Knowledge, Attitude and Practices (KAP) concerning Hepatitis B among Adolescents in the Upper West Region of Ghana. The Rural­Urban Gradient. BY
BATHOLOMEW CHIREH
MASTER OF SCIENCE THESIS IN PUBLIC HEALTH
2011
Supervisor:
Ass. Prof. LENNARTH NYSTRÖM
Umeå International School of Public Health
Epidemiology and Global Health
Department of Public Health and Clinical Medicine
Umeå University, Sweden
i TABLE OF CONTENT
Content Page TABLE OF CONTENT ............................................................................................................................... ii LIST OF FIGURES ..................................................................................................................................... v LIST OF TABLES....................................................................................................................................... vi ABBREVIATIONS AND ACRONYMS ................................................................................................... vii ACKNOWLEDGEMENT ........................................................................................................................ viii ABSTRACT ................................................................................................................................................. ix 1. INTRODUCTION ................................................................................................................................... 1 1.1 Background ............................................................................................................................... 1 1.2 Statement of the problem......................................................................................................... 2 1.3 Literature review and Epidemiology of HBV .......................................................................... 3 1.3.1 Historical background of HBV ............................................................................................... 3 1.3.2 Transmission route of hepatitis B .......................................................................................... 4 1.3.3 Prevention and treatment of Hepatitis B ............................................................................. 5 1.3.4 Hepatitis B epidemiology globally ........................................................................................ 6 1.3.5 Hepatitis B epidemiology in Africa ....................................................................................... 9 1.4 Knowledge attitude and practice of HBV ............................................................................... 11 1.4.1 Knowledge ................................................................................................................................ 11 1.4.2 Attitude ..................................................................................................................................... 12 1.4.3 Practice ..................................................................................................................................... 13 2. THEORETICAL/CONCEPTUAL FRAMEWORK ............................................................................ 16 2.1 Ajzen and Fishbein’s theory of reasoned action .................................................................... 16 2.2 Rationale: Why adolescents? ..................................................................................................17 2.3 Hypothesis and objectives ..................................................................................................... 18 3. MATERIALS AND METHODS .......................................................................................................... 19 ii 3.1 Geographical maps of the study area ..................................................................................... 19 3.2 Health care system ................................................................................................................. 21 3.3 Major diseases in Ghana ........................................................................................................ 22 3.4 Human resource and infrastructure in the health sector ..................................................... 23 3.5 Study area ............................................................................................................................... 24 3.5.1 Upper West region.................................................................................................................. 24 3.5.2 Wa West district ..................................................................................................................... 25 3.5.3 Wa Municipal/district ........................................................................................................... 26 3.6 Study design ........................................................................................................................... 28 3.7 Study population .................................................................................................................... 29 3.8 Sampling procedure and sample size .................................................................................... 29 3.9 Study period ........................................................................................................................... 29 3.10 Measurement instrument .................................................................................................... 29 3.11 Data collection ...................................................................................................................... 30 3.12 Statistical methods ............................................................................................................... 30 3.13 Ethical issues ........................................................................................................................ 30 4. RESULTS .............................................................................................................................................. 31 4.1 Socio-demographic characteristics of adolescents................................................................ 31 4.2 Respondents general knowledge about HBV in relation to causes, effects and modes of
transmission ................................................................................................................................. 31 4.3 Adolescents attitudes towards HBV and infected persons ................................................... 32 4.4 Adolescent practices and efforts made to prevent themselves from being infected with
HBV .............................................................................................................................................. 32 4.5 Comparison of mean, range and p-value differences among rural and urban adolescents
with regards to HBV..................................................................................................................... 33 4.6 Educational level and adolescents’ knowledge, attitude and practices concerning HBV ... 33 5. DISCUSSION ........................................................................................................................................ 43 5.1 Adolescents’ general knowledge about HBV ......................................................................... 43 iii 5.2 Adolescent’s attitudes or perceptions about HBV ................................................................ 45 5.3 Adolescent’s practices and HBV prevention ......................................................................... 47 6. STRENGTHS AND LIMITATIONS ................................................................................................... 48 7. CONCLUSIONS .................................................................................................................................... 49 8. GENERAL RECOMMENDATIONS .................................................................................................. 50 9. REFERENCES ...................................................................................................................................... 52 10. APPENDIX .......................................................................................................................................... 57 iv LIST OF FIGURES
Figure 1: Map of global HBV prevalence………………………………………………………………………………8
Figure 2: A snapshot of the effects of HBV……………………………………………………………………………9
Figure 3: Theoretical framework of the study ……………………………………………………………………..17
Figure 4: Maps of regions of Ghana and districts of the study area………………………………………..19
v LIST OF TABLES
Table 1: Health indicators for Ghana 2008…………………………………………………………………………20
Table 2: Socio-demographic characteristics of respondents by sex and p-value for chi2 test of
association………………………………………………………………………………………………………………………35
Table 3: Socio-demographic characteristics by area of residence………………………………………….35
Table 4: Percentage who answered Yes on the knowledge questions concerning HBV among
rural and urban adolescents………………………………………………………………………………………………36
Table 5: Percentage of rural and urban adolescents who responded Yes to attitude questions
concerning HBV……………………………………………………………………………………………………………….37
Table 6: Rural and urban adolescent’s practices and HBV prevention………….……………………….38
Table 7: Mean, range, and p-value difference about adolescent’s knowledge, attitude and
practices concerning HBV..………………………………………………………………………………………………39
Table 8: Rural and urban adolescent’s educational level and their knowledge about HBV………40
Table 9: Adolescent’s educational level and their attitude towards HBV……………………………….41
Table 10: Adolescent’s educational level and their practices with regards to HBV prevention….42
vi ABBREVIATIONS AND ACRONYMS
Abbreviation
ADS
ART
CDC
GHBF
GHS
In Plain Text
Auto-disposable Syringes
Anti-Retroviral Treatment
Centers for Disease Control and Prevention
Ghana Hepatitis B Foundation
Ghana Health Service
GSS
HBV
HCC
HCV
HIV
IFNA
JHS
MOH
NGO
NHIS
OHBVI
PHC
STD
STI
UNICEF
WHO
Ghana Statistical Service
Hepatitis B Virus
Hepatocellular Carcinoma
Hepatitis C Virus
Human Immunodeficiency Virus
Interferon-Alpha
Junior High School
Ministry of Health
Non-Governmental Organizations
National Health Insurance Scheme
Occult Hepatitis B Virus Infection
Primary Health Care
Sexually Transmitted Diseases
Sexually Transmitted Infections
United Nations Children’s Fund
World Health Organization
vii ACKNOWLEDGEMENT
My sincere gratitude first goes to the Almighty God for giving me the opportunity to undertake
this academic journey and seeing me through to the end.
To my most cherished uncle, Honorable Joseph Yieleh Chireh, Minister of Health (MP). No
amount of words can explain how valuable you are to me. I am forever grateful to you for how
far you have turned my life around. To the entire Chireh’s family it couldn’t have been possible
without your love, support, encouragement and your calls I receive every blessed day kept me
moving in full gear. Words cannot express the joy of being part of this great family.
I am very much grateful to my parents, Mr. John-Paul Chireh Sobebe and Mrs. Margaret
Boyour Baaboryir for your words of encouragement and support throughout my stay in Sweden.
I would like to express my heartfelt appreciation to my Supervisor Prof. Lennarth Nystrom for
his constructive criticisms and positive corrections in writing this thesis. You were like a father
to me. I so much cherished the cordial relationship the existed between us right from the
beginning to the end.
Special thanks to my siblings, James, Jonas, David and Cecilia Chireh Sobebe. Your calls alone
motivated me to step up my fight. You guys are so awesome and this will forever remain in my
mind.
My special thanks to my cousins, Carlos, Prosper, Emilda, Thomas Chireh, Alex Bereh and all
Heads and Pupils of Junior High Schools in the selected schools. But for your kind support, my
data collection process would have been a fiasco. Hope you will always be there for me at such
crucial times of my life.
Million thanks to my second family here in Sweden, Mr. Ali Mohammed, Mrs. Zaina Ali, Dr.
Osei Ampomah, Mrs. Monica Ampomah, Henrietta Opoku and the Ghanaian community in
Umea. I could not have realized my dream in this cold weather without your continuous support
in all forms. Your presence in Umea is strategic and that made me not to miss home so much.
I enjoyed the time I had together with all the staff of the Department of epidemiology and
Public Health Sciences especially Nawi Ng and Sabina Bergsten, which have left an indelible
mark on me that will last for a lifetime.
My appreciation goes to my lovely girl friend, Vida Niiretey for such an awesome encouragement
and motivation. That is just the beginning of the journey and I hope your care will continue.
Lastly, but definitely not the least, the great cohort in Umea! MPH class of 2009/2011, it has
been a wonderful two years together. Been with you has taught me a lot of lessons that will
certainly help me in life. I cherish the strong bond of friendship that linked us together despite
our different backgrounds. I hope to meet you in the future for more friendship and
collaboration.
viii ABSTRACT
Background: The threat posed by the global HBV epidemic continues to assume alarming
proportions in areas of public health and national development. Globally, two billion people
have been infected with HBV at some point in time in their life time and 360 to 400 million
people which represents more than 5% of the world’s population are chronic carriers with an
estimated 600,000 deaths each year due to consequences of HBV.
Objectives: The general objective of the study is to assess the knowledge, attitude and
practices (KAP) concerning hepatitis B (HBV) among rural and urban adolescents in Ghana with
specific emphasis on in-school adolescents in Wa Municipal and Wa-West District in the Upper
West Region 0f Ghana.
Methods and materials: The study was cross-sectional, carried out among in-school
adolescents in rural and urban districts of Wa- West and Wa- Municipal respectively in the
Upper West Region of Ghana. The tool of study was structured questionnaire specially designed
for this study. A total of 408 of both rural and urban adolescents responded to the survey. Data
were computerized using Excel and analyzed using SPSS.
Results: The study showed that on the average, sampled adolescents had a fair idea about
hepatitis B even though there were significant differences between rural and urban adolescents.
The study also discovered a significant difference between female and male students in both
rural and urban settings regarding their knowledge about types of HBV and different modes of
transmission especially the horizontal one. Regarding the student’s attitude towards patients
infected with HBV, the findings showed that females had more negative attitude towards these
patients than males.
Conclusions: This study was able to highlight three thematic areas and the need for prompt
action to be taken. First and foremost, even though most adolescents in both rural and urban
areas have a fair idea about the disease HBV, the study deduced that majority of them were not
knowledgeable about the causes, modes of transmission and effects of HBV although rural
adolescents were a little informed compared to urban adolescents. Secondly, although most of
the adolescents indicated HBV as a big health problem in the country, the issue of stigmatization
against already infected persons was very strong among adolescents in both rural and urban
areas. Thirdly, vaccination which is paramount for HBV prevention was very low among
adolescents in both settings.
Keywords: Knowledge, attitude, practices, hepatitis, adolescents, rural and urban Ghana.
ix 1. INTRODUCTION
1.1 Background
Viral hepatitis is one of the most common diseases worldwide. Hepatitis B, also called
inflammation of the liver, which was the first to be discovered, is one of the five types of
hepatitis and can cause both acute and chronic diseases. The global burden of hepatitis B is
severe with an estimated 360 million people or more being chronic carriers. The major routes of
hepatitis B transmission include blood transfusion, from mother to infant during child birth and
sexually. The HCV can also cause chronic liver diseases and is transmitted in the same ways as
hepatitis B, although mother to infant and sexual transmissions are less common. An estimated
170 million people are said to be chronic carriers of HCV. Hepatitis D, also called delta hepatitis,
is caused by an incomplete virus that requires hepatitis B virus to replicate. Hence, this type of
hepatitis is only seen in association with hepatitis B infection. Hepatitis A and E are both
transmitted by faecal-oral route, however signs and symptoms are not seen after being infected
with hepatitis A and E and can therefore result in a lifelong development of immunity. Some of
the viral hepatitis can be prevented by vaccination, and vaccines for hepatitis A and B have
existed for 20 years now. Hepatitis D can be prevented by using hepatitis B vaccines. As of now,
the only types of hepatitis that cannot be prevented by the use of vaccine are C and E hepatitis.
The most frightening aspect of this global epidemic lies in the fact that acute clinical signs and
symptoms of the different types of viral hepatitis are similar regardless of the etiologic agent and
may include fever, malaise, fatigue, anorexia, nausea, abdominal discomfort, dark urine, and
jaundice (CDC, 2006). This makes it difficult to realize the signs on time since these signs are
quite common in other diseases.
In health care delivery, HBV transmission posses a major challenge to both patients and
health workers especially those who frequently come into contact with blood. These groups of
people stand a higher chance of contracting the disease if care is not taken. Apart from health
workers, some people in the general public are more prone to contracting hepatitis B than others
e.g. drug users or injectors, people who pierce or tattoo their bodies and unprotected sex
engaged in by adolescents due to their lack of knowledge about sexual negotiation and safe sex
practices. In most countries where HBV prevalence is low, transmission usually occur during
adolescence or young adulthood as a result of the unsafe injections and unprotected sexual
activities. Research has revealed that, an estimated 21 million new HBV infections occur each
year due to unsafe injections in health care settings (Hauri et al, 2003). Hepatitis B is not only a
health issue but also an issue of social injustice which rears its ugly head in most endemic
1 countries in the world. Myths and misinformation about modes of HBV transmission have
resulted in widespread discrimination against chronically infected persons in some endemic
countries, such as China, the country with the world’s largest population of chronically infected
people, who are not allowed to work in the food industry, are often forced to go through a
routine pre-employment HBV testing, and can be expelled from school or work because of a
positive test (CDC, 2006).
1.2 Statement of the problem
The secret killer hepatitis B, though a major threat to health globally, is yet to catch the
attention of health institutions, policy makers, the general public and decision makers in Ghana.
The disease has a long history in the country immediately after the Second World War. A study
by Morrow et al, (1971) revealed that hepatitis has being on the increase in Accra which led to
the development of shanty towns with poor sanitation. Despite the long history of the disease in
Ghana, there have not been any bold and pragmatic measures put in place to curb it except the
formation of the Ghana Hepatitis B Foundation (GHBF) which started its operation just in
September, 2007. In the light of the lukewarm attitude shown towards the disease and due to
acts of selective prevention of infectious diseases by health professionals including HBV, the
disease is said to be fast spreading with an estimated number of four million people as carriers.
The 2009 Ghana Health Service report has released very scary figures suggesting an increase in
the prevalence ratio from 8:1 in 2005 to 6:1 in 2009 (GHS, 2009). This means one out of every
sixth person is infected with the disease. There has also been an increase in the number of
deaths associated with the disease in the country. In a 13-year hospital based study conducted in
a rural district of Berekum in the Brong and Ahafo region of Ghana to assess the role of indirect
causes of maternal mortality among the 229 maternal deaths recorded during the period of
review, 15 out of 229 deaths were due to HBV (Diederike et al, 2003).
Also, unlike HIV/AIDS, tuberculosis and malaria that have attracted the attention of
both government and foreign donors leading to the inflows of monies in developing countries
including those of President Bush’s 15-billion initiatives and the Global Fund for Malaria,
Tuberculosis and HIV/AIDS which Ghana is part of, health education on HBV activities are
extremely limited. This is evident by the fact that schools are not covered and a budgetary
allocation in the Ministry of Health is yet to be given to hepatitis B activities since it is not in
their topmost health priorities. Hepatitis B education is relegated to the background such that
even adults do not have any place to obtain information about this deadly disease.
2 It is also important to state that even though Ghana forms part of the 134 developing
countries and economies in transition that have successfully introduced hepatitis B vaccine into
their National Immunization Schedules by 2003, particularly for newly born infants (aged 6-14
weeks), there is no program for mass screening and vaccination of children born before vaccine
introduction, no screening for mothers, adolescents and the general public. It is an undeniable
fact that although hepatitis B screening and vaccination is carried out in some few health
facilities in Ghana, it is not a national policy and is not incorporated into national health policies
like the free counseling and testing for HIV or the mass immunization of children against
measles. This brings to the fore problems of accessibility and affordability which the general
public has to battle with. Apart from being expensive and preserve of the rich, the few people
who are willing to access it find it difficult to access these screening facilities because of the
inadequate and ill-equipped screening centers to cater for their needs. Media publicity on the
disease is not substantial as compared to other infectious diseases.
For this study, the Upper West Region of Ghana was chosen as the region is one of the
regions with the lowest literacy rate in the country and since the research is geared towards
measuring knowledge of in-school adolescents, the researcher intend to find out whether their
access to education can have any influence on the way they approach the issue of HBV.
The above mentioned factors and their threat to the health of the future leaders of the
country (adolescents) have motivated the researcher to champion two key areas in this research
aimed at improving the well-fair of the citizens in general and adolescents in particular. The two
main priorities of the researcher will be to use the research as an alarm blower in order to create
awareness on hepatitis B as a national health priority which will result in Non-Governmental
Organizations (NGOs) and government’s commitment to increase funding for HBV awareness,
research and other related activities. Secondly, this research will be used as a mouthpiece to
lobby for HBV immunization and treatment to be included under the current list of diseases
being taken care of by the National Health Insurance Scheme (NHIS) or incorporate HBV
screening and vaccination into the voluntary counseling and testing of HIV to be done
concurrently.
1.3 Literature review and Epidemiology of HBV
1.3.1 Historical background of HBV
The hepatitis B virus was discovered in 1965 when Blumberg and co-workers found the
hepatitis B surface antigen which was originally called the Australia antigen because it was
found in serum from an Australian patient (Blumberg et al, 1965, 1977). Dr Baruch Samuel
3 Blumberg was awarded the 1976 Noble Prize in Physiology or Medicine for this discovery. The
virus was fully described in the 1970s (Dane et al, 1970). In recent times, the rapid and
continuous discoveries of the viral disease around the whole world have improved our
understanding of the complexity of this unusual virus. Although there has not been any
substantial decrease in the overall prevalence of HBV, there is the hope that the next generation
will see a decline in both the worldwide carrier rate and the incidence of new HBV infections if
current HBV vaccinations are intensified.
1.3.2 Transmission route of hepatitis B
Grob and Esteban (1995) stated that HBV may be transmitted horizontally and vertically.
Horizontal transmission occurs during adolescence or childhood, throughout sexual exposure,
needle stick (both accidental or through intravenous drug use), and blood transfusion (Alter et
al, 1990). Therefore, any person with a bad history of sexually transmitted diseases (STDs),
multiple sexual partners or an injecting drug user stands a higher chance of being infected with
HBV (CDC, 2002). Exposure to blood is also by means of open wounds in households and other
close contacts and multiple transfusions in hemophiliacs (Meheus, 1995). This view of exposure
to risk was also shared by (Margolis et al, 2000) who argued that most of the infections occur
among adolescents and young adults due to exposure to high risk activities they engage in at this
stage of life.
A vertical transmission occurs when an infected mother transmits the virus directly to
the neonatal during child birth. Such transmissions are usually possible when the expectant
mother suffers an acute infection of hepatitis B during pregnancy or if she is a chronic carrier
during that period. The mode of this vertical transmission is not clear cut, but indications are
that, infection might occur through a placenta cutting during childbirth. Majority of countries in
Southeast Asia, the Western Pacific and Africa have high endemicity of HBV. In these settings
the major mode of HBV transmission has been identified as vertical, where by mothers directly
transmit virus to their infants during prenatal periods or where infected siblings, playmates,
other members of different households transmit the virus to their younger ones (Maynard et al,
1988). A cross-sectional study by Margolis et al (1991) clarified that without prophylaxis, an
estimated number of 6000 infants born to carrier mothers each year in the USA would develop
chronic HBV infection as a consequence of prenatal transmission.
A part from the above mentioned major modes of transmission, tattooing and bodypiercing tools have been recently discovered to have contributed significantly to the spread of
the disease. The incidence of reported hepatitis B in different age groups in the USA is indicative
of a life style disease linked with at-risk behavior in late adolescence (15-19 years) and young
4 adulthood (20-29 years).The disturbing risk factors are mostly sexual misconduct, tattooing,
body-piercing, drug use or injection. In less developed countries, the use of crude methods
during injections such as reused unsterilized or improperly sterilized needles and syringes are
estimated to cause millions of cases of hepatitis B and C as well as HIV and other blood borne
diseases globally (Kane, 1998).
1.3.3 Prevention and treatment of Hepatitis B
Even though HBV has become a major source of health concern worldwide, we should
also be reminded by the good news that it is the only STD that can be prevented by vaccination
(CDC, 2002).The prevention of HBV globally has become one of the topmost priorities of major
political actors and decision makers in recent years. The disease is prevented by the use of safe
and effective vaccine which became available in 1982 through funding and implementation of
hepatitis B immunization programs. Measures for HBV prevention have been geared towards
avoidance of unsafe blood exposure or blocking of transmission before the advent of the vaccine.
Unsafe blood transfusion has been a major force in the transmission of HBV globally (Wang &
Wong, 1960). The enactment of a law for the donation and management of blood in blood banks
across the world has aggressively fought this channel of HBV transmission. This
notwithstanding, current researches have showed that blood transfusion is regaining its position
as one of the major risk factors for HBV transmission globally. This finding is attributed to the
presence of occult HBV infection (OHBVI) among blood donors (Shang et al, 2007). It is also
worth mentioning that the global acceptance of the auto-disposable syringes (ADS) has
considerably reduced the incidence of HBV infections that occur due to unsafe injections. Also,
as a result of the extensive use of invasive medical procedures, iatrogenic HBV infections are no
longer frequent. There have also been speculations that dental care operations which are
capable of causing oral mucous membrane injuries is becoming a major route to HBV
transmission if steps are not taken to prevent it ( Zhang et al, 2008).
HBV per se does not have a permanent treatment; therefore the surest antidote to the
global epidemic is prevention. There has not been any universal agreement on drugs used for
the temporary treatment of the HBV in the world even though two therapeutic agents such as
interferon-alpha (IFNa) and lamivudine are currently used by many countries for the treatment
of the disease. Interferon-alpha is a potent cytokine with antiviral and immunomodulating
actions which is produced in response to viral infection (Sen & Ransohoff, 1993). Temporary
treatment of the disease is therefore aimed at suppressing viral replication, reducing the risk of
progressing to advanced liver disease or inflammation of the liver and the development of
complications such as liver failure or liver cancer. Chronic hepatitis B is therefore easily
5 managed rather than treated. Some of the general management strategies for HBV
recommended by medical experts include;
1. Avoidance of:
•
Heavy alcohol consumption.
•
Unprotected sexual intercourse with partners who are not vaccinated.
•
Sharing of needles or other items that potentially contain blood such as shavers or
toothbrushes
•
Donation of blood or organs
2. Screening of family members and sexual partners for HBV infection and vaccination of those
who are sero-negative
3. Patient education and long-term follow-up with regular testing of liver biochemistry and
surveillance of hepatocellular carcinoma in high risk groups
1.3.4 Hepatitis B epidemiology globally
The threat posed by the global HBV epidemic continues to assume alarming proportions
in areas of public health and national development. Globally, two billion people have been
infected with HBV at some point in time in their life time and 360 to 400 million people which
represents more than 5% of the world’s population are chronic carriers with an estimated
600,000 deaths each year due to consequences of HBV. It is estimated to be the tenth cause of
deaths worldwide (WHO, 2008). Hepatitis B virus mostly affects the liver and can cause liver
cancer. The disease is 50 to 100 times more infectious than the deadly human
immunodeficiency virus (HIV) and can remain on an untreated part of the body for close to
seven days (Hepatitis Foundation International, 2006).
The incidence of acute hepatitis B varies greatly from country to country as a result of
insufficient reliable data and comparisons between countries is often difficult due to different
reporting systems with limited quality (Grob, 1995). The WHO has therefore demarcated the
world according to chronic hepatitis B prevalence into three major blocks which include high,
intermediate and low prevalence. High prevalence areas have a prevalence of chronic hepatitis B
infection that is equal to or greater than eight (8%) made up of countries from North America,
South America, Sub-Saharan Africa and most Asian countries. Intermediate prevalence areas
have a prevalence rate which ranges between 2% and 7% and include countries from South
America, North Africa, Western Europe, Eastern Europe and the Indian subcontinent. Low
prevalence areas are estimated to have a prevalence of chronic infection less than (2%) which
includes most of the North American countries, Australia and most of Western Europe including
the United Kingdom (UK). Hepatitis B transmission route varies according to the prevalence
6 rate of the virus. Countries with very high prevalence rate usually have vertical transmission as
the main route of transmission which is mostly found during childhood. Countries with
intermediate prevalence rates normally have horizontal transmission as its major route where
the disease is transmitted through sexual contact or through injecting of drugs. In countries with
low prevalence rates such as the United Kingdom, the epidemic is mostly acquired during
adulthood through sexual intercourse or injecting of drugs.
According to the National Institute for Health and clinical Excellence (2006), chronic
hepatitis infection can be treated in high income countries with the combination of drugs and
that people with severe liver cases are given liver transplants as well as surgery and
chemotherapy for liver cancer patients to prolong their lives. These options are unfortunately
unavailable to those in low income countries due to the expensive nature of these treatments.
Hence the only option for them is to stick to the saying that, “prevention is better than cure”
through the use of vaccine. The WHO (2006) reported that hepatitis B vaccine has an excellent
record of safety and effectiveness with over one billion doses used worldwide since 1982 and
that it has a 95% capacity to prevent children and adults from contracting chronic infection if
they are not already infected with the disease. Completion of the hepatitis B vaccination series is
the safest and the most effective way of protecting against hepatitis B. The World Health
Organization has targeted hepatitis B as one of eight infectious diseases that should be
controlled through vaccination efforts. For the purpose of propagating this agenda the WHO in
1991 instructed all countries to incorporate hepatitis B vaccination into their national
vaccination programs. But as of 2006, only 164 countries have acted according to the directive
with most countries coming from East and South East Asia, the Pacific, Islands, Australia,
Western Europe and the Middle East (WHO, 2006). The global distribution of chronic carriers
of HBV is graphically represented in Figure 1.
7 Figure 1. Map of global prevalence of chronic infection with HBV by country, 2005.
Source: CDC, 2005
A snapshot of hepatitis B pictures depicting both causes and effects of the deadly disease to the
liver illustrated in Figure 2.
8 Figure 2: A snapshot of the effects of HBV on the liver
Source: CDC, 2005
1.3.5 Hepatitis B epidemiology in Africa
Africa, the second largest continent in the world covers 3,030,000 km2 of land i.e. onefifth of the global land area. Despite the fact that it is sparsely populated with an estimated 800
million inhabitants, it accounts for 12% of the world’s population. Although, the high prevalence
of infectious HBV has been well documented worldwide in well-equipped correctional facilities,
such information on the exact prevalence of the deadly disease has been so sparse in Africa. This
could be attributed to underreporting and ineffective data collection strategies in the continent.
However, from the few data available, it is estimated that out of the 360 million chronic global
carriers of HBV, about 65 million of these chronic carriers live in Africa (WHO, 2004). In
addition, of the estimated 1.3 million deaths recorded annually due to HBV related causes, about
250,000 come from Africa (Kew, 1992).
9 1.3.6. Hepatitis B epidemiology in Ghana
The exact hepatitis B prevalence in Ghana is not known as different studies targeted
different segments of the population and does not give a clear picture of the situation on the
ground. Although there is a relatively low prevalence of HIV with an estimated number of
260,000 carriers as compared to an estimated number of four million carriers of HBV, much of
the attention of Ghana Health Service and other health related organizations is focused on HIV
prevention and treatment through health education programs and provision of anti-retroviral
drugs to the neglect of equally deadly diseases like hepatitis B. Meanwhile, few studies
conducted in the country about HBV revealed its continuous increase. In a hospital-based study
conducted among blood donors it was revealed that HBV is endemic in the country with
prevalence rates ranging from 6.4% to 10% among blood donors, 6.4% among pregnant women
and 16% for children among the general population (Foli et al, 1971; Acquaye et al, 1991, 1994;
Martinson et al, 1998). Another hospital-based study conducted in two different hospitals in
Jirapa and Tumu in the Upper West Region of Ghana by a Cuban Medical Brigade has shown
that in 2009, 128 admitted patients were tested HBV positive and that majority of the cases
were between the ages of 30-44 years (GHS, 2009). In a cross-sectional study of children aged
15 years and younger in the rural Ashanti-Akim North district of Ghana Martinson et al (1998)
estimated the HBV prevalence at 5.4%. A hospital-based study of pregnant women in Accra the
capital of Ghana, estimated the prevalence at 2.5% (Lassey et al, 2004). Adjei et al (2006)
performed a cross-sectional study of prison inmates in two regional central prisons in Ghana
and found that the HBV prevalence was 19%. Prisoners have been found to be part of the high
risk groups of hepatitis prevalence in Ghana. The congested nature of most prisons in the
country coupled with the fact that prison inmates are not usually screened before serving their
prison sentence exposes them to HBV infection.
Unpublished data on causes of deaths in Ghana’s premier hospital, Korle Bu Teaching
Hospital, over a 20 year period (1980-2000) from the Department of Pathology revealed that
the commonest cause of liver diseases leading to death at autopsy in Ghana was cirrhosis of the
liver. Although statistics from the Ghana Health Service mentioned liver cirrhosis as the major
cause of all liver related deaths in Ghana, there have been very few studies of the possible role of
hepatitis B and other possible risk factors that account for the deadly epidemic in the country.
This is a clear manifestation that hepatitis B related causes of liver cirrhosis are relegated to the
background and not much documentation on it. In view of the above mentioned factors and
forces facilitating the spread of the disease worldwide, being knowledgeable about the facts and
10 figures on the ground and having positive attitudes and behaviors are paramount in the fight
against the spread of the global epidemic.
1.4 Knowledge attitude and practice of HBV
1.4.1 Knowledge
Knowledge is formed through interaction with the surroundings where individuals
themselves construct their understanding of the world through experience. Its exchange is an
integral part of learning as well as helping the individual to shape his or her abilities by
converting theoretical and practical skills into new knowledge. Human knowledge is mostly
acquired through communication and its processes. Knowledge is the key to prevention and
education is the key to knowledge. However, knowledge about the deadly disease in Ghana is
low. A talk with people across the country has given me the impression that a, majority of
Ghanaians have little or no knowledge or understanding of the importance of their liver
condition for good health. This lack of knowledge or awareness is not only limited to only
hepatitis B but also their overall well-being in terms of health. There are a lot of factors
impeding efforts put up by established institutions like WHO and other world organizations to
curb the menace of hepatitis B globally. Notably among these is the lack of knowledge and
awareness among health care providers, social service professionals, adolescents, members of
the public and even policy makers. It is an established fact that though there has been a safe and
effective vaccine for hepatitis B over the past 20years, universal vaccination is still lacking in
many countries. One of the major obstacles identified for this drawback is the lack of
commitment to preventive medicine and vaccines. Due to the apparent lack of knowledge about
hepatitis B, most governments which are supposed to be the major financiers of public health
activities have seriously not considered hepatitis B prevention as a topmost priority in health
care and have opted for selective prevention strategies. Most interventions aimed at reducing
HBV prevalence among high risks groups have failed because of the inability to access these
groups. There is also lack of perceived risk among these high risk groups and over 30% of those
with acute hepatitis B infection do not have identifiable risk factors (Mangtani, 1995).
Few literatures have been able to take into cognizance geographical locations when
assessing adolescent’s knowledge about the deadly HBV. In Ghana, there has not been any
available literature to support the claim of geographical location influences on adolescent’s level
of knowledge of hepatitis B or otherwise. However, in a cross-sectional study conducted in
Australia to assess secondary school student’s level of knowledge about STIs including hepatitis
B in rural and urban localities, it was found that rural students were more knowledgeable about
11 issues of STIs compared to their urban peers (Lucke et al, 1993). A survey of rural Canadian
students STDs knowledge revealed high levels of knowledge among both rural and urban
students (Svenson et al, 1992). A similar study conducted in the United States of America (US)
to determine adolescent’s level of HIV knowledge in low risk rural areas and urban high risk
urban areas showed that rural students had better knowledge of HIV and risk reduction
strategies than their urban counterparts (Svenson et al, 1992). Reliable research has also shown
that adolescents sexual health knowledge does not totally mirror the risks they are most likely to
encounter. Wyn (1994) and Wright (1991) revealed that although hepatitis B presents real risks
to adolescents, knowledge of the disease and asymptomatic presentation has been found to be
very low among secondary school students.
1.4.2 Attitude
Atkinson et al (2003) defined attitude as the favorable or unfavorable reaction to objects,
people, situations or other aspects of the world. Other social psychologists considered attitudes
to include factors such as cognition, affection and behavior (Kruglanski et al, 2007). They
further explained the cognition aspect of a person to mean a person’s knowledge of something,
the affective component represents an individual’s feelings and evaluations that influence the
standpoint for or against something and the behavioral aspect to be, the way people act towards
a situation or a person and the motivation to make changes. Attitudes as suggested by
psychologist are formed through experiences in lifetime and are usually determined by beliefs
and the evaluation of such beliefs. Attitudes formed by individuals in society can be
comprehensive as well as unspecific.
Fishbein et al (1975) indicated that comprehensive attitudes are more stable and are
usually strongly held by the owners therefore, very difficult if not impossible to be influenced as
compared to unspecific attitudes. A person’s behavior can be predicted by using the strength
and consistency of his or her attitude. In this regard, any intervention that is aimed at changing
the behavior of an individual must first of all have enough information about his or her attitudes
and then employ methods that will help change these attitudes. Attitudes of which one is aware
of or that are based on one’s own experience can predict behavior to a higher degree than
attitudes that do not meet these criteria (Smith et al, 2003).
Smith et al (2003) indicated those possible factors that could help influence the attitudes
of an individual include, the nature of the sender (e.g. the nurse, doctor, health worker or
professional in a counseling situation), the receiver (e.g. the patient), the message itself and the
social context in which the information was communicated. Trustworthiness, expertise and
interpersonal attraction are important signs that should be exhibited by the sender in order to
12 influence a person’s attitude. It is important to state that for a sender to be able to make an
impact on the attitude of a receiver factors such as sex, age, self-esteem and knowledge have an
important role to play.
Knowledge does not necessarily influence a person’s attitude. People may be
knowledgeable about a particular risk behavior but may still go ahead to do it. Knowledge about
hepatitis B is necessary but the provision of knowledge alone is not sufficient since it does not
necessarily lead to the behavior change. Attitudes, values and beliefs (including perceptions
about personal vulnerability to infection) as well as cultural norms and the influence of family,
peers and the media are all important determinants of whether or not appropriate behavior is
adopted by adolescents (Emmons et al, 1986). Another important motivation for a behavior
change among adolescents or anybody at risk of a health risk is the feeling of compassion for
those already affected. This is backed by the fact that stigmatization of disease is often a sign of
denial of potential personal risk (Parker & Aggleton, 2003).
Studies conducted by Johnson et al, (1999), which investigated adolescents attitudes
towards their risks of (STDs) supported the assertion that adolescent’s assessment of their risk
may not be appropriate relative to the true risk. In another study conducted by Samet et al
(1997) concerning the acquisition of (HIV), it was confirmed that, adolescents may continue to
engage in behaviors that increased their risk of disease acquisition despite knowledge of the risk.
Additionally, some adolescents might even demonstrate knowledge of the disease prevention
strategies but still feel that the risk of contracting the disease is inevitable. Samet et al (1997) has
suggested that adolescents who are more knowledgeable about a risk of a disease may be less
likely to take action against it in the form of screening or prevention.
1.4.3 Practice
Social psychologist defined it as the process of putting an intended behavior into action.
Practice may be executed consciously or unconsciously which may lead to positive or negative
outcomes. Individuals in society do different things for reasons best known to them. Some of the
practices people engage in and for that matter adolescents are due to individual preference, peer
influence, societal pressure or cultural beliefs, norm systems or for the sake of fun. In the case of
adolescents, where the struggle for self-identity and group acceptance is paramount, most of the
practices they engage in are peer-induced. Another prominent fact in determining adolescent
practices is cultural endorsement. In a society where tattooing and piercing of ears and eyes is
fashionable, adolescents are highly motivated to do so because they will not receive criticisms
from society. Societies where premarital sex is not punishable, adolescents are likely to engage
in sexual intercourse since it is at this stage they begin to explore the functions of their body
13 parts. This does not only expose them to sexually transmitted diseases like HB, HIV, syphilis
and gonorrhea, but also adolescent pregnancies and illegal abortions which are now albatross
around the necks of many developing countries in Sub-Saharan Africa. Previous literature on
practices adolescents engage in that expose them to HBV infection looked similar but divergent
across geographical boundaries. Adolescents the world over engage in a lot of practices that
predispose them to several health hazards. This has led to their classification among people at
higher risk of contracting sexually transmitted diseases such as HIV/AIDS, gonorrhea, syphilis,
hepatitis, etc.
Risk-taking has been identified by psychologist as one of the trademarks of adolescents.
The psychological literature on risk-taking suggests that males are greater risk-takers than
females, and that adolescents tend to be greater risk-takers than adults (Arnett, 1994). Risky
behaviors or practices include actions involving potentially negative consequences (losses),
which are offset by perceived positive consequences (gains) (Jessor, 1998). Despite these facts,
adolescents usually try to cover up the perceived negative consequences of these behaviors and
concentrate on the so-called positive ones such as pleasure, peer acceptance and satisfaction of
needs (Moore & Gullone, 1996). Few studies seem to justify the behaviors of adolescents
although they are well aware of the preceding consequences.
Jessor and Jessor (1997) argued that adolescents actively seek out risks in order to take
control of their lives, deal with anxiety, frustration, inadequacy and failure; gain admission to
peer groups. Carroll et al (2002) and Martel et al (2002) in a cross-sectional study discovered
that adolescents and young adults are increasingly acquiring body piercing in recent times.
Piercing of different body parts has globally become a fashion among a lot of adolescents in
various cultures for centuries (Miller, 1997). Millner et al (2001) considered body piercing as a
mainstream activity for adolescents and young adults in the western society even though most of
them are aware of its health effects such as bleeding, pain, infections, and allergic reactions. One
of the infection-related concerns of body piercing being raised by medical experts is its potential
to transmit HBV and HIV due to improper sterilization of piercing tools (CDC, 2002). A crosssectional study conducted among university undergraduates revealed that 51% of the students
reported currently or previously having body piercing (Mayers et al, 2002). A clinic based survey
conducted among adolescents aged 12-21 years at the Naval Medical Center in San Diego in
2000-2001 reported similar results with 27% of the participants having pierced their bodies
(Carroll et al, 2002). The study further highlighted the most commonly pierced parts of the body
of adolescents and young adults as navel, tongue and the cartilaginous portions of the ears and
that of the uncommon sites included, eyebrow, lips, nipples and genitals.
14 Several studies have shown an association between body piercing and hepatitis B seroconversion transmission. Johnson et al (1974) concluded that most of the cases of hepatitis B
that have been attributed to piercing, results in fulminant hepatitis and eventually leads to death
of the person. A cross-sectional survey conducted by Forbes, (2001) among 341 young students
in the Southwestern public University in America found that there was a statistically significant
difference between men and women with body modification including tattooing and piercing
compared to their counterparts. Another cross-sectional study by Braithwaite et al, (2001)
among 860 adolescents’ detainees in Atlanta in the United States also recorded similar results
among those with body piercing and those without. Cross-sectional survey by Carroll et al
(2002) on risk behavior and tattooing among adolescents documented that teenagers who
engage in tattooing or body piercing were significantly more likely to get involved in other high
risk behaviors such as drug use, unprotected sex, and suicides than non-participants.
The contribution of sexual intercourse to the transmission of HBV is dicey depending on
the context. While in most developing countries, unprotected sex with the opposite sex by
sexually active adolescents has been found to be the major source of transmission of infectious
diseases and viral diseases, their counterparts in the developed world are noted for men having
sex with men or women with women. This notwithstanding, the role of heterosexual intercourse
in these settings in the spread of hepatitis cannot be overemphasized. The contribution of
heterosexual sex in the spread of HBV has well been documented and reported with increasing
frequency as confirmed by a study conducted in the United States in 1988 which reported that
heterosexual transmission of HBV infection accounted for all reported cases of hepatitis B in the
United States (Alter et al, 1990).
Additionally, the risk of contracting any viral infections by blood transfusion of screened
blood largely depends on the use of donated blood during the window period, where the
antibodies were not easily detectable either because their production has not yet started or
antibody levels are so low that the test system could not detect them. In 2002, an epidemic
erupted in the West Nile where HBV was detected for the first time after a successful screening
and transplanting exercise (CDC, 2002). A similar study conducted in Kumasi, Ghana to assess
the risk of hepatitis B virus infection by transfusion revealed that recipients of screened blood
less than 10 years of age had 1:11 ratio chance of contracting HBV even after screening (Allain et
al, 2003). This was attributed to the underestimated risks of infection as well as the poorly
conducted manner in which screening test was done.
As public health is fast becoming an individual’s responsibility rather than a societal one,
there is the need to intensify the education on adolescents to enable them take up this challenge
15 into their hands and strive hard to protect and improve upon their health. Studies have shown
that adolescents are not making enough efforts to prevent diseases despite having knowledge of
the disease, ways of avoiding the disease and the risk of their possibility of contracting the
disease. This is usually due to the fact that adolescents underestimate the risk of getting the
disease. Though there are no available literature on efforts made by adolescents to prevent
themselves from contracting the HBV in Ghana, studies conducted in other parts of the world
gave divergent results. Dobson et al (1995) in a study on modes of HBV preventions have
suggested that due to the difficulties involved in getting teenagers to enter the clinics for
preventive health measures, school-based HBV vaccination programs should be resorted to
because of their effectiveness proven so far. The above practices engaged in by adolescents
mostly expose them to a lot of infectious diseases which hepatitis is not an exception.
2. THEORETICAL/CONCEPTUAL FRAMEWORK
2.1 Ajzen and Fishbein’s theory of reasoned action
According to the theory of reasoned action, the two main factors that influence a person’s
intention to perform a certain behavior are attitudes and subjective norms (Glanz, 2002). A
person holds a belief that a particular behavior leads to a particular outcome and evaluates the
outcome and consequently forms an attitude towards the behavior (Ajzen & Fishbein, 1980).
Subjective norms on the other hand arise from normative beliefs which in turn shape a person’s
perception of social pressure to perform certain behaviors. This is important because it makes it
possible for persuasive campaigns and other interventions to be more target-oriented through
evaluation of the beliefs i. e. (subjective and normative beliefs) that underlie performance of
certain behaviors. These beliefs, however, need not be necessarily rational in them but are
acquired as one learns about one’s world. The theory has also been found to predict attitude
behavior relationships effectively and is therefore an important theoretic frame work for HBV
risk reduction interventions. Fishbein and Ajzen buttressed their argument with the following
quotation made by them.
Fishbein cited: “I used the term “reasoned” because it is assumed that as one learns (e.g., forms
beliefs) about one’s world’s, one (often automatically) forms attitudes, perceived social norms,
and perceptions of control, that in turn (and again often automatically) influence one’s
intentions and behaviors, That is, these “higher order” constructs (e.g., attitudes, norms and
intentions) are assumed to follow reasonable from one’s beliefs about the world in which one
16 lives” (Fishbein, 2011 p2).These views of Fishbein and Ajzen are graphically represented in
Figure 3.
Figure 3: Theoretical framework of the study
Source: Fishbein & Ajzen (1975) 2.2 Rationale: Why adolescents?
According to sociologists, adolescence is a period of challenges and opportunities for
understanding oneself within the social context. Hall (1904), a renowned psychologist, made a
well-known note for more than 100 years ago describing adolescence as a period of “storm and
stress”. It is also estimated that about 27% of the world’s population is made up of adolescents
or young people aged (10-24 years). The definition of adolescence varies by program, funding
source, and need. For example, CDC defines adolescence from age 10 to 24. There are more than
1.7 billion people within this age group globally and about 87% of these young people live in
developing or low income countries (Population Reference Bureau, 2010).
In Ghana, about 33% of the country’s population is made up of adolescents between 1024 years, indicating that one out of every fifth person is an adolescent(Population Reference
Bureau, 2010). This gives a clear indication of how many adolescents in Ghana are and as such,
their health needs should not be swept under the carpet. Ghana has a predominantly younger
population as always the case of most developing countries. Young people at their transition
period from childhood to adulthood usually experience psychological and social changes at
17 puberty and the desire for sexual intercourse and issues of relationship are always at their peak
at this stage of life. In other words, it is called the stage of experimentation and discovery. It is
the stage where children take up characteristics of adults and behave like them even though they
are not yet adults. Because of the volatile nature of this stage, they are mostly predisposed to
many risks including drug use, smoking, drinking, unprotected sex which may lead to the
contraction of sexually transmitted infections (STIs) including HIV/AIDS, gonorrhea, syphilis,
hepatitis B and many more.
2.3 Hypothesis and objectives
With the vast socio-economic differences between rural and urban adolescents, it is
hypothesized that, there is a significant association between area of residence and adolescent’s
level of knowledge about HBV. The general objective of the study is to assess the knowledge,
attitude and practices (KAP) concerning hepatitis B (HBV) among rural and urban adolescents
in Ghana with specific emphasis on in-school adolescents in Wa Municipal and Wa-West
District in the Upper West Region. The specific objectives are:
•
To measure adolescent’s knowledge about the disease hepatitis B
•
To assess adolescent’s attitude toward the disease hepatitis B
•
To assess what adolescents are doing in their own capacity to prevent themselves from
contracting the disease by means of the practices they engage in.
•
To assess whether there are differences between rural and urban adolescents in terms of
their knowledge, attitude and practices about hepatitis B
18 3. MATERIALS AND METHODS
3.1 Geographical maps of the study area
Figure 4. Maps of regions of Ghana and districts of the study area
Source: Ghana Political Maps, 2010
19 Table 1. Health indicators for Ghana 2008. Total population 24,223,431 Population annual growth rate 2.4% Total fertility rate 4.0 Crude birth rate 32/1000 Still birth rate 19/1000 Neonatal mortality rate 43/1000 Infant mortality rate 50/1000 Perinatal mortality rate 45/1000 Under‐five mortality rate 76/1000 Crude death rate 11/1000 Female literacy 57% Male literacy 76% Maternal mortality ratio 450/100,000 Life expectancy at birth(years) 60% Delivery in health facilities 57% Delivery by a skilled attendant 55% Contraceptives prevalence rate 24% Estimated number of people living with HIV 260,000 Estimated adult HIV prevalence rate 1.9% Source: UNICEF, 2008
The emergence of the Republic of Ghana as a democratic giant follows a progressive,
peaceful and political stability chalked over two decades coupled with a robust and growing
economy in Sub-Saharan Africa. The country Ghana located on the West Coast of Africa is one of
the success stories of Africa in terms of its democratic credentials in the continent. The country
is globally referred to by many as the island of peace in the most chaotic continent in the world.
It is bordered to the east by Togo, to the west by La Cote d`Ivoire, to the north by the republic of
Burkina Faso and to the South by the Gulf of Guinea. The recent discovery of oil in commercial
quantities adds another boost to the already abundant resources the country is endowed with.
The economy of Ghana is dominated by agriculture with an estimated 60% of the population
engaged in agriculture as a source of livelihood. It is the second largest exporter of cocoa in the
20 world and other economic commodities such as gold and lumber. According to the 2010
population and housing census, the country covers a total land area of 238,533km2 and an
estimated population of 24 million people with over hundred ethnic groups, each with its unique
culture and language of communication (GSS, 2010). However, English language which is the
British legacy bequeathed to the country is the official language even though languages like Twi,
Ga, Fanti are widely spoken across the country. Ghana, formerly called Gold Coast gained its
independence from the British in 1957 to become the first country in Sub-Saharan Africa to
liberate itself from colonial rule.
This notwithstanding, poverty remains one of the major challenges in the country
especially in the three northern regions of the country. The poverty situation in these regions
accounted for half of the population of people living under the poverty line in Ghana. It is
estimated that about one third of rural populations lack access to safe drinking water and only
11% have adequate sanitation. Guinea worm, a parasitic infection largely attributable to drinking
unsafe water, continues to plague Ghana which reported more cases of Guinea worm than any
other country in the year 2004 (UNICEF, 2004). The global epidemic, HIV/AIDS seems to be
stabilizing in Ghana steadily. The relative low prevalence of HIV in Ghana differs marginally
according to geographic distribution, gender, age, occupation, and to some degree, urban-rural
residence. The rate of HIV self-reported cases in Ghana stood at 30%. This is attributed to
stigma, reduced health-seeking behavior and inadequate access to health services. Accessibility
to the Anti-retroviral (ART) drugs is a major challenge in Ghana. In 2004 out of 6000 HIV
positive children (aged 0-14), 469 received treatment (UNICEF, 2004). Some of the health
indicators according to UNICEF (2008) are illustrated in the table 1.
3.2 Health care system
Ghana has a well organized health care system and a well structured administrative
system since independence even though the country is still grappling with problems of
accessibility and unavailability of trained personnel. The general coverage of health services in
Ghana is estimated to be around 70% of the population where access to health facility on the
average is around 16 km within reach with half of the population living within a 5 km radius
(Van den Boom et al, 2004). The country introduced the referral system where major and
serious health cases are transferred to well-equipped hospitals to be addressed. The government
in collaboration with Japan International Cooperation Agency has also started another
community health delivery system called the Community-based Health Planning Services. It is a
system whereby health professionals are located at vantage points in the countryside to see to at
least the first aid needs of the indigenous people.
21 Modern health services are generally provided by the central government through the
ministry of health, local authorities, Christian Missions (private nonprofit agencies), and
relatively small number of profit making private practitioners. The medical system is directly
under the control of the ministry of health which also has over sight responsibility over
dangerous drugs control, narcotics, scientific research and the professional qualification of
medical personnel in the field. Regional and district health matters are taken care of by the
medical superintendants of that particular region or district. The implementations of major
health policies were some of the pragmatic measures taken by Ghana to improve the health
needs of the citizenry. The year 1989 saw a massive expansion and construction of additional
health facilities in order to extend primary health care services to about 60% of rural
communities (MOH, 1989). The primary health care (PHC) concept therefore came with the
recruitment and training of village health workers, community health workers and traditional
birth attendants for the propagation of health promotion and education messages. The most
recent of these policies was the successful nationwide implementation of the National Health
Insurance Scheme (NHIS) coupled with the free delivery services rendered to pregnant women
since 2005.
3.3 Major diseases in Ghana
Ghana, like any other country in Sub-Saharan Africa, is burdened with a lot of infectious
diseases. According to the WHO, the most common diseases in Ghana include, cholera, typhoid,
pulmonary, anthrax, pertusis, tetanus ,chicken pox, measles, infectious hepatitis, trachoma,
malaria, schistosomiasis and yellow fever. Malaria tops the list of all morbidity and hospital outpatient department attendance in the country according to the Ghana Health Service report for
2009 with a national hospital attendance of 5,270,108 between the periods of 2001-2009 (GHS,
2009). The report also ranked the top ten causes of death in Ghana to include malaria,
HIV/AIDS related, anemia, cerebrovascular accidents, pneumonia, septicemia, hypertension
related deaths, cardiac diseases, meningitis and diarrheal diseases. The WHO report for the
same period indicated that about 70% of all deaths that occur among under- five years children
in Ghana are infections induced and compounded by malnutrition especially in the rural
communities.
The ability to recognize a particular public health problem and its acceptance by the
health systems is a peculiar problem in most African countries and Ghana is no exception. In the
case of Ghana chronic disease prevention and education have been relegated to the background
for two major reasons. First and foremost, there is dormant assumption among medical experts
and lay people that chronic diseases are rare and preserve of the developed world and does not
22 pose any threat to developing countries. Secondly, Ghana’s health sector is not only structured
for the treatment of acute communicable diseases like HIV/AIDS, malaria, Tuberculosis, Swine
Flu (H1N1) etc, but also faced with inadequate financial support which prevents them from
championing the course of chronic diseases. Chronic diseases treatments, though neglected in
Ghana have a long history in Ghana. For example, cancer of the liver was discovered in the
country in 1817 among the Akan communities while sickle cell was also detected in 1866 (Addae,
1996). A hospital-based study in Korle Bu Hospital, the premier teaching hospital in the country,
showed a steady increase in stroke and cardiovascular diseases incidence between the 1920s and
1960s (Pobee, 2006). Further studies conducted by the Ghana diabetes association in the
southern sector also suggested a prevalence rate between 2% and 3% in urban areas. It is worth
mentioning that Ghana is not only neglecting the treatment of chronic diseases, but is also
engaged in selective prevention of the infectious diseases with hepatitis as one of the neglected
infectious diseases yet to catch the attention of both policy makers and health experts.
3.4 Human resource and infrastructure in the health sector
Ghana is facing challenges in both human resource and infrastructural development in
the health sector. The problem of health professional’s unavailability is attributed to the brain
drain syndrome that is very prominent in Sub-Saharan Africa. A study in Ghana revealed that
about 60% of all doctors trained in Ghana left the country in the 1980s and that 200 of them left
the country in 2002(Sagoe et al, 2002). Another study showed that in 2003, of the 5880 African
health and medical professionals that were granted work permit in the United Kingdom, 850
were from Ghana (House of Commons, Hansard, 2005). In 2003, 166 medical doctors, 3
dentists, 26 medical assistants, 583 professional nurses and 449 auxiliary nurses emigrated
(Sagoe et al, 2002).The national estimated doctor population according to 2009 Ghana Health
Service report stood at 2033 with a national doctor to patient ratio of 11,929:1 and that of nurses
stood at 24,974 with an estimated national nurse to patient ratio of 971:1 (GHS, 2009).
Another problem the Ghana Health Service is still battling with is inadequate
infrastructure for effective health delivery. The substantial increases in hospital attendance
without a correspondent increase in health facilities have stretched the already existing ones
beyond their capacity. As of 2009, there were 3011 health facilities in the country with a lot of
regional and district disparities where Ashanti Region has 549 health facilities as the highest in
the country compared to 135 in the Upper West Region as the lowest with an estimated target
population of 4, 725,046 and 677,763 respectively (GHS, 2009).The situation is almost the same
at the district level with some districts lacking district hospitals.
23 3.5 Study area
3.5.1 Upper West region
The study area is the Upper West region of Ghana, i.e. WA Municipal and WA West
district, which covers a geographical area of approximately 18,476 km2 and constitute about 13%
of the total land area of Ghana (GSS, 2010). The region is bordered on the North by the Republic
of Burkina Faso, on the East by Upper East Region, on the South by Northern Region and on the
West by Cote d’Ivoire. The region is located in the guinea savannah vegetation belt. The
vegetation consists of grass with scattered drought resistant trees such as the Shea, the baobab,
dawadawa, and neem trees. The heterogeneous collection of trees provides all domestic
requirements for fuel wood and charcoal, construction of houses, cattle kraals and fencing of
gardens. The shorter shrubs and grass provide fodder for livestock. The climate of the region is
one that is common to the three northern regions. There are two seasons, the dry and the wet
seasons. The wet season commences from early April and ends in October. The dry season,
characterized by the cold and hazy harmattan weather, starts from early November and ends in
the latter part of March when the hot weather begins, with intensity and ends only with the
onset of the early rainfall in April.
The Upper West Region was carved out of the then Upper Region with its capital based
in Wa in 1983 in order to facilitate administrative efficiency. In the region, there are two
predominant ethnic groups, the Mole Dagbon 76% and the Grusi 18%. The Wala which forms
part of the Mole Dagbon group constituted 16% whereas the Sissala with the Grusi is made up of
16% of the region’s population and also a major sub grouping in the region. Other indigenous
ethnic groupings collectively constitute an additional 5% of the population in the region, while
all Akan ethnic groups put together constitute 3% (GSS, 2000). However, there are major
variations in all the districts with Dagaabas, one of the major ethnic groups dominating in
Nadowli, Lawra and Jirapa-Lambussie districts with an estimated 90% in all three districts. The
major occupations in the region are agriculture and related work 72%, production and transport
equipment work 12%, sales work 5%, service work 4%, and professional, technical and related
work 4%.T he five together constitute at least 96% of the occupations in each district (GSS,
2000).The age structure for the sexes shows that although at the regional level there are more
females than males, there are variations by age.
The region has only 135 health facilities including a regional hospital. It has a doctor
population of 14 and a nurse population of 895 with the doctor and nurse to patient ratio as
47932:1 and 750:1 respectively (GHS, 2009).According to the 2009 health report, the region
recorded the lowest OPD attendance with a regional figure of 420,775. This can be attributed to
24 the sparsely populated nature of the region. The same report recorded antenatal health care and
supervised delivery coverage of 96% and 33% respectively and 3.1% as HIV prevalence among
pregnant women attending antenatal services (GHS, 2009).
3.5.2 Wa West district
The Wa West District is located in the North Western part of the region. It stretches from
longitudes 40°N to 24°S and from latitudes 9"W to 32°W, thus covering an area of 5,899 km2.
To the South, North-West and East, it has a common boundary with the Northern region,
Nadowli district and Wa Municipal respectively, and to the West with Burkina Faso. The
population from the 2000 Population and Housing Census is 69,284. Generally, there is no
major concentration of population in the District. The District is predominantly rural with all
communities having less than 2000 population (GSS, 2000).
There are 5 health centers, (4 public and 1 mission) and 1 private maternity home. There
is however no district hospital and office accommodation for the district health service and
inadequate staff accommodation. In addition to above health service deliverers, there are other
institutions that offer health care to the people. Notably among them include the traditional
birth attendants. They play a very important role in health delivery especially in the rural areas.
To further improve their activities, the Ghana Health Service has been carrying out training
program for the TBAs. Attendance per capita increased slightly from 0.4 to 0.5 per capita which
is far lower than the national value of 0.81 (GHS, 2009).
The major constrain to utilization of services is geographical access. Only a small
proportion of the total population lives within 8km radius. Most clients are able to seek health
care only on market days when they can have access to transport. Road network in the district is
in a deplorable state that some residents can boast of seeing a car only on market days especially
during the rainy season. People are therefore unable to access the few health facilities to their
fullest.
Staffing is also a major problem in the health care delivery in the district. Just a hand
full of health professionals accept postings to the place because of the unavailability of basic
facilities like potable water, electricity, good road network to mention but a few. The district is
one of the two districts in the region that is yet to be connected to the national grid or national
electricity. This discourages a lot of health personnel from accepting postings to the place.
Even though there is no baseline data for diseases such as TB and HIV/AIDS because of
the absence of laboratory facilities, data from case reports indicate that the district is endemic
for trachoma and Guinea Worm while diseases such as malaria, acute respiratory-tract
infections, skin diseases and snakebites are common cause of out-patient department
25 attendance (GHS, 2009). Despite the absence of sentinel services in the district to record HIV
and TB incidence cases, there are signals of the presence of these diseases in that; increasing
number of children orphaned, the district sharing a common border with Burkina Faso which is
noted for its high HIV prevalence in Sub-Saharan Africa as well as the increasing number of
unexplained deaths are indications of the presence of the diseases. Also, due to the remote
nature of the district, indications are that hepatitis accounts for some deaths in the districts due
to lack of laboratories for early detection. Screening for hepatitis especially for hepatitis B virus
is yet to get to this district.
The district has four different levels of educational institution. These include preschools, primary schools, junior secondary schools and senior secondary schools. The
educational system in the district is bedeviled with a number of challenges. These range from
staffing, infrastructure, lack of teacher motivation etc. Most of the schools in the district are
under-staffed, especially schools located in the most deprived parts. There are still instances
where only one teacher oversees all classes in the primary or all subjects in the (junior high
school).Factors that adversely affect staffing in the district include: lack of staff accommodation
and other essential facilities such as good drinking water, medical care and means of transport.
Improvement of these services facilities will attract and retain teachers in the district.
Educational infrastructure in the district is inadequate. Most of the existing structures are in
deplorable conditions. Considering the low level of education in the district, considerable
financial resources should be committed to providing the educational needs of the district. Out
of the 107 basic schools in the Wa West district, a good number of them hold classes under trees.
Apart from having to study under trees, the pupils have to sit on the ground due to lack of
furniture.
3.5.3 Wa Municipal/district
WA municipal is located in the North Eastern part of the region. Wa municipal has the
largest population of 224,066, representing 39% of the region’s population. The Municipality
shares its boundary to the East with Wa East district, to the West with Wa West district and to
the North, by Nadowli district. Being the regional capital, Wa Municipal could be described as
the largest urban town in the region even though Sissala district is also considered an urban
district in recent times.
Unlike the Wa West district which is predominantly a rural area and a farming
community, the Wa Municipal could be considered as the largest urban town in the region. The
municipality has four hospitals including other health centers and clinics. However, the region
cannot boast of a well-equipped regional hospital as in the case of other regions. The regional
26 hospital is currently under construction which will serve as a referral point for the whole region.
In order to facilitate health delivery in the municipality, a program called health extension
program has been introduced to train young people in areas of caring, basic first aid and other
health delivery services. The municipality has also established a health assistant training school
attached to one of the hospitals in order to train more health professionals for the purposes of
health education and prevention programs. According to the Ghana health service (2009)
attendance to health facilities in the municipality increased from 0.4 to 0.72 as against the
national attendance figure of 0.81. This gives a clear signal that the few health facilities are put
into good use. This can be attributed to the good road network system in the municipality. Even
though not all the roads in the municipality are tarred, most of the communities are linked to
the municipality by well constructed feeder roads and effective private transport system. The
municipality is also privileged to have an ambulance system which rushes for emergencies. It
can also be stated that even though staffing in the health sector is a general problem in Ghana,
the case of Wa municipal is much better than all the other districts in the region. Despite the fact
that most health professionals posted to other districts refuse postings with the claim of lack of
access to basic amenities such as electricity, schools , telephone services etc., the case of Wa
Municipality is much better.
Malaria, as in the case in of all other regions in the country has always being the topmost
disease in the health records of the Ghana health service. A single hospital in the municipality
can record up to 50 or more malaria cases a day. It is one of the diseases with the highest outpatient department attendance in the municipality. But the case of malaria seems to be
assuming a downward trend with the introduction of the mosquito treated bed nets system and
anti-malaria spraying exercise currently underway in the municipality. In such a system, all
pregnant and nursing mothers are given treated bed nets for use to prevent infants from
mosquito bites. The municipality recorded an HIV/AIDS prevalence rate of 3.2% as against the
national prevalence of 1.9% in 2008 as result of the implementation of a cultural value. This is a
cultural system whereby a brother is obliged to take over the wife of the deceased brother after
his death. Hence, because most of them do not go for a medical checkup before stepping in for
the late brother, the disease continues to spread through that act.
With education as one of the development priorities in the region, the municipality has
invested in the development of infrastructure in order to realize their dream of Free Compulsory
Universal Basic Education as is the policy of the Ghana education service. The municipality with
the help of some development partners has invested massively on the educational infrastructure
as well as implemented the rural volunteer program by recruiting young teachers for the rural
27 schools. The contribution of Non-governmental Organizations like, Action Aid Ghana, Plan
Ghana etc towards education in the municipality cannot be overemphasized. The municipality is
also privileged to have other private schools to supplement the efforts of government in the
provision of basic education. The municipality has 5 secondary schools as against (1) in the Wa
West district. In the case of junior secondary schools and primary schools, an exact figure
cannot be found regarding that. But the municipality is better placed in that regard compared to
Wa-West district. The biggest assert to the region is the University for Development Studies
which was established in 2000. The municipality is the only district with a university in the
whole region which led to the cosmopolitan nature of the municipality as a result of the inflow of
both local and international immigrants.
In general, even though all is not well with the two districts in all aspects of life especially
health and education, it can be said that Wa Municipality stands tall than Wa West in all
aspects. This has motivated the researcher to conduct a research into these two vast different
areas to assess whether adolescents in these areas are different in terms of their knowledge,
attitude and practice about hepatitis B.
3.6 Study design
The study design was a descriptive cross-sectional survey. According to Gay &
Airasian(2006), the descriptive survey is concerned with the conditions or relationships that
exist, such as determining the nature of prevailing conditions, practices and attitudes; opinions
that are held; processes that are going on; or trends that are developed. They also argue that it is
only descriptive studies that lead to generalization beyond the given sample and situation. This
type of study design was chosen because, considering the purpose of this study, the research
questions and the target population, it is the most appropriate design that will help the
researcher design and collect data from respondents. Walker (1985) described descriptive
survey as the type of study design that determines and report the way things are. This research
design has a number of advantages. The design has the advantage of eliciting responses from a
wide range of people. It involves asking the same set of questions to large number of individuals
through mails, telephone and by hand on the basis of data gathered at a point in time. It is also
appropriate when the researcher attempts to describe some aspects of a population by selecting
unbiased samples of individuals who are asked to complete questionnaire, interview and test
Silverman (2006). The descriptive survey is not without weaknesses or disadvantages. Dey
(2007) contended that errors and inadequacies of a survey research in education at many points
appear the way problems are initially chosen and defined through the selection of population
and sample to items construction and analysis of resulting data. Also, getting a sufficient
28 number of the questionnaire completed and returned so that meaningful analysis can be made is
another weakness of descriptive survey (Higgins, 1996). Despite these shortcomings, the
descriptive design is most appropriate to providing answers to many research questions and
enduring achieving the purpose of the study.
3.7 Study population
The target population of the study was all in-school adolescents in the Upper West Region
of Ghana. A list of all JHS in the region was made and based on it; an accessible population of
some twelve selected JHS was made by the use of a simple random sampling technique.
3.8 Sampling procedure and sample size
Four-stage cluster sampling technique was used for the study. In the first stage, two out
of the nine districts were randomly selected; Wa-West rural district and Wa-Municipal urban
district. In the second stage in each district six junior high schools were randomly selected. In
the third stage at each junior high school, one grade 1 and one grade 2 class was selected. In the
fourth stage 17 pupils were randomly selected through a lottery system of selection introduced
whereby “YES” and “NO” pieces of paper were circulated around for students to pick. Those who
picked “YES” took part in the research while those with “NO” were made to leave the classes to
enable their colleagues respond independently to the questionnaire.
Due to the large number of in-school adolescents, time and financial constraints, it was
difficult if not impossible to include all of them to respond to the questionnaire. A simple
random sample of 408 respondents was included in the study taking into cognizance the total
population of adolescents in the study area in order to facilitate generalizability.
3.9 Study period
The data collection was performed between June to August, 2010.
3.10 Measurement instrument
The main instrument used for the data collection was a standardized close-ended
questionnaire. It was designed from a sample questionnaire used in a similar study in
Alexandria, Egypt (Hanan et al, 1999) to measure the knowledge, attitude and practices of
adolescents towards hepatitis B virus. The instrument was chosen because of its simplicity,
ability to save time, and the possibility to make comparison as well as gather data from a group
of people at ago. The questionnaire was divided into four major sections made up of 32 items.
Section A sought to know the respondents background information such as age, sex, educational
29 level and area of residence. Section B basically talks about adolescent’s knowledge about
hepatitis B. Section C talks about the attitude of adolescents towards the spread of the disease
hepatitis B as well as their attitude towards carriers of the disease. Section D was to enquire
from adolescents what they are doing in their own capacity to prevent themselves from
contracting the disease by means of the practices they engage in.
3.11 Data collection
A suitable time for the research was agreed upon by headmasters or headmistresses
and the researcher for the administration of the questionnaire. Seventeen respondents were
picked in every class through the lottery selection process in all the twelve schools visited. A
sample size of 34 students of both grades 1 and 2 was selected in all the schools. After the
selection process, a vivid explanation was made to the students sampled for the study, the
purpose of the research as well as their right to opt out of the study if they so wish and the need
for them to answer the questions individually. The researcher also assured them of
confidentiality and promised not to release the data for any other purpose apart from the
purpose it was meant for. After the explanation, the questionnaires were personally
administered to the respondents with the help of some staff of the various schools who showed a
lot of interest in the research. They were given 30 minutes to respond to the questions, after
which the questionnaires were collected back from them.
3.12 Statistical methods
Data were computerized using Excel and analyzed using SPSS version 18. Descriptive statistics
in the form of cross tabulation and Pearson chi-square tests were used to test the statistical
significance with a significant level of 0.05. Frequencies and percentages were generated. There
were no missing values in the data analysis.
3.13 Ethical issues
A written informed consent was obtained from the Headmasters and Headmistresses of
the various selected schools involved in the study. An oral informed consent was also obtained
from adolescents who were willing to participate in the study. The questionnaires were
anonymous and did not require any identity and all data were kept confidential. Institutional
consent and ethical approval was sought from the Department of Public Health and Clinical
Medicine, Umeå University, the Ghana Education Service Directorate of Research and Ethics
Committee as well as the Ghana Health Service Directorate of Research and Ethics Committee.
30 4. RESULTS
4.1 Socio-demographic characteristics of adolescents
The overall response rate was 408 (100%). Of the total number of 408 respondents, 204
(50%) were from the rural district and 204 (50%) from an urban district. Respondents were
sampled from age range 10-18 of which 18 (8.4%) and 17 (8.8%) males and females respectively
were from age 10-12, 99 (46%) males and 120 (62%) females were also from age 13-15 years and
97 (45%) males and 57 (29%) females were selected from age group 16-18.
There were 109 (51%) males from junior high school one as compared to 95 (49%)
females. Junior high school two also recorded a male population of 105 (49%) and female
population of 99 (51%). In relation to area of residence, 121 (57%) males and 83 (43%) females
from the rural area responded to the survey as against 93 (44%) males and 111 (57%) females
from the urban area who took part in the survey. Overall, there were 214 (52%) rural and urban
males as compared to 194 (48%) rural and urban females in the study. There was a significant
difference in the sample size according to age range as well as area of residence between males
and females with p-values of (0.003 and 0.006 respectively). There were more adolescents 94
(46%) in age group 13-15 in the rural area as well as 125 (61%) in the same age group in the
urban area. More males in the rural area 121 (59%) responded to the questionnaire as compared
to more females 111 (56%) in the urban district. Socio-demographic characteristics of
respondents are represented in tables 2 and 3.
4.2 Respondents general knowledge about HBV in relation to causes,
effects and modes of transmission
In general, more urban adolescent males and females indicated they have ever heard
about HBV with a 91% yes response compared to 74% for that of their rural counterparts with a
p-value of (p<0.001). There was however a general trend on the causes and mode of
transmission of HBV among rural and urban adolescents. While 67% of rural adolescent were
aware of HBV being a viral disease, 57% of urban adolescents were aware of it being a viral
disease. In addition, whereas 57% of rural males and females were aware that HBV causes
cancer, only 41% of their urban colleagues were aware with significant difference p-value of
(p<0.001). With regards to the effects of HBV on the liver, 74% of rural adolescents indicated
that HBV primarily affects the liver as compared to 63% of urban adolescents. In terms of the
mode of transmission, majority of rural adolescents, 56% were aware of the role of un-sterilized
syringes in the disease transmission compared to 41% of urban adolescents with a significance
p-value difference of (p<0.002). Rural adolescents were again more knowledgeable when it
31 comes to reused blades and HBV transmission compared to their urban colleagues. However,
urban adolescents were more aware that HBV has no boundaries and can affect any age group as
compared to rural adolescents with the percentage difference of 76% and 68% respectively.
Detail results in relation to adolescent knowledge can be found in table 4.
4.3 Adolescents attitudes towards HBV and infected persons
Even though on the average majority of adolescents indicated HBV as a major health problem in
Ghana, 85% of urban adolescents admitted to it compared to 75% of rural adolescents with a pvalue of difference of (p<0.009). More urban adolescents, 78% did indicate they will ask for
screening of blood before transfusion compared to 68% of rural adolescents, a difference of ten
percent. Also, more urban adolescents, 69% were ready to be vaccinated against HBV should the
service be offered free compared to 65% of rural adolescents. Although, most adolescents were
ready to go in for further treatment should they be tested positive to HBV, urban adolescents
were more willing than rural adolescents. In relation to adolescent attitudes towards already
infected persons, rural adolescents were more receptive as compared to urban adolescents who
did indicate that infected persons should be isolated from other people to prevent them from
infection. In addition, 47% of urban adolescents were of the believe that infected persons should
be prevented from traveling or visiting friends or relatives as compared to 40% of rural
adolescents. However, more than half 59% of urban adolescents were ready to sit close to a HBV
positive patient compared to 34% of rural adolescents with a significance p-value difference of
(p<0.001). On the other hand, more rural adolescents, 40% were ready to visit their friends who
are tested HBV positive but were not ready to sit close to them. The above discussion sought to
reveal some evidence of stigmatization being exhibited by both rural and urban adolescents
towards already infected persons. Detail results can be seen in table 5.
4.4 Adolescent practices and efforts made to prevent themselves from
being infected with HBV
The total number of adolescents
who have being tested for the HBV is less that
30%.While 16% of urban adolescents indicated they have been tested for the disease, an equally
low percentage of 11% of rural adolescents indicated ever testing for the disease. There was a
general apathy towards HBV vaccination among rural and urban adolescents either due to the
unavailability of vaccination services or due to lack of perceived risk of contracting the disease.
This was evident by a rural and urban adolescent’s vaccination percentage of 17% and 12%
respectively. More urban adolescents, 50% indicated ever asking a health professional to change
or use new syringes whenever is required compared to a rural adolescents percentage of 35%
32 with a significant p-value difference of (p<0.004). However, on the average, more than 80% of
both rural and urban adolescents indicated ever asking their barbers to change or use new
blades during shaving of their hair (Table 6).
4.5 Comparison of mean, range and p-value differences among rural
and urban adolescents with regards to HBV
Table 7 summaries the total number of yes responses that were answered by
males and females adolescents in both settings. The mean score was used in this case to
depict on the average, how many yes responses were answered correctly regarding
questions on knowledge, attitudes and practices. Although it can be said that most male
adolescents responded yes to the questions, the differences were not statistically
significant except for urban adolescents on questions regarding knowledge with a pvalue of (p<0.002). The range was also used to demonstrate the lowest and highest
number of questions that most respondents answered. These differences may however
be influenced by the sample size difference between males and females in the study.
4.6 Educational level and adolescents’ knowledge, attitude and
practices concerning HBV
Results on different educational levels and adolescents knowledge on HBV revealed very
interesting findings. While 74% of rural JHS adolescents reported to have ever heard about
HBV, 91% of urban JHS adolescents answered yes to the same question. There were however
significant difference between rural JHS 1 and 2 as well as urban JHS 1 and 2 with p-value
difference of (p<0.002 and p<0.03 respectively). There was a general trend regarding
knowledge on mode of transmission, causes and effects of HBV between rural and urban JHS
adolescents . While urban adolescents exihibited a high level of knowledge about having heard
about the disease, they seem not to know much about the causes, mode of transmission and
effects compared to the rural adolescents. It is however important to note that some variations
exist between JHS 1 and 2 in both rural and urban areas. In the case of mother to child
transmission of HBV, 75% of rural JHS 2 knew about it compared to 60% of rural JHS 1
representing a significant difference of ( p<0.03). Also, on the issue of types of hepatitis, 40% of
urban JHS 2 reported their knowledge of it compared to 23% of urban JHS 1. After a careful
examination of the results on (Table 8) it can be stated that there was a trend to the effect that
adolescents in JHS 2 were more knowlegeable about HBV in both rural and urban areas.
33 Adolescents in both areas of residence differ marginally in terms of their view as to
whether HBV is major health problem or not. While 85% of urban JHS adolescent thought of it
as a major health problem, 75% of rural JHS adolescents saw it as a health problem as well
therefore constituting a percentage difference of ten. Results from Table 9 revealed that rural
JHS adolescents were more willing to go in for HBV screening even though the difference was
not that much. Mentioned can be made of the existence of a trend on who is more receptive
towards HBV chronically infected persons. While 59% of urban JHS adolescents were ready to
visit infected persons and even sit close to them, only 34% of their rural colleagues were ready to
do that and 22% rural and 34% urban JHS adolescents were of the view that infected person
should be isolated from other people(Table 9). Similarly, JHS adolescents attitude toward
screening, vaccination and treatment has a trend when comparing rural JHS adolescents against
urban. In the case of screening, while 78% of urban adolescents were ready to go for screening,
68% of rural adolescents held that view. On vaccination, 69% urban adolescents were ready to
go for vaccination should it be offered free of charge against 65% of rural adolescents. Again,
80% of urban adolescent were also prepared to go for further treatment if they were tested HBV
positive as compared to 77% of rural adolescents. From this it can be deduced that urban JHS
adolescents have positive attitudes toward screening, vaccination and treatment as compared to
rural JHS adolescents. The trend was however not the same for JHS1 and 2 in both settings
(Table 9).
Results on practices of JHS adolescents in both rural and urban areas showed some
dissimilarity. In the urban area, while 16% of adolescents reported ever making themselves
available to be tested for HBV, 11% of their rural counterparts reported ever making such efforts.
The results also showed that rural JHS adolescents, 17% were more likely to make an attempt to
get vaccinated against HBV compared to 12% of urban JHS adolescents. Again it was observed
from (table 10) that urban JHS adolescents, 50% were more likely to ask medical professionals
to use new syringes when required compared to rural JHS adolescents of 35%. In general,
majority of both rural and urban JHS adolescents did mention asking their barbers to change
blades during shaving of their hair, although it was a little higher in rural adolescents than
urban. An equal percentage of 75% of both rural and urban adolescent reported ever shaving
their hair from a professional barber. These practices were however different between rural JHS
1 and 2 as well as urban. Whereas 9% of JHS1 in rural adolescents indicated to have been tested
for HBV, 13% of rural JHS2 reported on such test. Also, while 18% of urban JHS1 reported being
tested for the disease, 15% of urban JHS2 reported such as well (Table 10).
34 Table 2: Socio‐demographic characteristics of respondents by sex and P‐value for chi2 test of association (n=408)
Characteristic Males Number
% 18 8.4 99 46 97 45 109 51 105 49 121 57 93 44 214 100 Age (years): 10‐12 13‐15 16‐18 Educational level: Junior high school I Junior high school II Residence: Rural Urban Total Table 3: Socio‐demographic characteristics by area of residence (n=408) Characteristic Rural Number % Age (years): 10‐12 23 11 13‐15 94 46 16‐18 87 43 Sex: Males 121 59 Females 83 41 Educational level: Junior high school I 102 50 Junior high school II 102 50 Total 204 35 Females Number % 17 8.8 120 62 57 29 95 49 99 51 83 43 111 57 194 100 Urban Number 12 125 67 93 111 102 102 204 P‐value 0.003 0.69 0.006 % 5.9 61 33 46 56 50 50 Table 4: Percentage who answered yes on the knowledge questions concerning hepatitis B among rural and urban adolescents (n=204) (n=204) Knowledge questions Males 80% 64% 75% 55% 70% 61% Rural Females 64% 71% 71% 61% 65% 71% Can hepatitis B be transmitted by un‐sterilized syringes? Can hepatitis B be transmitted by used blades of barbers? Is hepatitis B transmitted by shared tooth brush? Is hepatitis B transmitted by tattooing, ear and nose piercing? 52% 48% 65% 34% Can hepatitis B be transmitted by polluted water or food? Is there an available vaccine for hepatitis B? Does infectious hepatitis B have types? Do you know the most serious type of hepatitis B? Can hepatitis B be transmitted from a mother to her baby during pregnancy? 47% 64% 55% 33% 60% Have you ever heard of hepatitis B? Is hepatitis B caused by virus? Does hepatitis B primarily affect the liver? Can hepatitis B cause cancer? Can hepatitis B affect any age group? Is hepatitis B transmitted by contaminated blood? 36 Total 74% 67% 74% 57% 68% 65% Males 89% 63% 74% 42% 79% 70% Urban Females 92% 51% 54% 40% 73% 63% 63% 61% 72% 35% 56% 53% 68% 34% 61% 51% 55% 41% 71% 53% 58% 55% 36% 67% P‐value Total 91% 57% 63% 41% 76% 66% <0.001 0.04 0.03 <0.001 0.09 0.84 42% 51% 58% 25% 40% 46% 58% 25% 41% 48% 58% 25% 0.002 0.28 0.03 0.04 60% 58% 60% 34% 51% 41% 64% 51% 29% 56% 50% 61% 55% 31% 56% 0.49 0.55 1.00 0.30 0.02 Table 5: Percentage of rural and urban adolescents who responded yes to attitude questions concerning hepatitis B. (n=204) (n=204) Attitude questions Males Rural Females Total Rural 75% 75% 36% 34% 23% 21% 39% 40% Urban Males Females P‐
value 89% 36% 14% 46% 82% 25% 14% 48% Total Urban 85% 30% 14% 47% 40% 31% 34% 33% 0.12 40% 17% 27% 25% 34% 12% 29% 21% 66% 16% 36% 25% 53% 15% 25% 41% 59% 16% 30% 34% <0.001 0.25 0.91 0.008 69% 68% 68% 81% 76% 78% 0.03 70% 81% 57% 68% 65% 76% 74% 82% 65% 78% 69% 80% 0.34 0.28 Do you think hepatitis B is a major health problem in Ghana? Have ever thought of going in for hepatitis B screening? Have you yourself got vaccinated against hepatitis B? Infection with infectious hepatitis B can affect the ability of the person to visit his or her friends or for travelling? 75% 33% 20% 41% If I know my friend has hepatitis B I will be afraid of catching the infection and I will not visit him or her 37% 40% If you visit a hepatitis B patient, will you sit close to him or her? Will you kiss him or her? Can you use his or her cup of water? Should infected person with hepatitis B be isolated away from the people to prevent their infection? Will you ask for screening against hepatitis B of blood before transfusion? Will you like to get vaccinated for hepatitis B free of charge? If you are found positive for hepatitis B, would you like to have further treatment? 31% 8.3% 31% 20% 37 0.009 0.34 0.07 0.16 Table 6: Rural and urban adolescent’s practices and hepatitis B prevention (n=204) (n=204) Practice questions Have you made yourself available to be tested for hepatitis B? Have you yourself made any attempt to be vaccinated against hepatitis B? Rural Males Females Total Urban Males Females P‐value Total 10% 12% 11% 13% 19% 16% 0.11 17% 16% 17% 12% 13% 12% 0.21 Have you asked from medical staff to use new syringes when required for you? 35% 36% 35% 48% 51% 50% 0.004 Have you asked your barber to change the blade for shaving or cutting of hair? 85% 83% 84% 84% 76% 80% 0.30 Have you got shaved from a well trained barber? 76% 72% 75% 80% 70% 75% 1.00 38 Table 7: Mean, range and p‐value differences about adolescent’s Knowledge, attitudes and practices concerning HBV. Sex Number Mean Range P‐value Knowledge Urban Females 111 7.8 2‐15 0.02 Males 93 8.7 2‐15 Rural Females 83 9.2 0‐14 0.15 Males 121 8.6 0‐15 Attitude Urban Females 111 5.6 1‐12 0.15 Males 93 5.9 1‐10 Rural Females 83 5.2 1‐9 0.99 Males 121 5.2 0‐9 Practicie Urban Females 111 2.3 0‐5 0.69 Males 93 2.4 0‐5 Rural Females Males 8.6 9.2 83 121 39 0‐14 0‐15 0.80 Table 8: Rural and Urban adolescent’s educational level and their knowledge about HBV (n=204) (n=204) Knowledge questions
Form1 Have you ever heard of hepatitis B? Is hepatitis B caused by virus? Does hepatitis B primarily affect the liver? Can hepatitis B cause cancer? Can hepatitis B affect any age group? Is hepatitis B transmitted by contaminated blood? Can hepatitis B be transmitted by un‐sterilized syringes? Can hepatitis B be transmitted by used blades of barbers? Is hepatitis B transmitted by shared tooth brush? Is hepatitis B transmitted by tattooing, ear and nose piercing? Can hepatitis B be transmitted by polluted water or food? Is there an available vaccine for hepatitis B? Does infectious hepatitis B have types? Do you know the most serious type of hepatitis B? Can hepatitis B be transmitted from a mother to her baby during pregnancy? 64% 60% 71% 53% 65% 63% 61% 55% 65% 36% 63% 56% 48% 33% 60% 40 Rural
Form2 P‐ value 83% 74% 77% 62% 72% 68% 51% 52% 72% 32% 43% 61% 62% 39% 75% 0.002 0.04 0.34 0.20 0.29 0.46 0.16 0.67 0.29 0.56 0.005 0.48 0.05 0.38 0.03 Total Rural JHS 74% 67% 74% 57% 68% 65% 56% 53% 68% 34% 53% 58% 55% 36% 67% Form1 86% 60% 58% 47% 68% 60% 45% 51% 51% 28% 53% 56% 47% 23% 57% Urban
Form2 P‐ value 95% 58% 69% 34% 83% 73% 36% 65% 65% 22% 46% 67% 63% 40% 55% 0.03 0.77 0.11 0.06 0.009 0.05 0.20 0.58 0.05 0.42 0.33 0.11 0.02 0.007 0.78 Total Urban JHS 91% 57% 63% 41% 76% 66% 41% 48% 58% 25% 50% 61% 55% 31% 56% Table 9: Adolescents’ educational level and their attitude towards HBV.
Attitude questions (n=204) Rural Form1 Form2 P‐ value Do you think hepatitis B is a major health problem in Ghana? Have ever thought of going in for hepatitis B screening? 74% 29% 77% 39% 0.63 0.14 Total Rural JHS 75% 34% Have you yourself got vaccinated against hepatitis B? Infection with infectious hepatitis B can affect the ability of the person to visit his or her friends or for travelling? 21% 43% 22% 37% 0.86 0.39 If I know my friend has hepatitis B I will be afraid of catching the infection and I will not visit him or her 47% 33% If you visit a hepatitis B patient, will you sit close to him or her? Will you kiss him or her? Can you use his or her cup of water? Should infected person with hepatitis B be isolated away from the people to prevent their infection? Will you ask for screening against hepatitis B of blood before transfusion? Will you like to get vaccinated for hepatitis B free of charge? If you are found positive for hepatitis B, would you like to have further treatment? 28% 8.0% 27% 20% 71% 69% 71% 41 Form1 (n=204) Urban Form2 P‐
value 82% 27% 88% 33% 0.24 0.28 Total Urban JHS 85% 30% 21% 40% 17% 46% 12% 48% 0.32 0.78 14% 47% 0.05 40% 36% 29% 0.30 33% 40% 16% 32% 25% 0.08 0.08 0.36 0.40 34% 12% 29% 22% 62% 17% 29% 30% 56% 15% 30% 37% 0.39 0.70 0.88 0.30 59% 16% 30% 34% 66% 61% 80% 0.45 0.24 0.10 68% 65% 76% 79% 68% 77% 77% 71% 83% 0.61 0.65 0.22 78% 69% 80% Table 10: Adolescents’ educational level and their practices with regards to HBV prevention. Practice questions (n=204) Rural Form1 Form2 P‐
value Have you made yourself available to be tested for hepatitis B? Have you yourself made any attempt to be vaccinated against hepatitis B? Have you asked from medical staff to use new syringes when required for you? Have you asked your barber to change the blade for shaving or cutting of hair? 9.0% 20% 35% Have you got shaved from a well trained barber? 75% 81% 42 13% 14% 35% 87% 75% 0.37 0.26 1.0 Total Rural JHS 11% 17% 35% 0.25 1.00 (n=204) Urban Form1 Form2 P‐
value 18% 11% 51% 15% 14% 48% 0.57 0.52 0.67 Total Urban JHS 16% 12% 50% 84% 78% 83% 0.29 80% 75% 68% 81% 0.03 75% 5. DISCUSSION
The role played by epidemiologists, health care professionals, and other health related
institutions or bodies such as WHO, UNICEF, CDC etc in the fight against the global epidemic,
HBV cannot be overemphasized. HBV prevention is therefore a multi-faceted approach as it
pertains to public policy, advocacy, civil society, stakeholders and the individual. The global
epidemic is generally accepted as a threat to health even though this assertion is yet to be fully
accepted in most developing countries such as Ghana and the need for immediate steps to be
taken to halt it. However, its attendant consequences are so many as it leads to morbidity,
mortality and increased health expenditure in terms of managing chronic carriers and
hospitalization. Despite the long history of the disease in Ghana, there have not been
appropriate policies and pragmatic measures put in place to curb it coupled with the act of
selective prevention vigorously exhibited by health professionals which led to low level of
knowledge about HBV in the country (GHBF,2007). As stated in the introduction, this thesis is
to assess the knowledge, attitude and practices concerning HBV among rural and urban
adolescents in Ghana with specific emphasis on in-school adolescents in Wa Municipal and WaWest District in the Upper West Region.
5.1 Adolescents’ general knowledge about HBV
The present study revealed that on the average, sampled adolescents have a fair level of
knowledge about hepatitis B even though there were significant differences between rural and
urban adolescents.
The study revealed that there was a significant difference between female and male
students in both rural and urban settings regarding their knowledge about types of HBV and
different modes of transmission especially the horizontal one (Table 4). Female students in both
settings exhibited higher knowledge regarding types and modes of HBV transmission as
compared to their male counterparts. This can be attributed to curiosity on the side of female
students who will be future mothers to know about the dangers that they might face in their
lives. So they look for much information about some threatening problems as hepatitis B.
The study however showed that both rural and urban students knew very little about the various
modes of transmission of HBV (Table 5), less than half of the studied sample knew that hepatitis
B is transmitted by tattooing, ear and nose piercing, un-sterilized syringes and used blades of
barbers. Although the above finding cannot be described as satisfactory regarding students’
knowledge on modes of HBV transmission, it is much better the situation India. The Indian
scenario became prominent after epidemiologic and laboratory findings confirmed an outbreak
43 of viral hepatitis B in a village in India that was linked to the use of un-sterilized needles, reused
blades and syringes. The lessons drawn from the Indian setting offers an opportunity to place
more emphasis on health education campaigns to tackle all possible modes of transmission to
prevent the spread of this often fatal infection (Singh et al, 1998).
Also, while acknowledging the contributions of education in the prevention of Hepatitis
B, the present study presents very interesting results regarding educational level and knowledge
about HBV. While both urban JHS1 and 2 adolescents exhibited a high level of knowledge about
having heard about the disease, they seem not to know much about the causes, mode of
transmission and effects compared to the rural adolescents. This study confirms a similar study
among high school adolescents on their reproductive health knowledge, attitudes and needs by
Wyn (1994) and Wright (1991) in Australia where it was reported that although hepatitis B
presents real risks to adolescents, knowledge of the disease and asymptomatic presentation has
been found to be very low among secondary school students in the different grades. It is
however important to note that some variations exist between JHS1 and 2 in both rural and
urban areas (Table 8). This lack of student’s level of knowledge about HBV transmission modes,
effects or causes may be due to uncovering of this important topic in our schools either
informally in different school activities as health clubs or regular health news, beside the health
education programs or formally in the form of school curriculum. My interaction with most
heads of schools in this current study revealed that nothing like HBV education was part of the
curriculum and that the occasional visits by health professionals were targeted at HIV/AIDS,
TB, malaria and the current swine flu (H1N1) education.
The study also observed that although both rural and urban JHS1 and 2 adolescents
have a fair idea about HBV, adolescents in the higher grade, JHS2 in both rural and urban
residence were more knowledgeable compared to those in the lower grade in both settings. The
difference was statistically significant as clear in (Table 8). This difference may be due to the
presence of some parts in their curriculum related to infectious diseases and their modes of
transmission or some students took it upon themselves to explore new areas of interest as their
future and careers lie in their own quality of health.
On the other hand, the study illustrates a significant difference between area of residence
and adolescent’s knowledge about HBV (table 4). There was however a general trend on the
causes and mode of transmission of HBV among rural and urban adolescents. Whereas in
general, more urban adolescents have reported to have heard about the diseases in their lives,
more rural adolescent were knowledgeable about causes and modes of transmission compared
to urban adolescents. These results were however surprising in that they challenge the widely
44 anticipated view that urban adolescents should be more knowledgeable about causes and modes
of transmission of HBV because of their easy access to information on internet TV, radio,
newspapers, and magazines. The current study however coincides with similar cross-sectional
studies conducted in Australia and USA to assess secondary school student’s level of knowledge
about STIs including hepatitis B in rural and urban localities where it was found that rural
students were more knowledgeable about issues of STIs compared to their urban peers (Lucke et
al, 1993; Svenson et al, 1992). This study however failed to confirm a survey of Canadian
adolescents students STDs knowledge which revealed high levels of knowledge among both rural
and urban students (Svenson et al, 1992). This current finding might be due to the spread of
rural community radio stations extension program which is currently pursued by the Ghana
media commission to help entertain, inform and educate the rural folks on major health issues.
The finding could also be due to over concentration on HIV/AIDS campaigns to the neglect of
other equally deadly diseases in the urban municipality which was reported to have experienced
astronomical increase in HIV prevalence of 3.2% in 2008 as against a national figure of 1.9 %(
GHS, 2009). This low level of knowledge about hepatitis B among both rural and urban
adolescents especially regarding
causes, effects and modes of transmission might be due to
shortage of health education campaigns or clubs regarding different health problems and
especially this serious infection.
5.2 Adolescent’s attitudes or perceptions about HBV
Regarding the student’s attitude towards patients infected with HBV, (Table 5) shows
that females had more negative attitude towards these patients than males. A significant
difference was obvious as sitting close to the patients were concerned. But, although males also
had negative attitude towards other behaviors such as kissing the patient and using his or her
cup and equipment, the difference between them and females was not statistically significant.
This finding confirmed the arguments by the theory of reasoned action which forms the
theoretical bases for which this study was conducted that a person holds a belief that a particular
behavior leads to a particular outcome and evaluates the outcome and consequently forms an
attitude towards the behavior (Ajzen & Fishbein, 1980). This presupposes that after a carefully
assessment of themselves, female adolescents came to a firm belief that, infected persons
should be either be isolated or prevented from visiting friends as compared to their males
counters. These beliefs, however, must not necessarily be rational in adolescents since they are
acquired as one learns about one’s world. It was therefore possible this decision was taken by
the female adolescents in both settings for the simple reason that they did not know much about
HBV modes of transmission, causes and effects.
45 On the other hand females in both rural and urban areas were more unsympathetic with
hepatitis B patients as 66% of them indicated that already infected people should be isolated
away from the people compared to 45% of males. The difference was statistically significant.
These results therefore failed to reflect the very nature of females of being sensitive, sympathetic
and caring about themselves as well as others than do males. This attitude of females is a mark
of stigmatization to infected person. The present finding goes to confirm the assertion by Parker
& Aggleton, (2003) that stigmatization of diseases often marks the beginning of denial of
potential personal risk. This is because an important factor for a behavioral change among
adolescents or anyone at risk of a disease is to have a sense of compassion or humor for those
already affected.
Furthermore, the role played by adolescent’s level of education and the way they
approach issues of HBV particularly their attitude towards already infected persons, their
perceptions about causes and modes of transmission presents very interesting results in this
current study. Adolescents in both areas of residences differ marginally in terms of their view as
to whether HBV is major health problem or not. While 85% of urban JHS adolescents perceived
it as a major health problem, 75% of rural JHS adolescents saw it as a big health problem as well
with a ten percentage difference. Although screening services are difficult to come by, results in
(Table 9) revealed that rural JHS adolescents were more willing to go in for HBV screening even
though the difference was not statistically significant. The current study also detected a trend in
the receptiveness of JHS1 and 2 students in both areas towards HBV chronically infected
persons. While 59% of urban JHS adolescents were ready to visit infected persons and even sit
close to them, only 34% of their rural colleagues were ready to do that just like 22% of rural and
34% of urban JHS adolescents were of the view that infected person should be isolated from
other people (Table 9). A clear sign that more rural JHS students were stigmatizing compared to
their urban colleagues. This finding is a confirmation that health professionals have not been
able to adequately deal with stigma towards carriers of HIV/AIDS, TB and HBV in their health
education campaigns in Ghana especially in the rural areas in the basic schools.
Similarly, while rural JHS2 adolescents had positive attitudes toward chronic carriers
of HBV with regards to visiting them, sitting close to them and using their equipment, the
reverse was the case in the urban area where JHS1 adolescents had positive attitudes towards
chronic carriers compared to JHS 2 adolescents.
It was also deduced from results of (Table 9) that urban JHS1 and 2 adolescents have
positive attitudes toward screening, vaccination and treatment as compared to rural JHS 1 and 2
adolescents. This finding might be due to their lack of knowledge about the availability of these
46 services at various health facilities. It could also be due to their lack of perceived risk of
contracting the disease and hence there was no need to go for such services.
This risk
assessment of rural JHS 1 and 2 adolescents coincides with a similar view by Johnson et al,
(1999) which investigated adolescent’s attitudes towards risks of sexually transmitted diseases
(STDs) which indicated that adolescent’s assessment of their risk might not be appropriate
relative to the true risk.
5.3 Adolescent’s practices and HBV prevention
The study revealed a very disappointing percentage of adolescents being vaccinated
against HBV in the study so far with respective percentages of 17% and 12% for rural and urban
adolescents respectively (Table 6).This study was not different from a similar study by Cydulka
et al (1991) where the same value of 17% of the surveyed respondents in the study had received
hepatitis B vaccine at the time of the survey. The above finding also supported the claim by the
theory of reasoned action that the two main factors that influence behavior change are attitudes
and social norms which lead to the development of an intention and also the eventual execution
of that intention into practice. This can be applied in the current study in the sense that because
there was a perceived lack of risk among adolescents leading to stigma and negative attitudes
towards chronic carriers, it could not influence their desire to go in for HBV prevention
measures. In other words, their intention negatively influenced their practice which led to such
low percentage of adolescents being vaccinated.
The results also indicated that while more males were vaccinated against HBV in rural
area, the reverse was true in the urban area where more females where rather vaccinated than
males even though these differences were not statistically significant. This particular finding
might be due to sample size differences between males and females in both settings. The current
study is consistent with two different studies in Egypt and Chicago respectively. Whereas the
Egyptian study confirmed that more males were vaccinated against HBV, the Chicago study
revealed that more females had received the vaccine than males (Hanna et al, 1999; Cydulka et
al, 1991).This lukewarm behavior of male adolescents towards vaccination may be mainly due to
their perceived lack of risk to the disease. The finding was consistent with a study conducted by
Arnett, (1994) that suggested that males are greater risk-takers than females, and that
adolescents tend to be greater risk-takers than adults.
It was also reported that whereas 20% of rural JHS 1 made efforts to get HBV vaccine, a
little above 10% of their urban counterparts reported ever making such attempts. A percentage
of 14% was recorded in both rural and urban JHS 2 as having made efforts to be vaccinated.
More urban JHS 1 and 2 were willing to ask a medical staff to change syringes compared to rural
47 JHS students. These differences were however not statistically significant. This general low
vaccination among rural and urban adolescents might be as a result of the following;
unavailability of vaccination facilities in the country, lack of perceived high risk, cost of
vaccination not covered by central government and therefore too expensive or fear of vaccine
side-effects among adolescents.
In the light of all the above barriers and lukewarm practices of adolescents to vaccination
against HBV, it is important to seriously consider a school-based vaccination centers established
in all basic schools to enable us reach out to all those adolescents who are not even willing to go
in for it even if it is offered free of charge. This suggestion is in line with what Dobson et al,
(1995) suggestion that school-based HBV vaccination programs should be resorted to because
of their effectiveness proven so far and to also solve the problem of getting teenagers to enter the
clinics for preventive health measures such as HBV prevention.
6. STRENGTHS AND LIMITATIONS
The strengths of this study are many and could provide a platform for further discussion
on this subject matter. These include the following;
First and foremost, the fact that this study was the first of its kind to be conducted in the Upper
West Region of Ghana provides useful information for strategy planning and health education
campaigns. Secondly, the current study even though unable to provide causal relationships, will
provide a baseline data for further studies and could also be a useful baseline guide in the health
delivery
assessment of Ghana health service . Thirdly, the fact that the study focused on
adolescents, a vulnerable segment of the Ghanaian population whose health needs are usually
neglected is another important strength of this present study. Furthermore, because the study
does not involve a follow-up period before data could be generated, it was faster, cheaper and
easier to perform. Additionally, in order to ensure reliability of the measurement instrument, a
pilot study was first conducted among a small sample of adolescents to ascertain the length of
the questionnaire and their level of understanding of the questions. Also, to ensure a possible
generalizability and comparison the measurement instrument was drafted from a similar study
conducted in Egypt to assess the knowledge, attitude and practices of adolescents concerning
STIs which met the WHO recommended standards.
Despite the numerous strengths of this study, it cannot be said to be without weaknesses
or limitations. Some of the limitations of the study include;
The first limitation of this present study is that because it was restricted to only in-school
adolescents, it has the potential of denying out of school adolescents the opportunity to be
included and this may create some biases. Secondly, because this study was a cross-sectional
48 study, it could not draw any conclusion on causation or effect. But it is still important to set the
stage for more detailed study in the deadly epidemic. The third major limitation of this study
was that because some of the schools especially in the rural area were in-mortorable at the time
of the study, adolescents were only selected from rural schools that could be reached and this
could create a possible selection bias. Other potential limitations were, the study failed to
triangulate the data collection process in the form of adopting a qualitative approach in addition
to the quantitative approach. This was because, it was felt that the qualitative approach might
take some time to build trust with participants that will facilitate full participation and honest
self-representation. The fact that this study was unable to successfully deal with the issue of
“design effect” which is a major obstacle in cluster sampling as well as the use of ”yes” and ”no”
responses to measure attitude instead of an attitude scale were setbacks in the study.
Finally, despite the fact that this study has been able to answer some important
questions regarding adolescent’s knowledge about HBV, there are still some unanswered
questions to be answered such as: to what extent does adolescent’s knowledge about HBV affect
the prevalence of the disease in the region?
7. CONCLUSIONS
This study which sought to assess the level of adolescent’s knowledge, their attitudes and
practices concerning hepatitis B among rural and urban adolescents in the Upper West Region
of Ghana, was able to highlight three thematic areas and the need for prompt action to be taken.
First and foremost, even though most adolescents in both rural and urban areas have a fair idea
about the disease HBV, the study deduced that majority of them were not knowledgeable about
the causes, modes of transmission and effects of HBV even though rural adolescents were a little
informed compared to urban adolescents. Secondly, although most of the adolescents indicated
HBV as a big health problem in the country, the issue of stigmatization against already infected
persons is very strong among adolescents in both rural and urban areas. Thirdly, vaccination
which is paramount for HBV prevention was very low among adolescents in both settings. This
was either due to lack of well-equipped health facilities or lack of perceived risk among them.
The study also revealed that, females were more knowledgeable about causes, modes of
transmission and effects of HBV in both rural and urban settings compared to males. On the
other hand, it was realized that females in both settings had more negative attitude towards
chronic HBV patients than males. These findings are needed to help assess the effectiveness of
health education campaigns carried out by the Ghana health services at the various regional and
district health directorates. These surprising revelations are an indication that a clear strategy is
needed to make the health education sessions more effective.
49 8. GENERAL RECOMMENDATIONS
The researcher upon careful analysis and discussion of the results came to the point that much
still needs to be done to win the fight against the HBV completely. The recommendations are
categorized into two blocks, such as recommendations for researchers and secondly,
recommendations for policy makers, educational institutions and health care providers.
1st For the Researcher
►More studies that cover large numbers of rural and urban, in and out of school adolescents are
recommended to investigate the level of knowledge of HBV among them and if possible
investigate the prevalence of the disease in the Upper West Region.
► Additional studies, a blend of a qualitative with quantitative approaches are recommended
to enable health care providers understand the adolescent’s perceptions about HBV and their
health seeking behaviors particularly in the rural areas of the region.
► Further studies are required to measure other factors that may contribute to the low level of
adolescent’s knowledge about HBV particularly concerning mode of transmission, effects and
causes in Ghana with special emphasis on rural Ghana.
2nd For Policy makers, educational institutions and
health care providers
►The integration of knowledge about hepatitis B within formal and informal school programs.
Conscious efforts should be made to blend HBV education into the curriculum or extracurricular activities in schools.
►Health education campaigns about the disease and its complications in the clubs, NGOs and
the mass media to increase the awareness of the adolescents, and to help in modification of their
different risk behaviors that will cover out of school adolescents as well as cover vulnerable and
high risk groups and also intensify the campaign on stigma on chronic carriers.
►The health authorities should carry out a program of compulsory vaccination of adolescents
who were born before HBV vaccine introduction in Ghana. It should be backed by a national
comprehensive immunization policy and should cover the screening of pregnant women, risk
groups and the general public.
►Formulation of a Legislative Instrument to enable the Ghana Hepatitis B foundation function
as a commission. The autonomy of this foundation will enable it have a budgetary allocation
which will eventually lead to an increase in funding for hepatitis B activities and research. Since
the foundation cannot work in isolation, there should be effective collaboration between it and
50 key stakeholders such as health care workers, schools, government of Ghana and its
immunization development partners.
►HBV immunization should be covered as part of preventive services in the NHIS. The
exclusion of HBV treatment in the list of diseases covered by NHIS in the country denied a lot of
chronic carriers from seeking treatment because of its high cost of treatment. Its inclusion will
offer the vulnerable and poor access to treatment.
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56 10. APPENDIX
UMEÅ INTERNATIONAL SCHOOL OF PUBLIC HEALTH
EPIDEMIOLOGY AND GLOBAL HEALTH
DEPARTMENT OF PUBLIC HEALTH AND CLINICAL MEDICINE
UMEÅ UNIVERSITY, SE-90285, SWEDEN
The aim of this research is to assess the knowledge, attitude and practices of adolescents
concerning hepatitis B. The research is purely for academic purposes. The responses that you
willingly give will facilitate the completion of the study. I assure you of strict confidentiality that
is why your name is not required. Please tick the most appropriate response.
QUESTIONNAIRE FOR STUDENT
SECTION A: DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
1. Sex
• Male ( )
• Female ( )
2. Age
• 10-12 ( )
• 13-15 ( )
• 16-18 ( )
3. Educational level
• JHS 1 ( )
• JHS 2 ( )
• JHS 3 ( )
4. Area of residence
• Rural ( )
• Urban ( )
SECTION B: RESPONDENTS KNOWLEDGE ABOUT HEPATITIS B.
Table 1: Questions about knowledge of hepatitis B
Have you ever heard of hepatitis B?
Yes
No
Is hepatitis B cause by virus?
Yes
No
Does hepatitis B primarily affect the liver?
Yes
No
Can hepatitis B cause cancer?
Yes
No
57 Do not
know
Do not
know
Do not
know
Do not
Know
Can hepatitis B affect any age group?
Yes
No
Is hepatitis B transmitted by contaminated blood?
Yes
No
Can hepatitis B be transmitted by un-sterilized syringes?
Yes
No
Can hepatitis B be transmitted by used blades of barbers?
Yes
No
Is hepatitis B transmitted by shared tooth brush?
Yes
No
Is hepatitis B transmitted by tattooing, ear and nose piercing?
Yes
No
Can hepatitis B be transmitted by polluted water or food?
Yes
No
Is there an available vaccine for hepatitis B?
Yes
No
Does infectious hepatitis have types?
Yes
No
Do you know the most serious type of hepatitis?
Yes
No
Can hepatitis B be transmitted from a mother to her baby during
pregnancy?
Yes
No
Do not
Know
Do not
know
Do not
Know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
Know
SECTION C: RESPONDENTS ATTITUDES TOWARDS HEPATITIS B.
Table 2: Questions about attitude towards hepatitis B
Do you think hepatitis B is a major health problem in Ghana?
Yes
No
Have you ever thought of going in for hepatitis B screening?
Yes
No
Have you yourself got vaccinated against hepatitis B?
Yes
No
Infection with infectious hepatitis B can affect the ability of the person
to visit his or her friends or for travelling?
If I know my friend has hepatitis B I will be afraid of catching the
infection and I will not visit him or her
If you visit a hepatitis B patient, will you sit close to him or her?
Yes
No
Yes
No
Yes
No
Will you kiss him or her?
Yes
No
Can you use his or her cup of water?
Yes
No
Should infected person with hepatitis B be isolated away from the
people to prevent their infection?
Will you ask for screening against hepatitis B of blood before
transfusion?
Yes
No
Yes
No
58 Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Do not
know
Will you like to get vaccinated for hepatitis B free of charge?
Yes
No
If you are found positive for hepatitis B, would you like to have further
investigations or treatment?
Yes
No
Do not
know
Do not
know
SECTION D: PRACTICES OF RESPONDENTS ABOUT HEPATITIS B.
Table 3: Questions about practices on hepatitis B
Have you been tested for hepatitis B?
Yes
No
Do not
know
Have you yourself got vaccinated against hepatitis B?
Yes
No
Do not
know
Have you asked from medical staff to use new syringes when required
for you?
Yes
No
Do not
know
Have you asked your barber to change the blade for shaving or cutting
of hair?
Yes
No
Do not
know
Have you got shaved from a barber?
Yes
No
Do not
know
59