positive attitude brings about a positive change in the practices of patients.

The findings of this study indicate that HB patients lacked an understanding of infection control and management. Extensive health education campaigns should be provided to HB patients in both hospital and community settings using a patient-centric approach. Physicians, pharmacists and nurses should play a role in developing a collaborative care model to provide education to the patients. Empowering the patients will be helpful in disease management as well as in controlling the further spread of infection to the healthy population.