Predictive factors of vaccination status, knowledge, attitudes, and practice towards prevention of hepatitis B infection among Bangladeshi people: A cross‐sectional study

Abstract Background and Aims Infection with the hepatitis B virus is a serious public health problem that is growing all over the world. Therefore, in this context, there is no exception to public participation in disease burden reduction. Consequently, for the first time in Bangladesh, the current study aims to assess the level of vaccination status, knowledge, attitude, and practice of hepatitis B infection among general people. Methods A cross‐sectional study was carried out between December 15, 2021, and January 17, 2022, including sociodemographic information as well as questions about vaccination status and knowledge, attitude, and practice related to hepatitis B. Data were analyzed using descriptive (frequency) and inferential statistics (Mann–Whitney U, Kruskal–Wallis H, χ 2, binary logistic regression, and spearman's rho correlation coefficient). Results Results indicated that about one‐third (37.9%) of the 807 participants had received hepatitis B vaccine, with an overall mean score of 11.506 ± 5.403 for knowledge, 5.435 ± 1.038 and 4.252 ± 1.776 for attitude and practice, respectively. Risk factors related to vaccination were age, religion, educational qualification, occupation, residence area, marital status, comorbidity, and family member suffering from hepatitis B. Higher level of knowledge was significantly found among the young people aged between 10 and 29; had higher secondary or tertiary education (median = 13); were employed (median = 13.5, interquartile range [IQR] = 8); living in divisional city (median = 13, IQR = 7); were single (media = 13, IQR = 7); and whose family members were suffering from hepatitis B. Besides, poor practice was observed among those aged between 50 and higher (p = 0.004), had no formal education [p < 0.001), a retired or housewife (p < 0.001), divorced or widowed (p < 0.001), absence of comorbidity (p = 0.02), and whose family members were not infected with hepatitis B (p < 0.001). Conclusions The results exposed that vaccination rates and preventative behavior are unsatisfactory, which will hinder efforts to eradicate hepatitis B worldwide by the year 2030.


| INTRODUCTION
In the healthcare setting, hepatitis B (HB) is widely considered as a global public health threat since HB is a potentially fatal viral infection caused by the hepatitis B virus (HBV). 1,2 This virus can easily be transmitted from one infected person to another, with the most common transmission routes being perinatal transmission (mother to child at birth) or horizontal transmission (exposure to infected blood). 2,3 In addition, unprotected sexual contact, sharing of eating utensils and other barber shop and beauty salon equipment, tattooing, ear piercing, acupuncture, dialysis, and even syringe use can all be potential sources of infection. 1,2,4,5 People infected with HB generally exhibit the common symptoms of yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting, and abdominal pain. 2 Based on the severity, HB infection can be acute or chronic, with infants and children being more vulnerable than adults. 2 Although acute HB can be cured with prompt medical attention, people with chronic HB such as liver disease, liver cirrhosis, and hepatic-cellular carcinoma may experience lifelong complications and even death in extreme cases. 1,[6][7][8] According to the World Health Organization (WHO) report 2019, approximately 296 million people have lifelong chronic HB infection and there is an ongoing increase in the detection of new cases around the world. 2,9 WHO also estimated that about 1.5 million new infections occur each year all over the world along with 820,000 deaths caused by chronic HB, primarily liver cancer. 2 Despite the fact that HB is classified as a "priority disease" in a global context. In line with the situation, the WHO Western Pacific Region has a massive burden of HB infection, while the WHO South-East Asia Region has 18 million. 2 As part of South Asia, Bangladesh was reported to be one of the top 10 burdened countries for viral hepatitis due to the lack of health education, illiteracy, poverty, and a lack of HB vaccination. [10][11][12] Consequently, Bangladesh has an intermediate chronic HB prevalence estimated at 2%-6% although epidemiology may vary between geographic regions and sociodemographic factors. 10 As mentioned earlier, the prevalence of HB is increasing over the world, therefore, prevention is seen as one of the best ways to protect people's health. 9,13 There is no exception to public participation in reducing disease burden in this context, and evidence suggests that the public's health-related behavior is determined by their knowledge, attitude, and practice (KAP). 3 KAP studies are widely regarded as an important component of public health because they represent a specific population's health-seeking behaviors based on what the participants know, believe, and practice about a specific disease. 3,9 Although HB is a significant occupational hazard especially for health workers, 14 it can also be a threat for all people because of their unawareness. To reduce the HB infection among the people of Bangladesh, it is critical to understand their vaccination status, knowledge, attitude, and preventive behavior, as Bangladesh is unable to control it without public participation due to limited healthcare resources. Previously, few studies were conducted in the country in response to the issues, 5,[15][16][17][18][19][20] but to the best of knowledge, none of the studies evaluated the level of KAP along with its predictors among general people in Bangladesh.
Therefore, the current study aims to investigate this knowledge gap.
The study's main strength is that it provides a better understanding of the scenario of HB infection in Bangladesh, which is important for HBV prevention. Hence, it is anticipated that the present study findings would be helpful for the government of Bangladesh to take necessary steps based on the study findings to prevent HB infection in Bangladesh.

| Study procedure, participants, and ethics
Data were collected using an online-based data collection tool (e.g., Google form) due to the outbreak of the omicron variant of the COVID-19 pandemic in Bangladesh. Data collection was completed between December 15, 2021, and January 17, 2022. Initially, a structured questionnaire was developed and pretested among the research assistants although minor modification was done after the pilot testing. This questionnaire was distributed among the target population through utilizing diverse social media sites such as Facebook, Messenger, WhatsApp, and so on. Besides, data from illiterate people were collected through an interview. To take part in the survey, participants had to be active Bangladeshi people at least 13 years old and be interested in the study. In addition, the respondents gave their informed consent to participate in the study after learning about the study's goals and objectives (consent was provided by the legal guardians whose age was under 18).
Furthermore, the data's confidentiality and anonymity were also guaranteed. Primarily, 863 respondents completed the survey where 807 data were utilized for final analysis in the study after the incomplete survey was eliminated. For all variables in our survey, "mandatory" fields were used to exclude missing data. All procedures were carried out in accordance with the Helsinki Declaration of 2013 and its subsequent amendments. 21 Besides, the ethical aspects were also granted by the Biosafety, Biosecurity, and Ethical Committee of Jahangirnagar University, Bangladesh.

| Measures
The survey questionnaire included sociodemographic information,

| Knowledge about HB infection
The overall mean knowledge score for HB infection was 11.506 ± 5.403 among the general people.
The predictive factors that influenced vaccination status were depicted in (

| Correlation between knowledge, attitude and practice
The correlation between KAP is depicted in Table 3  participants (aged between 50 and above) received less HB vaccine. A consistent result was found compared to a prior study where about 2.1% of people who received vaccines were aged between 40 and higher. 23 Their decreased incidence of immunization status, however, might have a particular cause. It could be due to the the vaccine's accessibility since it was first initiated in 1986. 24 Additionally, there was a significant relationship between religion and vaccination status, with Muslims having a lower vaccination rate than those of other religious faiths. This result contrasts with a previous study's lack of a meaningful association. 23 The decreased rate of vaccination status indicated by participants who were divorced or widowed, who had comorbidities, and whose family members did not have HB infection and it was never investigated in any Bangladeshi study.
A previous study of general population participants found no significant association between gender and KAP. 9 In contrast with the previous study's findings, the current study yielded different results although similar to others studies. 25,26 In addition, knowledge was significantly higher among people between 10 and 29 years while in contrast with the previous study. 9 However, the study revealed that after the age of 20-29 years, the level of knowledge among participant's drops significantly and is mostly inferior to those aged 50 and up. In terms of educational qualification, participants with a higher level of education demonstrated adequate knowledge. It was also found that with the increment in educational status, knowledge levels significantly increased among the participants. However, a prior study depicted that secondary education was the significant predictor of good practice against HB infection, which is identical with our present findings. 18 Students reported adequate knowledge when compared to others and at the same time, employed people reported a significantly higher positive attitude and practice which could be attributed to organizational constraints such as the need to maintain regulatory enforcement of occupational health and safety standards. In contrast, less practice was found among the retired and housewife. According to a previous study, people in cities had more knowledge and practices than people in rural areas, 9,27  visualization; writingreview and editing.

ACKNOWLEDGMENT
The authors acknowledge all the participants and research assistants, without whom the study was not possible to carry out. The present study did not get any financial support.

CONFLICT OF INTEREST
The authors declare no conflict of interest.

TRANSPARENCY STATEMENT
The lead author Ismail Hosen affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The data can be found from the corresponding author upon request.