Social Awareness and Knowledge of Parenteral Viral Hepatitis (B and C) Among Residences of Menoufia Governorate, Egypt: A Questionnaire-Based Field Study

Corresponding Author: Wesam S. Morad Department of Epidemiology and Preventive Medicine, National Liver Institute, Menoufia University, Egypt Email: wesammorad@gmail.com Abstract: Egypt had led a unique successful campaign in treating and surveillance of the most prevalent viral infections. However, social awareness evaluation is an unmet need for viral eradication strategic plans. Assess the level of knowledge and awareness of the community about HCV and HBV infections. This community-based cross-sectional survey, was conducted between November 2018 and March 2019 in Menofia Governorate, Egypt. A well-structured pretested questionnaire testing knowledge and awareness regarding HBV and HCV infections and their modes of transmission in 14000 medical and non-medical, urban and rural participants. Knowledge about HBV found to be good regarding transmission (81.9% correct answers), while in cure 51.7% of participants gave false answers. For HCV infection, good knowledge (79.3% of correct answers) was documented, while the curable nature of disease was denied in 40.9%. Blood and blood products (53.2%), sexual contact (27.8%), mother to child during delivery (7.3%) and others were reported as the commonest modes of transmission of HCV respectively. Television and newspapers were the main sources of knowledge (33 and 22% respectively). On asking participants about precautions against HCV infections, 30.2% stated that they are being educated on this issue, 22.3% had heard something like that and 47.5% of participants did not know anything about that. Multivariate logistic regression revealed that for both HBV and HCV knowledge and awareness were affected by age, residence and level of education. Despite the good results, levels of social awareness should be more elevated for proper viral eradication programs.


Introduction
Viral hepatitis is estimated to be the 7th leading cause of mortality worldwide (Stanaway et al., 2016). Hepatitis C Virus (HCV), is a primary cause for liver fibrosis, cirrhosis and cancer which is responsible for one half of this mortality (Mohd Hanafiah et al., 2013;Lavanchy, 2011).
On the other hand, more than 240 million are chronically infected with Hepatitis B Virus (HBV) which is responsible for about 500,000 to 700,000 annual deaths (Toy et al., 2011;WHOEB, 2009;WHO, 2012).
Egypt has the highest prevalence of HCV infection. In which HCV antibodies sero-prevalence among adult population aged 15-59 years was 14.7% in 2009 and at 10.0% in 2015 which was substantially higher than global levels as stated in The Egypt Demographic and Health Surveys (EDHS) (Mohd Hanafiah et al., 2013;Lavanchy, 2011).
Despite of the lower prevalence of HBV in Egypt (Ismail et al., 2017), it still constitutes the second most common viral infection of the liver which needs effective measures for control.
To cope with this challenge, Egypt developed a national project for HCV elimination (Gamal, 2014;EESJU, 2014;EMHP, 2017). The National Committee for Control of Viral Hepatitis (NCCVH) was launched in 2006 by the Egyptian Ministry of Health and Population (MOH) to cope with the serious problem of HCV epidemic in the country (El-Akel et al., 2017). On the beginning of its work, The Egyptian NCCVH issued the national treatment strategy for control of HCV infection, which represented the road map for its work (Doss et al., 2008).
After successful negotiations for 99% discounted Directly Acting Antiviral drugs (DAA) prices (Kim et al., 2015), Egypt started an ambitious national HCV treatment program with the goal to treat over 250,000 individuals with HCV infection per year, with the hope of reduction of HCV prevalence to < 2% by 2025 (McNeil Jr., 2015).
Several studies suggest that the incidence of HCV infection has decreased since the second half of the 20th century. First, most countries have age-specific prevalence of serological evidence of past or present infection, suggesting lower incidence in recent years (Bruggmann et al., 2014;Saraswat et al., 2015;Liakina et al., 2015;Armstrong et al., 2000). Second, countries that conduct surveillance for acute hepatitis C reported decreases in the rates (Williams et al., 2011). Third, countries that conducted more than one biomarker survey, such as Egypt, reported an evolution over time that suggests a decrease in incidence (MHPICFI, 2015). Fourth, injection safety improved, which reduced the incidence of injection-associated HCV infection (Pépin et al., 2014).
Worldwide, 7% of those diagnosed (1.1 million) were started on treatment in 2015. The Eastern Mediterranean Region accounted for the largest proportion of those started on treatment (12%), boosted by the large-scale elimination plans in Egypt (Estes et al., 2015). Of those started on treatment in 2015, about half received DAAs. Given that more people were initiated on treatment the following year, WHO (2016) global report on access to hepatitis C treatment estimated that about 1 million persons had accessed DAAs in selected countries. However, there is wide variation in terms of access to DAAs from country to country.
For example, in 2015, the HCV elimination program in Egypt was based on the use of DAAs.
These measures could only succeed if based on good knowledge and awareness of both infections by community members who require comprehensive contribution of both health care delivery system and the Egyptian community.
Thus, this study was conducted on a cohort of population in order to assess the level of knowledge and awareness of the community about HCV and HBV infections.

Study Design and Data Collection
This community based cross sectional survey was conducted between November 2018 and March 2019 in Menofia Governorate which is located at the Nile delta at north of Egypt. This Governorate is populous with a surface area of 2,543 km 2 and a population number of 4,077 million.
We excluded those < 18 years old and those who refused to participate in the study from the start or who refused to complete the questionnaire.
The study was done by using a well-structured pretested questionnaire containing 10 closed-ended (yes/no) and 8 open-ended questions. The questionnaire tested the demographic and socioeconomic characteristics of participants along with 19 questions testing knowledge and awareness regarding HBV and HCV infections and their modes of transmission.
The awareness about prevention of HBV and HCV infections including vaccination status was included in a set of questions with a focus on the source of participants' information. Also, the screening status of participants and their family members was included in these questions, Tables 3, 4, 7 and 8.
This questionnaire was developed on basis of previous studies (Du et al., 2012;Denniston et al., 2012). The original questionnaires were in English and some of its questions were not suitable with the Egyptian culture. So, we chose some of these questions and translated it to simple questions that could be easily understood. The questionnaire was revised and modified several times by some professors of National liver institute. A small pilot study was done on 50 of the employees of the National Liver Institute and some of the companions of the attending patients to the outpatient clinic of the National Liver Institute hospital before it was finally approved.
The study was done with the help of 5 interviewers (including 4 nurses and one employee from National Liver Institute). The idea of the study and items of the questionnaire was explained to all of the interviewers before starting the study.
Printed copies of the questionnaire were distributed to 14682 participants using systematic random sampling technique by the interviewers.
Of the 14,682 participants, 14000 were recruited in which 682 individuals refused to participate in the study; 1000 from medical students of the Faculty of Medicine, Menoufia University, 3000 were non-medical students from three faculties other than the faculty of medicine belonging to the same University. Five thousand residents were recruited from five rural areas of Menofia Governorate and lastly 5000 residents were chosen from other five urban centers of the same Governorate.
After obtaining verbal approval to be included in the study, all participants were asked to fill the administered questionnaire at their own will and convenience. Then filled questionnaires were anonymously returned to the interviewers. The interviewers helped some participants who felt difficulty to understand some questions and they filled the questionnaire by themselves for illiterate persons.

Important Definitions
However, there is a distinct difference between awareness and knowledge.
Awareness is perceiving, knowing, feeling, or being conscious of events, objects, thoughts, emotions, or sensory patterns.
Knowledge is facts, information and skills acquired through experience or education.
A knowledge score depending on the mean percentage of correct answers was assigned. A percentage of correct answers equal to or greater than 60% of all questions was considered "good", if less than 60% or equal poor.
Statistical Analysis Data were coded, tabulated and analyzed using the Statistical Package for Social Science (SPSS) version 26.0 for Windows (SPSS, Chicago, IL, USA). Continuous variables were described using mean and standard deviation and categorical variables were described using frequencies and percentages. The zratio was used for the significance of the difference between two independent proportions and a p value less than 0.05 was considered statistically significant. The Analysis of Variance (ANOVA) test was used for the significance of the difference between quantitative variables and a p-value less than 0.05 was considered statistically significant.

Socio-Demographics of Participants
A sum of 14682 inhabitants of Menofia Governorate voluntarily participated in this study. Participants were asked to fill out the study questionnaire under supervision of the interviewers. Among all participants, 682 individuals returned unfilled questionnaires or refused to continue the interview (response rate, 95.4%) and they were excluded from the study.
While for public residents group (urban and rural), males were (47.4% and 47.7%) and females were (52.6% and 52.3%) with mean age (46.4±16.2 and 47.2±17.4 years) and range between (18-65 and 20-67 years) for residents of rural and urban areas respectively.
According to the socioeconomic level of these residents, (48.7% and 49.4%) were of low and intermediate levels and (51.3% and 50.6%) of high socioeconomic levels for residents of rural and urban areas respectively.
About 49.3% and 56.2% of participants underwent previous screening for hepatitis B and C respectively while 5.6% and 7.2% were not sure about HBV and HCV screening respectively.

Knowledge About HBV
Knowledge about HBV was tested by questions 1 to 6, There was no significant difference between percentage of correct answers between medical and nonmedical students and between residents of rural or urban areas, Table 2.
Knowledge of participants about HBV transmission was significantly affected by their age category, residence area, current jobs, level of education and socioeconomic standard measured by monthly income (p < 0.05), Table 3.
While gender of participants and their marital status did not affect their knowledge about HBV infection, Table 3.
As regard modes of HBV transmission, blood and blood products transfusions (50.9%), followed by sexual contact (30.1%) and from mother to child during delivery (6.7%) were reported as the common modes of HBV infection, Fig. 1.   (1000)     About 72.6% of participants were vaccinated for hepatitis B infection while 7.2% did not know about their vaccination status. Amazingly, 47.3% participants stated that none of their family members were vaccinated against HBV and 21.5% were not sure whether about vaccination status of their family members.
Source of participants' knowledge was variable. About (32.1%) gained their knowledge from television materials and (24%) of them gained it from newspapers and magazines, Fig. 2.

Awareness About HBV
Awareness about HBV preventive measures was tested by questions number 7 to 10, Table 1. Participants had good awareness about measures of HBV prevention and availability of HBV vaccine with (92.13%) correct answers to supplied questions.
Percentage of correct answers was not significantly different among different study groups, Table 2.
On Univariate analysis, age category, residence, marital status and level of education of participants was significantly related to their level of awareness about HBV prevention. Whereas, gender, job and no monthly income had no significant relationship, Table 4.

Knowledge About HCV
The study revealed good knowledge (79.3% of correct answers) regarding HCV infection (reflected by the first six questions in Table 5) among all participants except for the curable nature of HCV,  Table 5 and Fig. 3.
The percent of correct answers did not differ between medical and non-medical students and between residents of rural and urban areas, Table 6.
Knowledge about HCV transmission was significantly related to participants' age category, residence area, current jobs and level of education and socioeconomic standard of participants. While, gender and marital status of participants had no significant relationship, Table 7.
Participants stated that they had their knowledge mainly from television materials and newspapers (33 and 22% respectively), Fig. 4.

Awareness About HCV
The awareness of participants about measures to prevent HCV was tested by the last 3 questions in Table   5. About (92%) of participants gave correct answers on these questions.
Age of participants, their residence area, marital status and education level varied significantly with their awareness about prevention of HCV infection, Table 8.
On asking participants about precautions against HCV infections, 30.2% stated that they are being educated on this issue, 22.3% had heard something like that and 47.5% of participants did not know anything about that.

Multivariate Analysis
Multivariate logistic regression of significant factors which affected participants' answers revealed that knowledge and awareness about HBV infection were affected by age category of participants, their residence and increased level of education, Table 3 and 4. While for HCV infection, awareness about HCV infection was significant with participants' age category, residence and level of education, Table 8. In addition to these factors, knowledge about HCV infection was affected by the monthly income of these participants, Table 7.

Discussion
Hepatitis C constitutes a major health problem in Egypt, which has strong negative clinical, social and economic impact on patients and their families and also on the healthcare systems. Many studies tried to measure the level of knowledge and awareness about HCV and HBV infections among different groups of population in Egypt. But, results of these studies were heterogonous (Shalaby et al., 2010;Norton et al., 2014).
This community-based cross sectional study was conducted on 14000 residents of Menoufia Governorate residents of different socio-economic and education levels in order to provide comprehensive data about knowledge and awareness of community members about HCV and HBV infections.
In this study, we found that 81.9% of participants had good knowledge about HBV infection and 92.13% had good awareness about HBV prevention. This was surprisingly higher than expected especially when compared with other studies from countries with high prevalence of HBV infection.
In a study by Rajamoorthy et al. (2019) they found only 36.9% of their study population had good knowledge and 38.8% had good awareness about HBV infection.
In another study on healthcare workers and University students at Malaysia, they also revealed that 39.1% of participants had good knowledge and 37.2% had good awareness about HBV infection (Lim and Rashwan, 2003).
On the other hand, participants' knowledge in our study about HCV infection was less than for HBV infection (79.3%). This may be attributed to false concepts about disease curability. This agreed with other studies on public population in Egypt which revealed lack of knowledge about HCV transmission (Chemaitelly et al., 2014;Sultan et al., 2018). But, awareness about HCV prevention was good among participants (92%).
Recently, many attempts occurred to improve awareness about viral hepatitis in Egypt by the Information, Education and Communication systems through hotlines, counseling, vaccination campaigns and celebration of World Hepatitis Day. The World Hepatitis Day celebration brought stakeholders together and conveyed important messages to the community (Wanis et al., 2014).
In our study, many participants stated that they had their information about HCV and HBV infection through television programs or newspapers, which reflects the success of this policy as regard improved knowledge and awareness about viral hepatitis in our study population.
This agreed with a study by Shalaby et al. (2010) who assumed that friends and relatives (47.9%), television (43%), newspapers (36.7%) and doctors (30%) were the main sources of information. Also, Chemaitelly et al. (2014) stated that the media is the main sources of HCV knowledge.
The level of education (illiterate, primary or secondary education, diploma, university and postgraduate levels) was one of the most important factors that affected knowledge and awareness about HCV and HBV infections. Also, there was difference between medical and non-medical students.
These results were similar to findings reported by the study at the University of Dammam, Kingdom of Saudi Arabia (Chemaitelly et al., 2014), at University of Lome students (Sultan et al., 2018), in the Medical College of Bitola (Wanis et al., 2014) and in medical colleges of Karachi, Pakistan, which revealed excellent knowledge about HBV and HCV transmission (Almansour et al., 2017).
In our study, the socioeconomic level of participants (measured by the monthly income and job of participant) affected knowledge but did not affect awareness about HCV and HBV infections which agreed with other studies (Wai et al., 2005;Taylor et al., 2002;Ahmad et al., 2016;Tosun et al., 2018). This may explain difference between answers of residents or rural than those of urban areas in our study.
In our study, most of the participants were high level students (medical and non-medical) and on the other hand, one half of included public participants were living in urban areas with better socioeconomic and education levels. This may explain the relatively better levels of knowledge and awareness about HCV and HBV infection.
Another point to be considered is the time of the study between 2018 and 2019, which was parallel to the successful national project of screening and treating HCV in Egypt. During this period, many campaigns, television programs, newspapers widely discussed the problems of HCV and other viral infections. This may have helped to raise community knowledge and awareness about these two health problems

Conclusion
Knowledge and awareness about HBV and HCV infections is the base at which the solution of these health problems should be built. Despite of the good results of this study about the level of knowledge and awareness about HBV and HCV infection and prevention, there is a need to do more studies on different population sectors at various socioeconomic and educational levels.
Declaration of Helsinki. All patients gave written informed consent, which was reviewed and approved by an independent ethics committee or institutional review board of National Liver Institute (IRB00003467). This study was approved (approval numbers 00129/2018).

Consent for Publication
Patients provided written informed consent for use of their anonymized and aggregated data for research and sharing with other parties.

Data Availability Statement
The data used to support the findings of this study were supplied by National Liver Institute, Menoufia University under license and so cannot be made freely available. Requests for access to these data should be made to [National Liver Institute Top manager, Menoufia Governorate, Egypt].
The qualitative and quantitative data used to support the findings of this study are restricted by the [National Liver Institute ETHICS BOARD] in order to protect [PATIENT PRIVACY]. Data are available from [National Liver Institute Top manager, Menoufia Governorate, Egypt] for researchers who meet the criteria for access to confidential data.
The qualitative and quantitative data used to support the findings of this study are available from the corresponding author upon request for researchers who meet the criteria for access to confidential data.
The qualitative and quantitative data used to support the findings of this study have not been made available because [National Liver Institute Top manager].

Funding Statement
This paper was funded by the authors of the paper themselves with no funding agency or funded personnel.