TABLE OF CONTENTS
DECLARATION……………………………………………………………………………………………….. a
DEDICATION………………………………………………………………………………………………….. ii
ACKNOWLEDGEMENTS……………………………………………………………………………….. iii
TABLE OF CONTENTS…………………………………………………………………………………… iv
LIST OF TABLES……………………………………………………………………………………………. vii
LIST OF FIGURES…………………………………………………………………………………………… ix
ABBREVIATION AND ACRONYMS………………………………………………………………. x
DEFINITION OF TERMS…………………………………………………………………………………. xi
ABSTRACT……………………………………………………………………………………………………. xiii
CHAPTER ONE: INTRODUCTION……………………………………………………………….. 1
CHAPTER TWO: LITERATURE REVIEW…………………………………………………. 10
2.1 Overview of HBV……………………………………………………………………………………………. 10
CHAPTER THREE: MATERIALS AND METHODS……………………………………. 18
CHAPTER FOUR: RESULTS……………………………………………………………………….. 25
Vaccination against HBV……………………………………………………………………………………………. 33
CHAPTER FIVE: DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS 52
REFERENCES………………………………………………………………………………………………. 67
APPENDICES……………………………………………………………………………………………….. 73
Appendix 1: Questionnaire………………………………………………………………………………………….. 73
Appendix 2: Interview Guide for Key Informants…………………………………………………………. 81
Appendix 3: Map showing study regions………………………………………………………………………. 83
Appendix 4: Ministry of Higher Education Science and Technology Authorization…………… 84
Appendix 5: Kenyatta University’s Approval………………………………………………………………… 85
Appendix 6: Western Province Authorization……………………………………………………………….. 86
Appendix 7: St. Mary’s Mission Hospital Authorization…………………………………………………. 87
LIST OF TABLES
Table 3.1 Study Variables……………………………………………………………………………………………….. 19
Table 4.1 Socio-demographic characteristics of respondents……………………………………………….. 27
Table 4.2 Responses of study participants to hepatitis B knowledge items……………………………. 30
Table 4.3 Description of knowledge as per socio-demographic characteristics of
respondents………………………………………………………………………………………………………… 32
Table 4.4 Responses of the study participants to advocacy measures items…………………………… 35
Table 4.5 Description of advocacy mechanisms as per socio-demographic
characteristics of respondents……………………………………………………………………………….. 36
Table 4.6 Attitude of HCW categorized as positive or negative…………………………………………… 37
Table 4.7 Responses of the study participants to hepatitis B attitude items…………………………… 38
Table 4.8 Description of attitude scores as per socio-demographic characteristics of respondents 39
Table 4.9 Responses of the study participants to hepatitis B uptake items…………………………….. 40
Table 4.10 Responses of the study participants to hepatitis B practice items…………………………. 41
Table 4.11 Uptake as per socio-demographic characteristics of respondents………………………….. 44
Table 4.12 Test of Association- knowledge characterized as good and poor as per socio- demographic characteristics of respondents………………………………………………………………………………… 46
Table 4.13 Test of Association- knowledge characterized as good and poor as per socio- demographic characteristics of respondents (continuation)……………………………………………………………. 47
Table 4.14 Test of association between knowledge and uptake of hepatitis B vaccination………. 48
Table 4.15 Test of association- Advocacy mechanisms characterized as None,
Inadequate and Adequate as per vaccination status…………………………………………………. 49
Table 4.16 Test of association – Attitude of HCW towards HB and uptake of hepatitis B vaccination………………………………………………………………………………………………………………………….. 49
Table 4.17 Test of association – advocacy mechanisms and attitude of HCW towards HB 50
Table 4.18 Test of association between knowledge and attitude of HCW towards HB………….. 51
LIST OF FIGURES
Figure 1.1 Conceptual Framework…………………………………………………………………………………….. 9
Figure 4.1 Overall scores on the responses of HCW regarding advocacy measures………………… 34
Figure 4.2 Status of Hepatitis B vaccination……………………………………………………………………… 41
ABBREVIATION AND ACRONYMS
| CDCP | Centers for Disease Control and Prevention |
| CHB | Chronic Hepatitis B |
| DF | Degree of Freedom |
| DNA | Deoxyribonucleic Acid |
| DTP-HB | Diptheria, Tetanus & Pertusis and Hepatitis B |
| DVI | Division of Vaccines and Immunization |
| EPI | Expanded Programme on Immunization |
| EPI-TF | Expanded Programme on Immunization Task Force |
| FDA | Food and Drug Administration |
| HB | Hepatitis B |
| HBIG | Hepatitis B Immune Globulin |
| HBsAg | Hepatitis B Surface Antigen |
| HBV | Hepatitis B Virus |
| HCC | Hepatocellular Carcinoma |
| HCV | Hepatitis C Virus |
| HCW | Health Care Workers |
| HIV | Human Immunodeficiency Virus |
| KEMRI | Kenya Medical Research Institute |
| KEPI | Kenya Expanded Programme on Immunization |
| MOH | Ministry of Health |
| MOPHS | Ministry of Public Health and Sanitation |
| NGO | Non- Governmental Organization |
| SIGN | Safe Injection Global Network |
| SSA | Sub-Saharan Africa |
| TFI | Task Force on Immunization |
| UNFPA | United Nations Population Fund |
| UNICEF | United Nations Children’s Fund |
| WHO | World Health Organization |
DEFINITION OF TERMS
Health Care Workers – refers to medical trained health personnel and this study has limited this to nurses, doctors, surgeons, clinical officers and laboratory technicians/technologists.
Hepatitis B – life-threatening infectious liver infection caused by the hepatitis B virus.
Hepatitis B Prevention Methods – a variety of preventive measures which include; immunization with hepatitis B vaccine (childhood and at-risk populations), routine screening of blood donors for HBsAg, universal precautions when handling human blood and body fluids (use of gloves, protective garments and masks, when handling potentially infectious or contaminated materials), good personal hygiene, strict surveillance, and appropriate environmental control measures to limit transmission.
Hepatitis B Vaccination – the process of inoculating persons with hepatitis B vaccine in three doses at 0, 1 and 6 months
Occupational Exposure – this study has limited this definition to constant contact of health care workers to patients, blood and other body fluids during their practice.
Perception – refers to the deeper understanding and awareness of Hepatitis B Vaccination.
Uptake – voluntary acceptance of hepatitis B vaccination
Vaccination – the process of inoculating persons with any antigenic material for the purpose of producing active artificial immunity.
ABSTRACT
Hepatitis B Virus (HBV) infection poses a grave public health problem worldwide. Over two billion people are infected and an estimated 387 million of these suffering from chronic HBV infection, with a rate of ten million new carriers each year. Another one million die annually. About 90% of these cases live in developing countries with half of Kenya’s population being estimated to be infected by HBV by the age of 30-40. Health care workers are among the most vulnerable groups to acquire HBV; with an estimated risk of four times higher than that of the general population. It is also a well- established fact that an unvaccinated individual stands the risk of 6% to 30% to acquire the infection on exposure to HBV contaminated blood or body fluids. Vaccination of high-risk groups is a key strategy for prevention. Despite the safe, effective and highly acceptable HBV vaccine that has been around since 1982, its use among health care workers in the developing world is low. Immunization among health care workers has two purposes; to protect them from several infectious diseases they may be exposed to through professional activities and to minimize the odds of infecting the patients they are taking care of. The study aimed at establishing the uptake of Hepatitis B vaccination and its determinants among high-risk health care workers in selected hospitals in Kenya. This was a descriptive cross-sectional study. Multistage sampling, including cluster and random sampling were used. Key informants from the Ministries of Public Health and Sanitation and Kenya Medical Research Institute were also interviewed. A pre-designed key informant interview guide and semi-structured questionnaires were used to collect the necessary data from 384 willing respondents. Chi-Square and Fishers Exact Test were performed to establish relations between variables. A high proportion of the respondents (78.6%) had good knowledge of Hepatitis B. Slightly more than half (50.3%) of the institutions did not have advocacy mechanisms in place, 36.5% had inadequate and only 13.3% had adequate advocacy mechanisms. Majority of the respondents (90.6%) had a positive attitude towards hepatitis B infection and vaccination. However, the uptake of hepatitis B vaccination among the high-risk health care workers was average, as only 59.6% had been vaccinated. Of these, only 32.0% had completed the recommended three dose vaccination. There was no statistically significant association between knowledge and uptake of vaccination (χ2 = 0.629; df = 1; P = 0.233 at 0.05 confidence level). There was also no statistically significant association between advocacy mechanisms and uptake of vaccination (χ2 = 0.425, df = 2 P = 1.710 at 0.05 level of significance). But there was a statistically significant association between attitude of health care workers and uptake of hepatitis B vaccination (Fishers Exact Test = 0.007, df = 3 and P value of 11.612 at 0.05 confidence level). There was a statistically significant association between the knowledge of HCW on HB and attitude of HCW towards hepatitis B vaccination (χ2 = 0.023, P = 5.151, 1= df at 0.05 level of significance and). In conclusion, the study found that attitude affects uptake while knowledge affects attitude. Therefore, the study recommends that institutions should put in place measures of increasing the knowledge of hepatitis B which will in turn improve the attitude of the health care workers towards hepatitis B. This will in ultimately increase the uptake of hepatitis B vaccination among the health care workers.
CHAPTER ONE: INTRODUCTION
Background Information
Hepatitis is a general term meaning “inflammation of the liver” and the most common cause is the infection with 1 of the 5 viruses called Hepatitis A, B, C, D and E virus. Of the 5 viral causes, Hepatitis B Virus (HBV) is the major cause of acute and chronic hepatitis worldwide (Yazigi, 2011). The HBV belongs to a family of DNA viruses called Hepadnaviridae and consists simply of a core particle (central portion) and a surrounding envelope (outer coat). The core is made up of the HBc antigen, whereas the envelope is made up of the HBs antigen. These viruses primarily infect liver cells. The severe pathological consequences of persistent HBV infections include the development of chronic hepatic insufficiency, cirrhosis and hepatocellular carcinoma (HCC). HBV infection occurs very often in early childhood where it is asymptomatic and often leads to the chronic carrier (Yazigi, 2011; WHO, 2009). Persons with chronic infection also serve as the main reservoir for continued HBV transmission (CDCP, 2006). Humans are actually the only reservoir of HBV (WHO, 2009).
HBV infection poses a grave public health problem worldwide, with over 2 billion people infected. An estimated 387 million are suffering from chronic HBV infection, with a rate of around 10 million new carriers each year (Samuel et al., 2009, and Baars et al., 2009). About 90% of these cases live in developing countries and 50 million of which are in Africa. It is the tenth leading cause of death worldwide accounting for an estimated one million deaths per year worldwide (Schmidt et al., 2013). HBV may be
the cause of up to 80% of all cases of hepatocellular carcinoma worldwide, second only to tobacco among known human carcinogens (Lavanchy, 2004).
In Kenya, HBV prevalence rate ranges between 4-6% and it is estimated that half of the Kenyan population will be infected with HBV by the age of 30 to 40 and 10% would have become carriers (MoPHS, 2008). Studies among Kenyans with HCC have shown that 32.7% to 83.3% of cases of HCC are attributable to HBV infection. Though the people of Kenya are healthy, one in every three people in every community in the country is infected with HBV (MoPHS, 2008).
According to the World Health Organization, vaccination of high-risk groups is a key strategy for the prevention of both horizontal and vertical transmission of HBV (WHO, 2002). Though preliminary studies show the need to include HBV vaccination in Kenya’s Expanded Program of Immunization (KEPI), high cost of the vaccine and a myriad of competing health care needs have so far slowed the uptake of this strategy countrywide (MoPHS, 2008). As a result, current strategies for the prevention of HBV infection include screening of blood units, proper sterilization or disposal of infecting equipment and strategic vaccination of high-risk groups such as health care workers (WHO, 2009).
Statement of the Problem
Health care workers are constantly exposed to the dangers of acquiring hepatitis B due to contact with blood and body secretions of patients (Franco et al., 2012). It is also a
well-established fact that an unvaccinated individual stands the risk of 6% to 30% to acquire the infection on exposure to HBV contaminated blood or body fluids (Sydnor and Perl, 2011). Fortunately, HBV infection is largely preventable by vaccination (Saieed, 2007). The vaccine prevents HBV infection in 90%-100% of people who produce sufficient antibody responses (Schmidt et al., 2013). Despite the safe, effective and highly acceptable HBV vaccine that has been around since 1982, its use among HCW in the developing world is low (Ziraba et al., 2010). In a study in Thika district, only 12.8% of HCW had received vaccination prior to the study signifying a low vaccine uptake among the HCW in Kenya (Suckling et al., 2006).
The study, therefore, was seeking to establish the uptake of HBV vaccine and its determinants among high risk HCW in selected hospitals in Kenya. It was further seeking to address the gaps in order to inform the development of strategies to enhance the uptake of HBV vaccination among HCW in the country. The study findings were trying to identify factors that facilitate or constrain HBV vaccination among HCW in Kenya and suggest possible interventions at both public and private facilities in the country.
Justification of the Study
Health care workers are key in prevention of Hepatitis B but can also be a major source of infection. Despite the availability of the vaccine, adherence to recommendations has not been as great as initially expected. It is also not a policy in most countries (Talas 2009; Herck et al., 2008). Few studies are available on uptake of Hepatitis B vaccine
and its determinants among high-risk health care workers in Kenya. In a study in Thika district, only 12.8% of HCW had received vaccination prior to the study signifying a low vaccine uptake among the HCW in Kenya (Suckling et al., 2006). Therefore, establishing uptake of hepatitis B vaccine and its among high risk HCW in selected hospitals in Kenya provide information that is hoped to be used to design programs to protect both the patients and the Health Care Workers.
Research Questions
- What is the level of knowledge on the risks of acquiring HBV infection among high-risk Health care workers in selected hospitals in Kenya?
- What advocacy mechanisms for HBV prevention exist for high-risk Health care workers in selected hospitals in Kenya?
- What are the attitudes of hepatitis B vaccination among high-risk Health care workers in selected hospitals in Kenya?
- What is the uptake of hepatitis B vaccination among high-risk Health care workers in selected hospitals in Kenya?
Hypotheses
- There is no significant relationship between HBV knowledge and uptake of Hepatitis B vaccine.
- There is no significant relationship between advocacy mechanisms and uptake of hepatitis B vaccine.
- There is no significant relationship between attitudes of hepatitis B vaccination and uptake of hepatitis B vaccine
Research Objectives
- General Objective
To establish the uptake of hepatitis B vaccination and its determinants among high- risk HCW in selected hospitals in Kenya.
Specific Objectives:
- To determine the knowledge on the risks of acquiring HBV infection among high-risk health care workers in selected hospitals in Kenya.
- To determine the existence of advocacy mechanisms and the influence on need for vaccination against HBV among high-risk health care workers in selected hospitals in Kenya.
- To establish the attitudes of hepatitis B vaccination among high-risk health care workers in selected hospitals in Kenya.
