Hepatitis B among Ugandan pregnant women: studies on epidemiology, knowledge, perceptions and behavioral intentions
Mutyoba, Joan Eron Nankya
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Introduction: The global drive to eliminate the public health threat due to hepatitis B virus (HBV) infection by 2030 was launched in 2016. Within sub-Saharan Africa (SSA), a high burden of chronic HBV coupled with limited resources to identify key at-risk populations for disease control presents a significant challenge. In order to strengthen prevention of HBV mother-to-child transmission, it is imperative to understand disease distribution and population awareness, perceptions and preventive behaviours among pregnant women. Methods: Studies were conducted among pregnant women attending routine antenatal care (ANC) in public health care facilities in Kampala , Wakiso and Arua districts, supported by preliminary formative studies among patients at the Uganda cancer institute and a rural community in Wakiso district, Uganda, to answer five specific objectives, namely: (i) To determine prevalence and risk factors for hepatitis B among pregnant women attending antenatal clinics in public health care facilities; (ii) To measure HBV awareness and knowledge, for hepatitis B and liver cancer prevention; (iii) To measure HBV-related perceptions and preventive behavioral intentions among pregnant women attending antenatal clinics in public health care facilities; (iv) To evaluate the effect of an education intervention among pregnant women on uptake of HBV and liver cancer knowledge and (v) To explore pregnant women’s perceptions, barriers and preferences in relation to the hepatitis B vaccine birth dose vaccination for newborns. Results: Objective (i): The overall prevalence of chronic HBV infection in pregnant women was 6.13% (19/310), significantly higher in the West Nile region (11%) compared to the Central region (1.3%), p<0.001. In both regions, majority of pregnant women themselves (61% West Nile region, 76% Central region) were susceptible to HBV. Overall, only 5.8% had been tested for HBV and 11.3% had been vaccinated. Objective (ii): Of 455 participants enrolled, about two thirds reported having heard about HBV. Almost half (47%) of participants from the central region, compared to 16% from the north, reported never having heard of HBV. Overall, only 162/455 (36%) of participants had adequate HBV knowledge. Knowledge about horizontal (256/455 (56%)) and mother to child transmission of HBV (242/455 (53%)) were suboptimal. About two thirds, 298/455 (66%) and 281/455 (62%), believed HBV was spread via sharing of utensils and mosquito bites respectively. Residing in the north, (PR=1.91(1.53 -2.38), p < 0.001) compared to central region and having a secondary education (PR=1.87(1.37 -2.55), p < 0.001) compared to primary or lower, were statistically significantly related to being knowledgeable about HBV. Objective (iii): Perceived risk of acquiring HBV (prevalence rate ratio (PRR) = 0.95(0.90–1.00), p = 0.055) was inversely associated with intention to take a HBV test. Conversely, perceived self-efficacy showed a consistent association with intention to take a HBV test (PRR = 1.18(1.10–1.23) p = 0.005), to vaccinate against HBV (PRR = 1.20(1.05–1.36) p = 0.006) and to seek treatment for HBV (PRR = 1.40(1.18–1.67) p < 0.001), if infected. Women from the north, compared to the central region (PRR = 1.76 (1.13–2.72) p = 0.012), and those who self-identified as Catholic (PRR = 1.85 (0.99–3.56) p = 0.056), and as Protestant, (PRR = 2.22 (1.22–4.04) p = 0.002), were more likely to have higher perceived self-efficacy for taking HBV-preventive actions, compared to Muslims Objective (iv): Proportion of women with adequate HBV knowledge at baseline was 21.1% and 24.4% in the control and intervention clusters respectively (Diff: 3.4% (95% CI, [-5.8%, 12.4%]) P = 0.487). Participants randomized to usual care health units showed a modest increase in HBV knowledge (after 3-4 months) from 21.1% to 32.1%, a within-group knowledge gain of 5.9% (95% CI [-0.6% ,22.6%] P = 0.066). Participants in intervention health units had significantly higher gain in HBV knowledge after 3-4 months, with proportion of women with adequate HBV knowledge increasing from 24.4% at baseline to 85.8% at the subsequent ANC visit, (3-4 month later) a statistically significant within-group difference of 61.4% (95% CI, [55.1%,67.7%]) P < 0.001. Objective (v): Both urban and rural-dwelling women-groups were aware of liver cancer but had never heard about HBV, or the HBV birth dose vaccination for newborns. Women revealed concerns about competence of Health workers, the safety of the birth dose vaccine, and its availability to newborns outside the health system. Rural-dwelling groups perceived absence of HBV services in antenatal care, while focus group discussions (FGDs) with young participants believed vaccine side-effects were existing barriers to planning and implementing the HBV birth dose vaccination for newborns. Most women-group preferred (i) oral to injectable vaccines; (ii) receiving HBV birth dose vaccination education and information during antenatal sessions, rather than via electronic or print media; (iii) that newborns receive the birth dose immediately after delivery, and in the mother’s presence. Conclusion: Pregnant women in Uganda have a high burden of HBV, with significant regional differences, low knowledge and inaccurate perceptions of HBV. Socio-cultural influencers of HBV-related perceptions and intention to engage in HBV preventive behaviours need to be addressed. A nurse-delivered HBV education intervention improved HBV knowledge among women. In addition, because women are willing to have their newborns vaccinated with the HBV birth dose vaccine, and prefer to receive this information as part of antenatal care services, efforts to provide them with accurate information and to engage them regarding the birth dose vaccination will prepare them when the birth dose is offered to newborns. These findings, collectively inform policy options that could be adopted to maximize efforts eliminate HBV in this sub-population.