Hepatitis B Knowledge Levels of Male Saudi Nursing Students in University of Hail NTRODUCTION: Viral hepatitis infections caused by hepatitis

B virus (HBV) are important public health issues (1). Currently, hepatitis B carriers are estimated to constitute 350-400 million of the whole population of the world (2). The incidence rate of HBV in Kingdom of Saudi Arabia (KSA) is 18.72 cases per 100000 people, and there are 4854 reported cases of HBV in KSA in .(2010, 3402 of them between 15 and 44 years of age (3 Hepatitis B virus (HBV) is a DNA virus that is transmitted by percutaneous injuries or per mucosal exposure to infectious blood products or other body fluids (4). Hepatitis B infection is a serious blood-borne disease, caused by the hepatitis B virus (HBV) which attacks the liver, and although in acute cases rarely results in liver failure and death; the main public health problem is that this can lead to lifelong chronic HBV infection, which may be followed by cirrhosis and/or liver cancer (5). Transmission Routes: ;Main transmission routes of HBV are outlined below Blood and infectious body fluids: The most important factor in .1 transmission of HBV is the blood and body fluids of infected individuals. Percutaneous transmission can occur in the following events as well: re-use of contaminated injectors, hemodialysis, acupuncture, ear piercing, and circumcision as well as sharing of personal items (towel, razor, shaving .(machine, and bathroom materials .Sexual contacts: Constitutes one of the main transmission routes .2 Perinatal transmissions: Generally takes place during birth as transmission .3 .from carrier mother to the child
4.

Horizontal transmission, household contacts, or family contacts. (61

8).

HBV is not transmitted by kissing, breast milk, water and foods, fecal-oral .(route, and handshake (9 Hepatitis B vaccination is the most efficient method of preventing several hospital-acquired infections such as HBV is through pre-exposure immunization (10). Vaccine provides 95% protection (2). The vaccine is applied via intramuscular route in 3 doses. Second and third doses are delivered 1 and 6 .(months later from the first dose, respectively (9 RESEARCH PROBLEM: Chronically infected HBV carriers are able to transmit HBV through contact with their body fluids, which includes occupational exposure to their blood and secretions. People at risk include health care workers (HCWs) in contact with blood and human secretions, all personnel at risk of needle stick/sharps injuries, which includes nurse and nursing students (5). In addition, poor adherence to universal precautions and poor maintenance of infection control measures contribute to risk of transmission (5). All health care workers in contact with blood and body fluids should know their antibody status and be vaccinated for HBV if they have not previously had HBV infection and should adhere to universal protective measures (11) This study will highlight the extent of non-immunization of student nurses at risk for occupational exposure, and link this to their knowledge regarding HBV infection and hepatitis B vaccination. This will assist in assessing and evaluating the level of knowledge for each college year regarding HBV infection, and will assist the college managers in collaboration with the clinical facilities managers to be aware of the extent of vaccination uptake, and develop strategies for promoting and improving HBV immunization uptake amongst student nurses if coverage is found to be low. PURPOSE OF THE STUDY: Research questions:
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The purpose of the study was to answer the following research questions: What is the level of knowledge about HBV among male nursing students? Is there a difference in HBV knowledge level regarding to college year and program type among male nursing students? Aim of the Study: The aim of this study is to determine knowledge levels regarding the prevention of hepatitis B virus infections, among male nursing students. Study Objectives: To assess level of knowledge among male nursing students regarding HBV infection. To compare the HBV knowledge level regarding to college year and program type among male nursing students. METHODOLOGY: Setting and samples: Cross-sectional study was conducted in the boy's college of nursing in January 2012. All the male students (about 135 student) in the College of Nursing were planned to be included in the study, no sampling was been performed. Full-time students include the second, third, and fourth year college students, while no one of the first college year students (introductory year) were included in the study. Currently, all the first year students in the College of Nursing are part-time students, who already worked as nurses (with diplomas degree) and who decided to continue education and obtain a bachelors degree. The Questionnaire: The questionnaire was non-standardised, self-generated, adapted and prepared in the light of the data reported in the literature (Babie and Mouton 2004:233). It was anonymous, self-administered, and consisted of thirty six standardized questions divided into three sections:
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Section A of the questionnaire covered questions on demographics of respondents. Section B of the questionnaire covered questions on current characteristics of the study group regarding hepatitis B. Section C of the questionnaire contained questions to evaluate knowledge of respondents. Survey forms were delivered to the students and they were asked to fill them out, the anonymity of respondents was assured and their verbal consent was obtained. 26% of the students couldnt be reached. Thus, 100 students (74%) were included in the study. Data Analysis: Each correct answer was given to 25 questions on hepatitis B, counted as one point. In the end, those points were summed up on a scale of 25 points. Then, the results were multiplied by 4 and converted into scores expressed on a scale of 100 points. The final values were recognized as hepatitis B knowledge scores. Students college years, and type of study program, were considered as independent variables that could have an impact over hepatitis B knowledge levels. Upon completion of data collection, data were entered and analyzed through statistical Package for Social Sciences (SPSS) version 16. Descriptive statistics were used mainly to summarize the data and provide answers to the first research objective, whereas, the independent sample ttests and one-way ANOVA tests and post hoc Tukeys HSD test were used to identify significant differences for the second research objective. P<0.05 will be recognized as statistically significant in all the analyses. :RESULTS
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Mean age of the participant students was 24.273.9 years. Various descriptive characteristics of the students included in the study are shown in .Table 1 As seen in Table 1, 70% of the study populations were single, and 59% were employed. While 11% of the study populations were second-year students, .27% were third-year, and 30% were fourth-year students As 68% of the study population was full time students, 32% were part time .students Several characteristics of the study group regarding hepatitis B are shown in Table 2.
Table 1: Various descriptive characteristics of students included in the study

Marital Status

Single Married Employment Status Employed Non Employed 2nd year college 3rd year college 4th year college Program Type Full time Program Part time evening program

N=100 70 30 59 41 11 27 30 68 32

As seen in Table 2, 96.9% of the students had no history of hepatitis B, whereas 67% had been vaccinated, 28% had hepatitis B immune response, and 90% had no hepatitis B carrier or patient in their family. Characteristics of the study group regarding hepatitis B vaccination are shown in Table 3.

Table 2: Current Characteristics of Study Group regarding hepatitis B Part-time 2nd year 3rd year N=100 students college college (N=32) (N=11) (N=27) Presence of past hepatitis B Yes 0 0 0 0 infection
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4th year college (N=30) 0

No Dont Know Hepatitis B immune response Yes No Dont Know Presence of hepatitis B patients or carriers in the family Yes No Not Known History of hepatitis B vaccination Yes No

98 2 28 19 53 2 90 8 67 33

31 11 26 30 (96.9%) (100%) (96.3%) (100%) 1 1 0 0 (3.1%) (3.7%) 11 1 5 11 (34.4%) (9.1%) (18.5%) (36.7%) 9 2 2 6 (28.1%) (18.2%) (7.4%) (20%) 12 8 20 13 (37.5%) (72.7%) (74.1%) (43.3%) 1 (3.1%) 30 (93.8%) 1 (3.1%) 25 (78.1%) 7 (21.9%) 0 11 (100%) 0 0 11 (100%) 1 (3.7%) 0

23 26 (85.2%) (86.7%) 3 4 (11.1%) (13.3%) 18 24 (66.7%) (80%) 9 6 (33.3%) (20%)

As seen in Table 3, 92.6% of the students had received hepatitis B vaccine in MOH hospitals and clinics equally, and 7.5% of the students had received hepatitis B vaccine in training college, whereas 62.7% had been received three doses of hepatitis B vaccine, 10.4% received two doses, and 9.4% received one dose. The knowledge level of the study group on hepatitis B and transmission routes are shown in Table 4.

Table 3: Characteristics of the study group regarding hepatitis B vaccination Part-time 3rd year 4th yea N=67 students College College (N=25) (N=18) (N=24) facility/institution were MOH 31 18 3 10 student received hepatitis Hospitals (46.3%) (72%) (16.7%) (41.7%) vaccine MOH 31 6 13 (722%) 12 (50%) Clinics (46.3%) (24%)
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University Health College Doses of hepatitis B vaccine received 1 dose 2 doses 3 doses Dont Remember Total

4 (6%) 1 (1.5%) 13 (19.4%) 7 (10.4%) 42 (62.7%) 5 (7.5%) 67

0 1 (4%) 2 (8%) 1 (4%) 19 (76%) 3 (12%)

2 (11.1%) 0

2 (8.3%) 0

7 4 (38.9%) (16.7%) 2 4 (11.1%) (16.7%) 7 16 (66.7%) (38.9%) 2 0 (11.1%)

The results indicate that 13 out of 25 items were answered correctly by more than half of the respondents. The score of the study population for hepatitis .B knowledge level was found to be 48.921.6 point As seen in Table 4, while 51% of the students expressed sexual intercourse as a transmission route of HBV, 39% mentioned perinatal route, 52% expressed use of sharing of personal items such as towel and toothbrush, 34% mentioned tooth extraction, 51% expressed tissue transplantation, 80% ,mentioned shared injectors expressed blood and blood products, 73% mentioned barbers 84% instruments, 28% expressed manicure and pedicure instruments, 41% mentioned tattooing process, 49% expressed circumcision instruments, 26% mentioned ear piercing, 55% expressed hemodialysis, 56% mentioned contact with open wounds/cuts, and 70 % expressed that people who are carriers of HBV are at risk of infecting others. 23% of the students knew that breast milk was not a transmission route for hepatitis B, whereas HBV was known to show no transmission through fecal-oral route, handshakehugging, and kissing in 24%, 66%, and 28% of the study population, .respectively
Table 4: Knowledge of students in the study population on hepatitis B and its transmission routes (N=100)
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Question

Correct Scored 1 N=% Yes 51 Yes 39 No 23 No 24 No 66 Yes 52 Yes 34 No 28 Yes 51 Yes 80 Yes 84 Yes 73 Yes 28 Yes 41 Yes 49 Yes 26 Yes 55 Yes 56 Yes 70

Responses Incorrect Scored 0 N=% No 25 No 16 Yes 30 Yes 38 Yes 5 No 17 No 15 Yes 31 No 8 No 2 No 2 No 7 No 29 No 14 No 5 No 28 No 6 No 15 No 13

Dont know Scored 0 N=% 24 45 47 38 29 31 51 41 41 18 14 20 43 45 46 46 39 29 17

Does HBV spread through sexual transmission route?* Does HBV spread through perinatal route? Does HBV spread through breast milk? Does HBV spread through fecal-oral route? Does HBV spread through handshakehugging?* Does hepatitis B spread through sharing of personal items? (Towel, toothbrush etc.)?* Does HBV spread during tooth extraction? Does HBV spread through kissing? Does HBV spread by tissue transplantation?* Does HBV spread through use of a shared injector?* Does HBV spread through delivery of blood and blood products?* Does HBV spread through a barbers instruments?* Does HBV spread by manicure and pedicure instruments? Does HBV spread during tattooing process? Does HBV spread through circumcision instruments? Does HBV spread by ear piercing? Does HBV spread through hemodialysis?* Can HBV be spread through contact with open wounds/cuts?* People who are carriers of HBV are at risk of infecting others*

.Items were answered correctly by more than half of the respondents * .Frequency number equal to percent, N=100

The knowledge level of the study group on hepatitis B and vaccination and .complication are shown in Table 5 As seen in Table 5, only 39% of the students considered liver cancer as a complication of HBV, 37% mentioned that hepatitis B vaccine cause mild side effects, 10% expressed that hepatitis B vaccine is made from human blood, while 58% of the students considered hepatitis B vaccine effective in protecting against HBV, 66% mentioned that there is three doses applied in hepatitis B vaccine, and 82% mentioned the intramuscular route of hepatitis B vaccine.
Table 5: Knowledge of students in the study population on hepatitis B and its vaccination and complication (N=100) Can HBV cause liver cancer? Yes No 51 39 10 Can the hepatitis B vaccine cause mild side Yes No 44 effects? 37 19 The hepatitis B vaccine is made from human Yes No 76 blood 10 14 Can the hepatitis B vaccine be effective in Yes No 31 protecting against HBV? 58 11 How many doses are applied in hepatitis B Three One/Two 21 vaccination? 66 13 Hepatitis B vaccine is administered through IM Other which route? 82 18 Overall Mean Score (SD) 48.921.6 .Items were answered correctly by more than half of the respondents * .Frequency number equal to percent, N=100 0

Comparison of the hepatitis B knowledge scores of students in the study in .terms of their college year and program type are shown in Table 6
Table 6: Comparison of the hepatitis B knowledge scores of students in the study in terms of their college year and program type. Mean SD ANOVA ANOVA Score F Sig. nd College 2 year college 29.8 19.5 Year 3rd year college 44.3 24.3 3.285 .044 th 4 year college 48.7 17.8 Program Full time Program 42.4 20.6 20.8 .000 Type Part time program 59.5 17.6
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The independent sample t-test and one-way ANOVA tests were used to determine which program type students were significantly different. Results revealed that part time students (M=59.5) and full time students (M=42.4) differ significantly from another regard to their knowledge levels (p=.000), that mean hepatitis B knowledge score of part time nursing students was 17.1 points higher than that of full time students. As seen in Table 6 and Figure 1, the results indicated that as the college year of the student's increases, scores of hepatitis knowledge elevate as well. The scores of the second-year students were significantly lower than those attending third or higher college years, while the knowledge scores of the fourth-year students were significantly higher than those of third-year students (p=.044). In addition to the independent sample t-test and one-way ANOVA tests, the post hoc Tukeys HSD test was conducted to determine which school year students were significantly different. Results revealed that student from 2nd (M=29.8) and 4th (M=48.7) year (p=.035), differ significantly from one another with regard to their knowledge levels. DISCUSSION HBV is one of the chronic hepatitis B causes which can be prevented by vaccination and is transmitted via blood and infectious body fluids, sexual intercourse, perinatal and horizontal route. Nursing students are under high risk for hepatitis B all along their school years, internships, and professional lives (12,13). As seen in Table 2, all the students had no hepatitis B history, whereas 67% stated that they had been vaccinated, 28% had hepatitis B immune response, and 90% had no hepatitis B carrier or patient in their family. In a study conducted on nursing and midwifery students, 87.2% of the students had no hepatitis B history, whereas 81.4% stated that they had been vaccinated, which is higher than our vaccination rate. In the same study,
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42.6% had hepatitis B immune response, and 78.1% had no hepatitis B carrier or patient in their family (14). Another study conducted among final year nursing college showed that the overall vaccination rate was 64.9% (15), which is similar to our vaccination rate. It's noticed no one in the present study had history of hepatitis B, the vaccination rate in other studies is higher than or comparable with the present study, while hepatitis B immune response is higher in the present study. As seen in Table 3, 92.6% of the students had received hepatitis B vaccine in MOH hospitals and clinics equally, and 7.5% of the students had received hepatitis B vaccine in training college, whereas 62.7% had been received three doses of hepatitis B vaccine, 10.4% received two doses, and 9.4% received one dose. In a study conducted among final year nursing students showed that 43.8% of the students had received hepatitis B vaccine in hospitals, 22.9% of the students had received hepatitis B vaccine in pharmacies, 14.1% of the students had received hepatitis B vaccine in a clinics, and 2.6% of the students had received hepatitis B vaccine in the training college. Whereas 38.6% had been received three doses of hepatitis B vaccine, 32.7% received .(two doses, and 24.3% received one dose (15 The results indicate that 13 out of 25 items were answered correctly by more than half of the respondents. The score of the study population for hepatitis .B knowledge level was found to be 48.921.6 point In a study conducted among Turkish nursing and midwifery students showed that 10 out of 20 items were answered correctly by more than half of the respondents, and the total score of the study population for hepatitis B knowledge level was found to be 69.819.4 point (14). Another study conducted on final year nursing students showed that 6 out of 7 items were .(answered correctly by more than half of the respondents (15
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It's noticed that the number of items answered correctly by more than half of the respondents, and the score of hepatitis B knowledge level is low in the .present study comparing to other studies As seen in Table 4, while 51% of the students expressed sexual intercourse as a transmission route of HBV, 39% mentioned perinatal route, 52% expressed use of sharing of personal items such as towel and toothbrush, 34% mentioned tooth extraction, 51% expressed tissue transplantation, 80% mentioned shared injectors, 84% expressed blood and blood products, 73% mentioned barbers instruments, 28% expressed manicure and pedicure instruments, 41% mentioned tattooing process, 49% expressed circumcision instruments, 26% mentioned ear piercing, and 55% expressed hemodialysis. 23% of the students knew that breast milk was not a transmission route for hepatitis B, whereas HBV was known to show no transmission through fecal-oral route, handshake-hugging, and kissing in 24%, 66%, and 28% of the study population, respectively. In addition, 56% mentioned contact with open wounds/cuts, and 70 % expressed that people who are carriers of HBV .are at risk of infecting others In a study conducted among Turkish nursing and midwifery students, 87.2% of the students expressed sexual intercourse as a transmission route of HBV, 67.4% mentioned perinatal route, and 79.8% mentioned use of sharing personal items such as towel and toothbrush, 75.5% mentioned tooth extraction, 83.1% expressed tissue transplantation, 94.6% mentioned shared injectors, 96.7% expressed blood and blood products, 78.5% mentioned barbers instruments, 79.8% expressed manicure and pedicure instruments, 69.8% mentioned tattooing process, 89.3% expressed circumcision instruments, 66.9% mentioned ear piercing, 73.6% expressed hemodialysis. In the same study, 78.1% of the students knew that breast milk was not a transmission route for hepatitis B, whereas HBV was known to show no transmission through fecal-oral route, handshake-hugging, and kissing in
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65.7%, 86.8%, and 56.2% of the study population, respectively (14). Another study conducted among final year nursing students, 95.8% mentioned contact with open wounds/cuts, 93.9 % of the students expressed .(that people who are carriers of HBV are at risk of infecting others (15 As seen in Table 5, only 39% of the students considered liver cancer as a complication of HBV, 37% mentioned that hepatitis B vaccine cause mild side effects, 10% expressed that hepatitis B vaccine is made from human blood, while 58% of the students considered hepatitis B vaccine effective in protecting against HBV, 66% mentioned that there is three doses applied in hepatitis B vaccine, and 82% mentioned the intramuscular route of hepatitis B vaccine. In a study conducted among final year college students showed that 82.6% of the students considered liver cancer as a complication of HBV, 75.2% mentioned that hepatitis B vaccine cause mild side effects, 49% expressed that hepatitis B vaccine is made from human blood, and 89.1% of the students considered hepatitis B vaccine effective in protecting against HBV (15). In another study conducted among Turkish nursing and midwifery students 86% mentioned that there is three doses applied in hepatitis B vaccine, and 67.4% mentioned the intramuscular route of hepatitis B vaccine (14). While results of studies made in groups concerning health show no similarity with our study, in studies made in other groups the knowledge concerning hepatitis B contagion ways is higher than that of our study group. As seen in Table 6, Mean knowledge score of the part-time program students was significantly higher than those attending second or higher college years. Furthermore, the knowledge scores of second-year students were lower than those of third-year and fourth-year students, while the knowledge scores of the fourth-year students were higher than those of third-year students. Thus, the increase in college year is accompanied with an elevation in the hepatitis
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B knowledge scores. Results revealed that only student from 2nd (M=29.8) and 4th (M=48.7) college year (p=.035), differ significantly from one another with regard to their knowledge levels. Th higher knowledge score among the part-time program student comparing to full-time program students related to their previous diplomas degree and experience as they are already worked as nurses and decided to continue education and obtain a bachelors degree. While no one of the full time, first college year (introductory year) students were included in the study. In a study conducted to establish the awareness and attitude about HCV infections among 210 full-time and part-time nursing students showed that full-time students have higher HCV awareness than part-time students (16). In another study on nursing and midwifery students, the increase in college year was accompanied with an elevation in the hepatitis B mean knowledge scores (14). The results of this study showed that numbers of items were answered correctly by more than half of the respondents and hepatitis B knowledge level lower than published studies had indicated low knowledge regarding transmission, prevention, and vaccination of hepatitis B infection. Nursing student expected to give information and education about hepatitis B to the society after their graduation, this knowledge lack before the graduate should absolutely be eliminated. Our study has shown that even though both groups of students have a no enough sufficient knowledge about HBV to face future challenges, they need further education on the subject. RECOMMENDATIONS Since nursing students begin to involve in clinical training in their second year, viral hepatitis should be taught earlier in the curriculum. Discussion in small groups for students will allow them to share their experiences in the different clinical practical environments (17).
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All the nursing students should be vaccinated against hepatitis B. Therefore, vaccination should be carried out on all new students lacking hepatitis B immunization in Nursing College. Additional efforts to help increase vaccination coverage among all categories of nursing students. Principles of vaccination against work related diseases should be included in the student nurses curricula like with principles of infection control from their first year of training. Follow up with vaccination doses received and serological test whenever there is an individual with work related injuries with biological material (18). LIMITATION OF THE STUDY The results may not represent all students in nursing college because only 100 students (74%) were included in the study, and relatively a small sample size. In addition, confining the study to a single institution limits the generalizability of these findings. CONCLUSION Hepatitis B knowledge score of undergraduate students in College of Nursing was 48.921.6 point, which is relatively low. Since hepatitis B knowledge score raises parallel to the elevation of college year. For the parttime students, who already worked as nurses (with diplomas degree) and who decided to continue education and obtain a bachelors degree. Hepatitis B education should be provided in the early in the curricula. Program type and college year of students were found to have an important influence on their knowledge scores. 67% of the participants had hepatitis B vaccination. REFERRENCES: 1. Shaw-Stiffel TA. Chronic Hepatitis. In: Mandell GL, Bennett JE, Dolin R: Principles and practise of infectious disease. 15. Ed. Churchill Livingstone, New York. 2000; 1297-1331.
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