Evaluation of Knowledge Levels and Lifestyle Practices of Patients with Chronic Hepatitis B in a Tertiary Hospital in Turkey

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1 226 KUWAIT MEDICAL JOURNAL June 2018 Original Article Evaluation of Knowledge Levels and Lifestyle Practices of Patients with Chronic Hepatitis B in a Tertiary Hospital in Turkey Pinar Korkmaz 1, Cemile Uyar 2, Ahmet Ozmen 2, Turkan Tuzun 2, Duru Mistanoglu Ozatag 1 1 Department of Infection Diseases and Clinical Microbiology, Dumlupinar University School of Medicine, Kutahya, Turkey 2 Department of Infection Diseases and Clinical Microbiology, Dumlupinar University, Evliya Celebi Training and Research Hospital, Kutahya, Turkey Kuwait Medical Journal 2018; 50 (2): ABSTRACT Objective: This study aimed to evaluate the knowledge levels and lifestyle practices of patients diagnosed with chronic hepatitis B (CHB). Design: Prospective study Setting: Department of Infection Diseases and Clinical Microbiology, Evliya Celebi Training and Research Hospital, Kutahya, Turkey Subjects: One hundred and ninety-five patients who were followed up with CHB in the outpatient clinic of infectious diseases between vember 2015 and May 2016 were included. Interventions: A questionnaire was applied to patients Main outcome measures: Level of knowledge and lifestyle practices Results: A total of 195 CHB patients were included in the study (51.3% were males). The mean age was 3.1 ± 13.1 years. The mean knowledge level of the patients about the hepatitis B virus (HBV) was 13.5 ± The percentage of patients with a good knowledge level was 55.9%, whereas.1% had a poor knowledge level. Higher educational status was found to be correlated with higher knowledge level (p < 0.05). After being diagnosed with hepatitis B, 99.7% of our patients stated that they did not donate blood and 98.5% of them stated that they did not share their personal items such as razor blades or toothbrushes. The percentage of patients that continued to share their dishes and cups with other people after their diagnosis was 63.1% and 15.9% used an alternative treatment method for hepatitis B. Conclusion: In conclusion, the current study found gaps and misperceptions in the knowledge levels of CHB patients, particularly concerning HBV transmission. Increasing the number of studies performed on this subject will help to understand how the patients regard their disease. KEY WORDS: hepatitis B, knowledge, misperceptions, practices INTRODUCTION Hepatitis B virus (HBV) infection, an important cause of acute and chronic liver diseases, is regarded as a significant public health problem worldwide, especially in endemic areas. HBV is one of the leading causes of cirrhosis and hepatocellular carcinoma (HCC) worldwide. The World Health Organization (WHO) reports that more than 350 million individuals are affected by HBV infection around the world [1-]. The prevalence of HBV infection in Turkey is approximately % [5]. Although our country has an intermediate-level endemicity for hepatitis B, there are only a few studies assessing the knowledge levels of the patients about HBV infection [6,7]. It is necessary for patients with hepatitis B to have information about symptoms, severity, follow-up, and treatment options of the disease to achieve appropriate self-care, adherence to follow-up, early detection of disease signs, and timely treatment [8]. It is also important for patients with chronic hepatitis B (CHB) to receive information about the disease to prevent transmission of HBV infection [6]. Such information can enable patient-centered care, helping patients and their families to better understand the illness and how Address correspondence to: Pinar Korkmaz, Cumhuriyet District, Yunus Emre Street, Zigana Apartment, F Block, :1, 3020, Kütahya, Turkey. Tel: +(90) , Fax: +(90) , Mob: +(90) , drpinarkor@gmail.com

2 June 2018 KUWAIT MEDICAL JOURNAL 227 it affects their lives. Also, it may help the patient lead as normal a lifestyle as possible [9]. There are only a few studies assessing the knowledge levels of patients with CHB and their lifestyle practices [6,9,10].Therefore, in this study, we aimed to evaluate the knowledge levels and lifestyle practices of patients diagnosed with CHB. SUBJECTS AND METHODS Study population The patients who were followed up with CHB in the outpatient clinic of infectious diseases of a tertiary hospital between vember 2015 and May 2016 were included in the study. The study was approved by the local Ethics Committee. Written informed consents of all patients who agreed to participate in the study were obtained after they were informed about the study protocol. A questionnaire evaluating demographic characteristics, level of knowledge, and lifestyle practices was administered to the patients. Questionnaire The questionnaire was developed based on information from various studies [6,9-1]. It contained a total of 0 questions as follows: 10 questions related to age, gender, geographic location, educational status, occupation, marital status, duration of hepatitis, history of antiviral use, and demographic data including screening and vaccination status of family members regarding HBV infection; 19 questions related to the knowledge level about HBV infection; 8 questions to evaluate lifestyle practices following diagnosis with CHB; 2 questions for comprehension and adequacy of the physician s explanations about CHB; and 1 question related to receiving an alternative treatment for CHB. The level of knowledge about HBV infection was assessed based on the answers to 19 questions. One point was given for each correct answer and no points were given for a wrong or don t know response. The mean knowledge score was used for discrimination. A score higher than the mean score was considered to be a good knowledge level and a score lower than the mean to be a poor knowledge level [15]. Statistical analysis The NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program was used for the statistical analysis. During the evaluation of the study data, regarding the comparisons of descriptive statistical methods (mean, standard deviation, median, frequency, ratio, minimum, and maximum) as well as quantitative data, Student s t-test was used for the intergroup comparisons of parameters with normal distribution. One-way ANOVA test was used for the comparison of three or more groups with normal distribution and Tukey honest significance test (HSD) test was used to determine the group causing the difference. Kruskal Wallis test was used for the comparison of three or more groups without normal distribution and Mann Whitney U test was used to determine the group causing the difference. Pearson s chi-square test, Fisher s exact test, Fisher Freeman Halton test and Yates continuity correction tests (Yates s corrected chi-square test) were used for comparison of qualitative data. Significance was evaluated at the levels of p < 0.01 and p < RESULTS Patient characteristics A total of 195 CHB patients were included in the study; 51.3% (n = 100) of them were males. The mean age was 3.1 ± 13.1 years (min: 18, max: 77). The duration of diagnosis of CHB ranged between 6 months and 36 years, with a mean period of 7.51 ± 6.92 years. Demographic characteristics of the patients are shown in Table 1. While the families of 86.7% (n = 169) Table 1: General characteristics of our CHB patients Characteristics n Percent Age (years) < Geographic location Marmara Mediterranean Aegean Central Anatolia Black Sea Eastern Anatolia Southeastern Anatolia Educational status Primary school Secondary school High school University Occupation Housewife Self-employed Worker Retired Officer Student Unemployed Marital status Married Single Widow Duration of diagnosis (year) and over

3 228 Evaluation of Knowledge Levels and Lifestyle Practices of Patients with Chronic Hepatitis... June 2018 Table 2: Answers given by our CHB patients to knowledge questions Questions Correct 151 (77.5) 150 (76.9) 18 (75.9) 132 (67.7) 129 (66.2) 72 (36.9) 135 (69.2) 12 (73.3) 85 (3.6) 18 (9.) 171 (87.7) 13 (73.3) 186 (95.) 12 (63.6) 69 (35.) 181 (92.8) 50 (25.6) 156 (80) 15 (7.7) Wrong 2 (1) 10 (5.1) 6 (3.1) 16 (8.2) 27 (13.8) 61 (31.3) 15 (7.7) 13 (6.7) 3 (2) 2 (1) 12 (6.2) 13 (6.7) - 31 (15.9) 91 (6.7) 8 (.1) 100 (51.3) 12 (6.2) 152 (77.9) I do not know 2 (21.5) 35 (17.9) 1 (21) 7 (2.1) 39 (20) 62 (31.8) 5 (23.1) 39 (20) 67 (3.) 9 (.6) 12 (6.2) 39 (20) 9 (.6) 0 (20.5) 35 (17.9) 6 (3.1) 5 (23.1) 27 (13.8) 28 (1.) Hepatitis B is a viral disease Hepatitis B can lead to hepatocellular carcinoma Hepatitis B can lead to cirrhosis Hepatitis B can lead to death People with HBV can be infected for life Hepatitis B virus always leads to symptoms in the infected individual Jaundice is among symptoms of hepatitis B disease Hepatitis B disease can be prevented by vaccine Hepatitis B virus can be transmitted through consumption of contaminated water Hepatitis B virus can be transmitted through sharing syringes Hepatitis B virus can be transmitted through sexual activity Hepatitis B can be transmitted from mother to baby during delivery Hepatitis B can be transmitted through blood transfusion Hepatitis B can be transmitted from an apparently healthy individual Hepatitis B virus can be transmitted through sharing dishes and cups Hepatitis B virus can be transmitted through sharing toothbrush, razor blade Hepatitis B virus can be transmitted through coughing and sneezing Hepatitis B virus can be transmitted by contact with an open wound Hepatitis B can be transmitted through handshaking of the patients were given a screening test, the families of 9.7% (n = 19) of the patients were not, and 3.6% percent (n = 7) of the patients did not know whether their families were given a screening test. While the families of 7.9% (n = 16) of the patients were vaccinated, the families of 20.5% (n = 0) of the patients were not vaccinated, and.6% (n = 9) of the patients did not know whether their families were vaccinated or not. 6.1% of the patients with CHB were followed up without antiviral treatment, while 35.9% (n = 70) of them used antiviral treatment. One hundred and eighty patients (92.3%) stated that they could usually understand their physicians explanations about hepatitis B and 79.5% (n = 155) found the explanations to be sufficient. Level of knowledge The mean knowledge level of the patients about HBV was 13.5 ± 2.87 (min: 2, max: 19). Answers given by our CHB patients to knowledge questions are shown in Table 2. One hundred and nine patients (55.9%) had a good knowledge level, but.1% (n = 86) of the patients had a poor knowledge level. Higher educational status was found to be correlated with higher knowledge level (p < 0.05). Correlation between knowledge levels and demographic characteristics of the patient are shown in Table 3. Evaluation of lifestyle practices after Hepatitis B diagnosis Lifestyle practices of our patients after being diagnosed with hepatitis B are shown in Table. The patients who continued to share their dishes and cups were determined to be more knowledgeable (p = 0.0; p < 0.05). The patients who did not donate blood after the diagnosis were determined to be more knowledgeable (p = 0.036; p < 0.05). Evaluation of the behaviors after diagnosis of the disease according to the knowledge levels are shown in Table 5. Use of alternative treatment Thirty-one patients (15.9%) used an alternative treatment method for hepatitis B. Only 1 of our patients stated what they used as alternative treatment. Ten of these patients stated that they used herbal teas and of them used artichoke extract tablets. A total of 19 patients explained the reason for the use of alternative treatment: 10 patients due to belief in the benefit from alternative treatment, 3 patients with the advice of their relatives, 2 patients due to not wanting to use drugs for CHB, 2 patients due to relying on a person who suggested alternative treatment, and 2 patients due to believing that there is no effective treatment of the disease. statistically significant difference was determined between the knowledge levels, antiviral treatment, finding the physician s explanations to be sufficient according to the state of using alternative treatment (p > 0.05). DISCUSSION There are only a few studies assessing the knowledge levels of patients with CHB and their lifestyle practices [6,9,10]. In a study performed in Turkey, 85.7% of patients knew that CHB could cause cirrhosis, 65.7% knew that CHB could cause HCC, and 58.1%

4 June 2018 KUWAIT MEDICAL JOURNAL 229 Table 3: Correlation between average knowledge levels about Hepatitis B and characteristics of the patients Characteristics Age (years) < Gender Men Women Educational Status Primary school Secondary school High school University Occupation Housewife Self-employed Worker Retired Officer Student Unemployed Diagnosis of hepatitis B (years) Found physician s explanations sufficient Screening for HBV by family members Vaccinating for HBV by family members Medical treatmet for HBV Understand physician s explanations Poor knowledge 11 (12.8) 16 (18.6) 28 (32.6) 17 (19.8) 1 (16.3) 0 (6.5) 6 (53.5) 57 (66.3) 11 (12.8) 6 (7) 12 (1) 39 (5.3) 12 (1) 15 (17.) 6 (7) 8 (9.3) 3 (3.5) 3 (3.5) (51.2) 27 (31.) 6 (7) 5 (5.8) (.7) 2 (27.9) 62 (7) 12 (1.5) 71 (85.5) 17 (21.3) 63 (78.8) 63 (73.3) 23 (26.7) 10 (11.6) 76 (88.) Good knowledge 19 (17.) 25 (22.9) 25 (22.9) 30 (27.5) 10 (9.2) 60 (55) 9 (5) 6 (2.2) 1 (12.8) 25 (22.9) 2 (22) 6 (2.2) 20 (18.3) 20 (18.3) 9 (8.3) 10 (9.2) 2 (1.8) 2 (1.8) 51 (6.8) 2 (22) 21 (19.3) 8 (7.3) 5 (.6) 16 (1.7) 93 (85.3) 7 (6.7) 98 (93.3) 23 (21.7) 83 (78.3) 62 (56.9) 7 (3.1) 5 (.6) 10 (95.) P-value knew that CHB could cause death [7]. Similarly, most of our patients knew that CHB could cause severe complications such as cirrhosis, HCC, and death. However, approximately 23-32% of the patients expressed that they did not know whether the disease caused or could cause severe complications. This shows us that some of our patients still lack information about the most fundamental features of the disease. Table : Evaluation of lifestyle practices of the patients after Hepatitis B diagnosis Lifestyle practices Answer n Percent I stopped smoking I stopped drinking alcohol/i reduced alcohol intake I do more physical activity I try to eat healthier foods I continue to share my dishes and cups with other people I encouraged my family members to have blood test for hepatitis B I do not engage in blood donation I do not share my personal items such as razor blade, toothbrush t smoking t drinking I do not We think that the insufficiencies on these fundamental issues are an important factor in decreasing adherence to treatment or follow-up. In our study, only 31% of our patients correctly replied to the question of whether hepatitis B always causes symptoms in infected individuals. Some similar studies found a lack of understanding that the disease can be asymptomatic [1,16]. CHB can be asymptomatic, even including the conditions that cause severe complications such as cirrhosis and HCC. Raising awareness of the patients about this subject may help to start treatment earlier and halt progression of the disease. In one study, 25.7% of the patients stated that the virus can be spread through sharing dishes [7]. A similar misperception is that the virus can be spread through sharing dishes of patients with CHB [9,16]. Similarly, in our study, approximately half of our patients stated that HBV could be spread through sharing dishes and cups or that they did not have information on this subject. These types of misperceptions cause anxiety in the patients about transmitting the virus, thus interfering with their social relations. They also cause patients to try to hide their disease for fear of social isolation [17]. As educational status increases, the knowledge level of the patients with CHB about the disease increases [9,10,18,19]. In the study performed by Mohammed et al, being in the age group of years, tertiary education level, and being aware of the disease for a longer time were found to be associated with a higher knowledge score [8]. In our CHB patients, only a higher education level and antiviral use were

5 230 Evaluation of Knowledge Levels and Lifestyle Practices of Patients with Chronic Hepatitis... June 2018 Table 5: Evaluation of lifestyle practices according to the knowledge levels after diagnosis of the disease Lifestyle practices Answer Knowledge level about Hepatitis B disease Poor knowledge 21 (67.7) 10 (32.3) 3 (33.3) 6 (66.7) 25 (5.3) 21 (5.7) 9 (10.5) 77 (89.5) 39 (5.3) 7 (5.7) 7 (8.1) 79 (91.9) (.7) 82 (95.3) 2 (2.3) 8 (97.7) Good knowledge 3 (73.9) 12 (26.1) 1 (8.3) 11 (91.7) 33 (51.6) 31 (8.) 23 (21.1) 86 (78.9) 33 (30.3) 76 (69.7) 10 (9.2) 99 (90.8) 0 (0) 109 (100) 1 (0.9) 108 (99.1) p-value I stopped smoking I stopped drinking alcohol I do more physical activity I eat healthier foods I continue to share dishes and cups with other people Encouragement of family members to have blood test for hepatitis B I do not engage in blood donation I do not share personal items such as razor blade, toothbrush found to be associated with a higher knowledge score about the disease. Significantly higher knowledge levels of the patients using antiviral drugs might be because using these drugs may cause patients to regard their disease more seriously and to pay more attention to it. Contrary to the study performed by Mohammed et al, in our study, no significant association was determined between period of awareness of the disease and knowledge level. In another study performed, which supports our data, no association was found between knowledge levels of the patients about HBV and time to referral to a hepatologist [20]. This suggests that evaluation of knowledge levels and correction of insufficient perceptions or misperceptions is more important for increasing the knowledge level rather than the period of awareness of the disease or follow-up. When it is considered that in Asian populations the most common route of transmission for HBV is vertical transmission, the patient s family becomes the primary target for screening programs. There is a small amount of information regarding barriers to communication with the families of HBVinfected individuals about HBV and screening of those families [21]. One study observed that as the knowledge level and educational status increased, the rate of patients having their families vaccinated for HBV increased [6]. Contrary to this, in our study, no significant association was determined between the knowledge level and educational status of the patients and vaccination of their families. Also, no significant association was determined between other sociodemographic characteristics and the status of vaccination of the families. Therefore, further clinical studies are needed to explore the underlying problems in order to increase the rate of vaccination. The percentage of our patients that continued to share their dishes and cups after being diagnosed with the disease was 36%. In the study performed by Mohammed et al, this ratio was determined to be 9.%. In this study, it was demonstrated that the practice of sharing dishes and cups decreased in the presence of Indian ethnicity, advanced age, and cirrhosis. The advanced age group was less educated, with a limited ability to access and understand health information. Accordingly, they took the unnecessary precaution of not sharing dishes and cups [9]. Similarly, in our study, it was determined that dishes and cups were less commonly shared by the advanced age group. Again, a good knowledge level about HBV was determined to be significantly higher in patients who shared their dishes and cups. Informing the patients about transmission routes of the virus could avoid unnecessary precautions to prevent transmission. CONCLUSION The current study found gaps and misperceptions in the knowledge level of CHB patients, especially about HBV transmission. Consequently, educational programs that address misperceptions related to HBV transmission in CHB patients are of vital importance. Increasing the number of studies performed on this subject will help to understand how patients regard their disease. Also, it might help these patients avoid taking unnecessary precautions to prevent transmission of HBV after diagnosis, thereby improving their quality of life.

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