This study aimed to assess factors influencing knowledge and practices of hospital cleaners towards hepatitis B prevention. This was a hospital-based cross-sectional study conducted at in Northern Province of Rwanda. A pretested self-administered questionnaire was used to gather data from study participants. A total of 134 cleaners were recruited in the study. Data were entered using Kobo collect toolbox and exported to Microsoft office excel for data cleaning and to entered in SPSS version 21 for analysis. Descriptive and logistic regression analysis was done and the significance level was 5%. More than a half of respondents were female (51.5%), and had primary level of education (54.5%). Results showed that only 9.7% of respondents had a high level of knowledge about HBV and only 2.2% had good practices on HBV practices. The odds of having high level of knowledge towards HBV prevention was 2.3 times (AOR=2.3, 95%CI: (1.1-27.3); p=0.045) among respondents with high school compared to those with no educational level. Respondents with work experience of 5-7 years were 1.5 times to have high level of knowledge towards HBV prevention than those with work experience of less than one year. Being aged between 20-30 years was associated with 2.5 times more likely to have good practices on HBV prevention than respondents aged less than 20 years. The odds of having good practice towards HBV had found to increase with work experience (AOR=2.3; 95%CI: (1.29-4.3); p=0.014). Considerable proportion of participants lacks the requisite knowledge of post-exposure treatment and prevention of HBV. Training programs on HBV infection, including PEP are highly recommended.
Academic Editor: Lucio Mango, "S.Camillo-Forlanini" General Hospital, Italy.
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Copyright © 2021 Jean Marie Vianney Nkurikiyintwali, et al.
The authors have declared that no competing interests exist.
Hepatitis B is a viral infection from the Hepadnaviridae family of viruses that attacks the liver and can cause both acute and chronic disease 1. The Hepatitis B Virus (HBV) is transmitted through infected blood products, unprotected sex, infected items such as needles, razor blades, dental or medical equipment, unscreened blood transfusions, or from mother to child at birth
HBV affects more than 2 billion people around the world with recent data identifying 257 million people worldwide suffering from chronic viral Hepatitis B 3. HBV can be prevented vaccines that are available, safe and effective 4. HBV prevalence for chronic infection amongst individual born prior to accessibility of the Hep B vaccine is much higher 5.
Regardless to initiation of universal Hep B immunization and powerful anti hepatitis B viral treatments in the sub-Saharan Africa and Asia, these regions bear the greater part of the burden of chronic viral hepatitis B infection around the world with 6.2% and 6.1% of older people being infected respectively. In the the Eastern Mediterranean Region, South-East Asia and the European Region, 3.3%, 2.0% and 1.6% of people are infected with only the 0.7% of general population infected in the America’s Region 6.
The essential primary transmission of Hep B disease is that might be spread by utilizing direct contact with blood or its body liquids 7. It can incorporate work-related exposure to human blood and body secretions, unprotected sexual intercourse activity. It is well known that health-care workers including hospital cleaners are at elevated danger for being infected with Hep B, mostly outstanding to infection transmission via blood contacting mucosa 8.
Acceptable knowledge and reasonable practices of hospital personnel are needed to reduce the spread of HBV disease. A study conducted in Northern Vietnam, Hang-Pham et al.9 found that healthcare professionals working at health facilities offering primary and tertiary health services that around 30.2 percent had incorrectly accepted that Hep B might be spread over food eating/or sharing by an infected client with hep B and in regards to 38.8% was not sure if the hep B vaccine is safe.
In African Countries like Tanzania, Debes et al.10 discovered that hospital workers has low level of knowledge of Hep B serostatus and immunization status where 91% of healthcare personnel were uninformed about their Hep B status and revealed that around 89% they had never received an HBV vaccine, this is often similar with the study conducted in Sudan by Mursy and Mohamed 11 where the greater part of the midwifery and Nursing staff didn't finish immunization calendar for HBV.
A Nigeria study “on knowledge and utilization of hepatitis B infection preventive measures and influencing factors among health care workers” shows that on self-revealed practice for Hep B precautionary measures was poor along with the majority of 62.4%of the study participants 12. In Nigeria, another additional study directed by Abiodun et al.13 demonstrated that knowledge of cleaners on prevention of Hep B infection was low at 65.2 %and 28.1%of the participants had ever had screening while none of them had been immunized for hepatitis B. Unlike other health care providers, cleaners are typically less well trained, no formal or little trainings, and lack of needed trainings related to infection prevention in the hospital settings may increase the risk to be infected 14.
In Rwanda, the prevalence of HBV for general population is unknown , therefore, prevalence rate of HBV is intermediate by global standards in different population of Rwanda, however it might be thought of low prevalence for the region as proved by Umutesi et al.15, have given approximations of Hep B prevalence along with numerous Rwandan populations living with HIV is 4.3% , which is extremely comparable with results from research done by Makuza et al.16 evidenced that, prevalence rate among screened Rwandan is 3.9%. In Rwanda, the general population epidemiology of HBV infection is not well known.
Health care workers including hospital cleaners are at greater risk of infection with Hep B compared to the general population 17, due to increased risk of contracting blood borne pathogens from their frequent occupational exposure to blood and body fluids 18 and inappropriate utilization of individual protective measures 19, 20.
However, in Rwanda hospital cleaners are recruited by private companies, not trained on infection control guidelines before starting the employment and cleaners are not considered in general hospital capacity building plan, and their vaccination status is unknown. The absence of awareness on HBV prevention measures, prophylaxis for post-exposition procedures, lack of trainings and safe protective equipments increase the risk of being infected 2. Acceptable knowledge and reasonable practices of hospital cleaners are needed to reduce the prevalence of disease. Knowledge is necessary for preventing hepatitis B spread between individuals. Therefore, this study investigated the factors influencing hospital cleaner’s knowledge and practices concerning prevention of HBV.
This study was descriptive cross-sectional survey and used quantitative method. This study utilized a standardized self-administered questionnaire to assess hospital cleaner’s knowledge and practices about HBV infection prevention in selected three rural district hospitals, northern Rwanda province. Purposive sampling was used to select the hospital; all three selected hospitals are located in rural area.
This study was done in three rural District Hospitals located in northern province of Rwanda. Those hospitals were Byumba Hospital located in Gicumbi District, Rutongo Hospital located in Rulindo District and Nemba Hospital located in Gakenke District.
The target population was hospital cleaners aged above 18 years old who worked daily in all clinical units and involved in waste management as well in sterilization and laundry process in the study site. This study was targeting a total population of 134 hospital cleaners from Byumba, Rutongo and Nemba District hospitals.
Sample Size and Sampling Procedure
This study was a quantitative cross sectional study, targeting a small population, Census method was used and entire study population was considered in the study. The study recruited all subjects from all research sites because the study population at each hospital was small (less than 50), all study participants was enrolled in the study. Hence the sample size was 57 cleaners for Byumba hospital, 34 cleaners for Rutongo and 43 cleaners in Nemba hospital.
The researcher used telephone calls to call cleaners scheduled for night shifts, and the collection of data taken place in separate for five consecutive days at each study site to create fair opportunities for study participation.
Before handing out questionnaires to study participants, the study goals and objectives were clarified. Additionally, cleaners who participated in the study were voluntarily. Thus, self-administered questionnaire was distributed to all study participants with a will to participate and met the inclusion criteria. A week prior to the actual data collection, the questionnaire was pre-tested. Findings of the pre-test were used to modify and clarify the collection tool before the actual data collection. Data collection was taken place at each hospital where study participants work.
After data collection, Data were entered using KoBo Collect Toolbox and exported to Microsoft Office Excel for data cleaning and to SPSS for analysis and retained by investigator in locked folder. The data was entered and verified twice to guarantee the reliability and data analysis was performed twice to reject any differences. The investigator also retained with all used survey forms in locked cabinet.
Data Analysis and Ethical Consideration
Data analysis was done by Statistical Package for the Social Sciences (SPSS). Descriptive analysis was done and level of knowledge and practice was determined based on the mean value of questions asked and bivariate and multivariate regression for analysis of relation between dependent and independent variables. P-Value < 0.05 was taken as significant. Factors influencing cleaner’s knowledge and practices for Hepatitis B prevention were analysed through multivariate regression. Factors were reported using odd ratio and 95% confidence interval.
In this study, the proposal was approved by Mount Kenya University Rwanda and before the data collection process, ethical clearance was obtained from the Mount Kenya University and hospitals wasguaranteed the data collection permit . In addition, after the institutional review panel of each of the three district hospitals, the researcher was given permission to collect data at each district hospital. Respondents received detailed information and description of the study then they signed the consent form before their participation as it was a voluntary participation. As presented in Table 1, Byumba DH is highly represented in this study with 42.5%, followed respectively by Nemba DH (32.1%) and Rutongo DH (25.4%). More than a half of respondents was female (51.5%) and males were 48.5%. A big part of respondents was aged between 20-30 years (64.9%), 59.0% were still unmarried, 54.5% had primary level of education. According to their work experience, 41.8% had less the 1 year of experience (3months-1year) and 39.6% had an experience between 2-4 years.Table 1. Socio-demographic characteristics of the respondents
|Variables||Items||Frequency (n=134)||Percent (%)|
|Workplace||Byumba District Hospital||57||42.5|
|Nemba District Hospital||43||32.1|
|Rutongo District Hospital||34||25.4|
|Age group||Below 20 years||10||7.5|
|Over 40 years||11||8.2|
|Level of education||No formal education||3||2.2|
|Work experience||3 months – 1 year||56||41.8|
|Over 7 years||11||8.2|
Socio-Demographic Characteristics of the Respondents
This part represents the respondent’s workplace, age group, marital status, gender, level of education, and working experience.
Findings in Table 2 show that 67.2% had heard about HBV. As reported by the respondents, the main sources of information were doctors (33.6%), nurses & midwives (23.9%), radio/TV shows and website (20.9%). More than a half (61.9%) knew that HBV is treatable, 32.8% did not know if somebody exposed to the HBV immediately develop an acute hepatitis versus 26.1% aware about HBV development after being exposed to it, 59% knew that HBV mainly affects liver and 47.0% knew that HBV is more contagious than HIV.
A total of 24 questions related to the knowledge of HBV prevention were assessed using SPSS assessment score. For a right answer, the rating was 3 marks and zero for the rest. A knowledge total score was determined by adding up the scores for on all 24 questions for each respondent. Findings in Table 3 demonstrate that 9.7% of respondents had a high level of knowledge about HBV, 45.5% of them had a medium knowledge, while 44.8% had a low knowledge about HBV. The mean knowledge score for all respondents was 38.4 out of a possible 72 marks to score (SD = 9.8). The minimum score was 24 marks and the maximum score was 72 marks.Table 2. General understanding of hospital cleaners on Hep B infection
|Variables||Frequency (n=134)||Percent (%)|
|Have you ever heard about Hep. B Virus?|
|Source of information|
|Newspapers and magazines||17||12.7|
|Nurses and midwives||32||23.9|
|Radio/TV shows and website||28||20.9|
|Brochures and Posters||5||3.7|
|Is Hep. B treatable or curable?|
|Does somebody exposed to HBV immediately develop acute hepatitis?|
|Is HBV mainly affects liver?|
|Is Hep. B more contagious than HIV?|
|Level||Frequency (n=134)||Percent (%)|
|High knowledge (Score: >50.4 )||13||9.7|
|Medium knowledge (Score: 36 – 50.4)||61||45.5|
|Low knowledge (Score < 36)||60||44.8|
|Minimum score: 24.0||Mean: 38.4|
|Maximum score: 72.0||Standard Deviation (SD): 9.8|
Practices of hospital cleaners concerning Hepatitis B prevention. The researcher wanted to determine the hospital cleaners’ practices towards Hepatitis B prevention. The key findings are presented in Table 4.Table 4. Respondents’ answers on practices related to HBV prevention
|Variables||Frequency (n=134)||Percent (%)|
|Have ever diagnosed Hep. B virus|
|Have screened about Hep. B virus|
|Have received treatment care after being tested positive of Hep. B virus|
|Have attended training sessions on Hep. B virus|
|Reporting in case of needlestick injuries|
|All the time||78||58.2|
|Number of vaccine doses received|
Findings on respondents’ practices on HBV prevention as presented in Table 4 revealed that 75.4% have not been diagnosed the HBV, 63.4% were immunized against HBV, 51.5% were screened the HBV, 90.3% received treatment care after testing positive for for HBV, 58.2% have received any training session on HBV, 58.2% have reported in case of needlestick injuries while 38.8% confirmed that they have received at least 3 doses of HBV vaccine while 28.4% said they did not get any dose of HBV vaccine.
The practices’ section encompassed ten (10) questions related to HBV prevention and were marked for each respondent. If a respondent provided a correct answer, he/she was given a score of 3 points. If he/she provided a false answer, he/she was marked by zero. Each respondent's overall practices score was calculated by adding the values from each of the ten HBV prevention questions. The total score was 30 points. Hence, only 2.2% of respondents presented good practices (scored more than 21 out 30 points), 69.4% of them had fair practices (scored between 15 and 21 points out of 30 points) and 28.4% presented poor practice on HBV practices (scored less than 15 points out of 30 points). The average practice scorer for all respondents was 16.2 out of 30 (SD = 2.45). The minimum scorer got 11 out of 30 points and the maximum scorer scored out 21 out of 30 points (Table 5).Table 5. Distribution of Hepatitis B virus practices amongst respondents
|Level||Frequency (n=134)||Percent (%)|
|Good practice (Score: >21)||3||2.2|
|Fair practice (Score: 15-21)||93||69.4|
|Poor practice (Score < 15)||38||28.4|
|Minimum score: 11.0||Mean: 16.2|
|Maximum score: 21.0||SD: 2.45|
Factors Influencing Hospital Cleaners’ Knowledge toward Hepatitis B Prevention
In the bivariate analysis, findings in Table 6 revealed that marital status (p=0.018), level of education (p=0.04) and work experience (p=0.039) were significantly associated with the level of knowledge towards HBV prevention. Multivariate logistic regression analysis, identified that the odds of having high level of knowledge towards HBV prevention was 2.3 times greater (AOR,=2.3, 95%CI: (1.1-27.3); p=0.045) among respondents with high school education compared to those with no educational level. Respondents with work experience of 5-7 years were 1.5 times more likely (AOR=1.5; 95%CI: (1.16-9.8); p=0.034) to have a high level of knowledge towards HBV prevention than those with work experience of less than one year.Table 6. Factors influencing hospital cleaners’ knowledge toward Hepatitis B prevention
|Variables||Item||Knowledge on HBV prevention||χ2||p-value||COR||AOR||p-value|
|High||Medium||Low||(95% CI)||(95% CI)|
|> 40 years||2(18.2)||6(54.5)||3(27.3)||-||-||-|
|Level of education||No educat.||1(33.3)||1(33.3)||1(33.3)||Ref.||Ref.||-|
|Work experience||<1 year||4(7.1)||24(42.9)||28(50.0)||43.5||0.039||Ref.||Ref.|
|Introduction to Hospital HBV Prevention policy||Yes||5(7.0)||29(40.8)||37(52.1)||3.64||0.162||-||-||-|
|Orientation on hospital IPC policies||Yes||6(7.9)||28(36.8)||42(55.3)||7.81||0.02||Ref.||Ref.|
|Trainings on use of PPEs||Yes||5(5.4)||43(46.2)||45(48.4)||6.78||0.034||Ref.||Ref.|
Findings presented in table 6 revealed that the orientation on hospital IPC policies (AOR=0.6; 95%CI: (0.19-1.96); p=0.042) and trainings on use of PPEs (AOR=0.2; 95%CI: (0.07-0.76); p=0.017) are less likely to influence the hospital cleaners’ knowledge in this study. 7,
Based on the results in Table 7 the respondents’ age group (p=0.029), level of education (p=0.007) and work experience (p=0.04) were associated with good practices towards HBV prevention. The multivariate logistic regression analysis showed that those aged between 20-30 years were 2.5 times more likely (AOR,=2.5; 95%CI: (1.33-3.50); p=0.02) to have good practices on HBV prevention than respondents aged less than 20 years. Respondents with a high school education were also 2.7 times more likely (AOR,=2.7; 95%CI: (2.4-5.61); p=0.019) to have good practices on HBV prevention than those with no level of education. The odds of having good practice towards HBV also increased with work experience (AOR=2.3; 95%CI: (1.29-4.3); p=0.014).Table 7. Factors influencing hospital cleaners’ practices toward Hepatitis B prevention
|Variables||Items||Practice on HBV prevention||χ2||p-value||COR||AOR||p-value|
|> 40 years||2(18.2)||6(54.5)||3(27.3)||1.5(0.1-11.5)||0.2(0.02-2.4)||0.94|
|Level of education||No educat.||1(16.6)||2(66.8)||1(16.6)||14.2||0.007||Ref.||Ref.|
|Work experience||<1 year||1(1.8)||42(75.0)||13(23.2)||34.26||0.04||Ref.||Ref.||-|
|Introduction to Hospital HBV Prevention policy||Yes||3(4.2)||36(50.7)||32(45.1)||25.1||<0.001||Ref.||Ref.||-|
|Orientation on Hospital IPC policies||Yes||1(1.2)||39(51.3)||36(47.4)||31.3||<0.001||Ref.||Ref.||-|
|Trainings on use of PPEs||Yes||1(1.1)||58(62.3)||34(36.6)||15.5||<0.001||Ref.|
The knowledge and practices of hospital cleaners from three district hospitals in Northern Province of Rwanda (Byumba, Rutongo and Nemba) in relation to HBV prevention were investigated in this study. The results of the study showed that only 9.7% of respondents had a high level knowledge about HBV, 45.5% of them had medium knowledge, while 44.8% had low knowledge about HBV prevention. The research findings are consistent with what was found in a research of nursing and midwifery staff in 2 maternity hospitals in Khartoum, Sudan, where 58.2 percent of participants had average knowledge level on HBV 21. However, a study conducted in Northwest Ethiopia showed that overall knowledge of HBV prevention, and modes of transmission was high (86.2 %) 22.
Additionally, research conducted in North Vietnam showed a significant lack of knowledge regarding Hepatitis B testing and interpretation of results, symptoms of chronic hepatitis B infection, its treatment and monitoring of patients with chronic hepatitis B infection. The median knowledge scores regarding chronic hepatitis B infection treatment, and monitoring were low amongst the eight HBV knowledge categories 23. This was similar to prior Cameroon research which showed that participants had strong understanding of HBV infection 24. But, at Haramaya University, Ethiopia, it was higher than the 56.2% knowledge level 25, 59 % from Iraq 26 and 14.5 % from Lao 27.
The study's findings revealed that knowledge about HBV prevention is strongly linked to level of education (AOR=2.3, 95%CI: (1.1-27.3); p=0.045) and working experience (AOR=1.5; 95%CI: (1.16-9.8); p=0.034). The results of this study are in line with a research done in Sudan's White Nile state, which showed that the level of HBV knowledge among HCWs was significantly linked to the level of education 28.
On one hand, our study results were in line with results of a study done in Khartoum where they found that there were no significant association between age, occupation, marital status; but on the other hand, our findings were in contrast with findings revealed in their study where Sanaa et al. showed that there was no statistically significant relationship between knowledge, attitude, educational level, practice, and working experience concerning HBV 21.
The findings from this study revealed that only 2.2% of respondents presented good practices, 69.4% of them had fair practices and 28.4% presented poor practice on HBV practices. A study in Pakistan conducted among the safe population of Quetta , found that 96.9% of respondents never went to Hep B screening and 86.8 per cent registered as negatively immunized against Hep B 29. This have been supported by a study conducted by Ul Haq et al. 30 found that 66.9% of patients w ere within the spectrum of inadequate practice, while 33.1% demonstrated good preventive practice with respect to Hep B. Most of 98.2% of patients have not been certainly screened with hep B before getting the infection.
The result from this study showed that being aged between 20-30 years was associated with 2.5 times (AOR,=2.5; 95%CI: (1.33-3.50); p=0.02) more likely to have good practices on HBV prevention than respondents aged less than 20 years. Respondents with high school had 2.7 times (AOR=2.7; 95%CI: (2.4-5.61); p=0.019) more likely to have good practices on HBV prevention than those with no level of education. The odds of having good practice towards HBV had found to increase with work experience (AOR=2.3; 95%CI: (1.29-4.3); p=0.014). In line with this finding, a study conducted by Ahmad et al. 31 shows that gender, age, marital status, education level, and vaccination status was significantly associated with safer practices towards hepatitis B.
Some of the cleaners in the Byumba, Nemba and Rutongo district hospitals in Rwanda are aware of HBV infection. However, many of the participants lacked the requisite knowledge for prevention and management of post- exposure with HBV. The results for this study found low coverage rate for vaccination and a high prevalence of needle stick injuries. Additional occupational exposure protection strategies, HBV infection training plans, and raising vaccination coverage to all cleaners are all needed.
Some of the cleaners in the Byumba, Nemba and Rutongo district hospitals are aware of Hep B infection. However, many of the participants lacked the requisite knowledge for prevention and management of post- exposure with HBV. The results for this study found low coverage rate for vaccination and a higher prevalence of needle stick injuries. Additional occupational exposure protection strategies, HBV infection training plans, and raising vaccination coverage to all cleaners are all needed.