Hepatitis B virus (HBV) is one of the smallest viruses known to infect humans (Hundie et al., 2017). It spreads through percutaneous or per mucosal revelation to infected blood or body fluids, primarily semen and vaginal fluids (Nigussie et al., 2013). The virus is more contagious than other bloodborne pathogens following percutaneous contact. The jeopardy of getting an infection from a single needle stick injury is 30%, which is very high compared to hepatitis C virus (3%) and human immune virus (0.3%) (Kesieme et al., 2011).

Internationally, 291,992,000 individuals were infested by HBV in 2016; of these, merely 29 million were detected and 4.8 million received treatment. The WHO African   Region  and  the  Western   Pacific   Region  are customarily affected (WHO, 2017). Death due to hepatitis is persistently amplified; 1.4 million deaths per year from acute infection and hepatitis-related liver cancer and cirrhosis which, is comparable to deaths due to HIV and tuberculosis; of those deaths, approximately 47% attributed due to HBV (WHO, 2016a). Likewise, around 257 million people were living with chronic HBV infection. HBV is also the second leading cause of carcinogens that causes malignancy next to tobacco (WHO, 2011). Of 360 million chronic infections about a million died every year due to HBV (Khan and Ross, 2013). By considering this, the World Health Assembly approved the global health sector strategy to eliminate viral hepatitis as a public health threat by 2030, with a target of reducing new infections by 90% and mortality by 65% (WHO, 2016a)

Healthcare workers (HCWs) are more liable to HBV exposure more often than the general population due to the environment of their career (Noubiap et al., 2014). WHO appraised that every year, 3 million HCWs experience percutaneous exposure to blood-borne pathogens, of these, 2 million are visible to HBV. Forty to sixty percent and < 10% of HBV infection among HCWs are attributed to professional threats in developing and developed countries respectively (Riou et al., 2016). Askarian and colleagues reported that the commonness and lifespan exposure of HBV infection among HCWs in tertiary hospitals are 8 and 48%, respectively (Askarian et al., 2011).

Ethiopia is one of the highly hepatitis affected country ranked as a medium to high endemicity for this hepatotropic virus (Negero et al., 2011). Studies conducted among different segments of the population in Ethiopia showed that HBV is a major public health problem in the country (Metaferia et al., 2016; Umare et al., 2016). Although vaccination of HCWs is recognized as a critical issue to control the disease burden and reduce the risk of nosocomial infection, attainment of the suggested vaccination rates among health care providers remains challenging (Byrd et al., 2013). The National Foundation for Infectious Diseases (NFID) reported that despite the presence of an effective (> 95%) vaccine, a higher number of individuals are still high risk for HBV (NFID, 2018).

Obedience with vaccination is poor among HCWs in various settings, particularly in developing countries (Ziglam et al., 2013). WHO estimates that only 18 to 39% of HCWs were vaccinated in low and middle-income countries as compared to 67 to 79% in high-income countries (Ouedraogo et al., 2013). Previous studies showed that HBV vaccination coverage in Ethiopia ranged from 4 to 12.9% (Abebaw et al.,  2017; Abeje and Azage, 2015; Feleke, 2016; Mesfin and Kibret, 2013). Even though the Ethiopian ministry of health starts to vaccinate health care providers and other high-risk population groups, vaccination coverage among HCWs is still very low and its progress is not satisfactory to achieve  the  goal  of   HBV  elimination  by  2030  (WHO,  2016b). Despite amply of evidence available worldwide, there is a scarcity of proof about the HBV vaccination and its associated factors in Southern Ethiopia. Therefore, the intent of this study was to assess HBV vaccination and its associated factors among HCWs working in Wolayita Sodo hospitals, Southern Ethiopia.

Study setting, design and period

An institution-based cross-sectional study was employed from May 10 to 25, 2018 to assess hepatitis B virus vaccination and its associated factors among health care workers working in Wolayita Sodo Hospitals, Southern Ethiopia. Wolayita Sodo is located 396 Km away from the capital city of Ethiopia, Addis Ababa and 16 km far from the Regional capital, Hawassa. There were two hospitals; Wolayita Sodo University Teaching and Referral Hospital (WSUTRH) and Sodo Christian General Hospital (SCGH).

Study population        

All HCWs working in WSUTRH and SCGH were the study population. HCWs who were not available in the hospitals due to maternity, annual or sick leave and students who were assigned for practical attachment were excluded.

Sample size determination and sampling

The sample size for this study was calculated using single population proportion formula by considering Proportion of HCWs receiving the complete series of HBV vaccine 35.8% (Yimer et al.,  2017), Z=1.96 at 95% CI, 5 % margin of error and 5% non-response rate. Then, the final sample size was 370. The sample was allocated proportionally to each hospital based on the number of HCWs working in each hospital. Hence, 219 and 151 HCWs were involved from WSUTRH and Sodo Christian hospital respectively.  The simple random sampling technique was used by taking the list of HCWs as a sampling frame. 

Data collection tool 

A structured self-administered questioners form was used to gather information about socio-demographic characteristics, knowledge about HBV and its vaccination, attitude and HBV vaccination status of HCWs. To assess the knowledge of HCWs about HBV and its vaccination; 10 questions about routes of transmission, natural history, diagnosis and prevention methods of HBV and 12 questions about HBV vaccine were used. The attitude of the HCWs about HBV infection and its vaccine was assessed using 9 Likert scale (1 (strongly disagree) to 5 (strongly agree) questions.

Data collectors and data collection procedure

Four trained BSC nurses and two public health professionals were recruited as a data collector and supervisor respectively. The data collection team received inclusive training about techniques of data collection and briefed on each question included in the data collection tool. Then, data collector provides the questioner for each study participant to fill by themselves and they collect it after checking  for  completeness  within  30 min.  Day to day supervision was carried out during the whole period of data collection by the supervisors and investigators.

Operational definitions

Vaccination status

Participants were dichotomized into ‘Fully vaccinated’ and ‘Not fully vaccinated’. HCWs was considered as ‘Fully vaccinated’ when they received three or more doses of hepatitis B vaccine (Abebaw et al., 2017).

Knowledge of HCWs about HBV infection and its vaccination

The HCWs was queried to reply to each question with ‘Yes’ or ‘No’. Each correct response was given a score of ‘1’ while an incorrect answer was given a score of ‘0’ both for HBV infection and its vaccine. Participants who responded appropriately for at least 70% of knowledge related questions were categorized as knowledgeable (Abebaw et al., 2017).

The attitude of HCWs

Participants who have responded positively for greater than or equal to the mean score of attitude-related questions were categorized as having a “Favorable” attitude (Akibu et al., 2018).

Data quality control

Further modification of the data collection tool was considered after pretest among 18 HCWs from Arba Minch general hospital. One day training about the whole process of the data collection was given for the data collectors and supervisors. Since the data collection technique was self-administered, to minimize recall bias the participants were given some cues to remember whether they took the vaccine or not. Investigators were checked on the spot and review all the questionnaires to ensure completeness and consistency of the information collected. Double data entry was done by two data clerks and the consistency of the entered data was cross-checked by comparing the two separately entered data.

Data processing and analysis

The collected data were checked visually by the investigators, then the data were coded, entered and cleaned using EpiData version 3.1 software and exported to SPSS version 22.0 for analysis. Simple frequencies, mean, standard deviation and range were used to describe the characteristics of participants. During analysis, the ‘Yes or No responses of each knowledge question were recorded as ‘1’ for correct responses and ‘0’ for an incorrect answer. Then, based on the total score obtaied knowledge of HCWs was categorized into ‘Knowledgeable’ and ‘Not knowledgeable. A total score of 7 out of 10 and 9 out of 12 were categorized as knowledgeable on HBV and its vaccine respectively. Likewise, the attitude of the HCWs was categorized as ‘favorable’ and ‘unfavorable’ after calculating the mean score; those who scored ≥ 35 (mean score) were catagorised as ‘favorable attitude’. The information was then presented using frequencies, summary measures, tables and figures.

Bivariate analysis was used to see the association between each explanatory variable and the outcome variable. Variables with a P-value of ≤ 0.25 on the bivariate analysis were included in the multivariable   logistic   regression    model.    Multi-collinearity   was checked using the variance inflation factor and standard error. Variables with VIF >10 and SE >2 were dropped from the multivariable analysis. Hosmer-Lemeshow’s test was insignificant and Omnibus tests were significant which indicate the model was fitted. Adjusted OR with 95% CI was estimated to identify the covariates associated with HBV vaccination. The level of statistical significance was declared at p-value < 0.05.

Ethical clearance

The study obtained ethical clearance letter from Arba Minch University, College of Medicine and Health Sciences, Institutional Review Board (IRB). Then, permission was secured from the respective hospital administrators. Study participants were clearly informed about the objectives of the study, risk, benefits and the rights of the participants. The participants were informed to withdraw from the study if they are not interested even after data collection is started. Moreover, written consent was obtained from each study participant before the commencement of data collection. To maintain the confidentiality of information gathered from each study participant, code numbers were used throughout the study. Participants were also informed that the information they provide do not disclosed to the third party.

Socio-demographic characteristics of HCWs

A total of 370 HCWs were participated in this study making a response rate of 100%. The mean age of the participants was 30.2 years with an SD of ± 4.3 and a range of 35 years (20-55). More than half (52%) of the participants were within the age group of 20-29 years. Of the participants, 56% were male, and 62% were protestant. Slightly more than half (54%) of the participants were married. Nearly half (47%) were qualified in nursing (Table 1).

Knowledge about HBV

Two-thirds (64%) and three-quarter (74%) of the HCWs replied correctly about HBV ways of transmission and prevention strategies respectively. All most all (99.5%) of the participants agreed that HBV is prevented through vaccination (Table 2 and Figure 1). Overall, 83.2% of the HCWs were knowledgeable about hepatitis B virus.

Knowledge about HBV vaccination

Of the participants, 356 (96%) retorted that there is an effective vaccine for HBV. The majority, 88% of the HCWs reacted that HBV vaccine should be given as part of workstation protection. Furthermore, 96% of the HCWS believed that HBV vaccine is suggested for all HCWs (Table 3). Overall 234 (63.2%) of the participants were knowledgeable about HBV vaccination.

Attitude of HCWs about HBV and its vaccination

Among the participants, 84% approved that hepatitis is a serious public health problem. 92% of the participants, decided that their job puts them at risk for HBV infection. Most, 96% of the participants declared that taking the HBV vaccine is necessary for them (Table 4). Generally, 208 (56.2%) of the HCWs were a favorable attitude about HBV vaccine.

Vaccination status of HCWs

Out of the participants, 307 (83.0%) received HBV vaccine; of these, 32 (10.4%) received only the first dose of  the  vaccine (Figure  2).   Overall,   62.70%   (95%  CI: 57.75%, 67.65%)) of the participants were fully vaccinated for HBV. Among those participants who did not vaccinate; 38% were due to the absence of the vaccine in their work setting (Figure 3).

Factors associated with HBV vaccination

After controlling confounding factors using multivariable analysis  five  variables:  Sex,  service  year,  department, knowledge, and attitude were significantly associated with vaccination (Table 5).

Female participants were 2 times [AOR=1.87 95 % (1.16, 3.01)] more likely to be fully vaccinated. Those participants who worked greater than four years were 2 times [AOR= 1.91 (95% CI: 1.22, 3.13)] more likely to be fully vaccinated compared to those who worked four years and below. Similarly, those participants who were working at ward and delivery room were 2 times [AOR= 2.26 (95 % CI: 1.41, 3.63)] more likely to be fully Vaccinated compared to those working in other units. Health care providers who had good knowledge and favorable attitude about HBV vaccine were two [AOR=2.0 (95% CI: 1.20, 3.04)] and two [AOR =1.9 (95 % CI: 1.17, 2.97)] times more likely to take all the recommended doses of hepatitis.

This study revealed that increment in service year is associated with full vaccination. Those study participants who work at least for 5 years were two times more likely to be vaccinated as compared to those who give service for less than or equal to 4 years.  Despite it is not statistically significant, this result is in line with the study conducted in Nigeria (Obi and Ofili, 2013). This could be due to the fact that as service year increases the HCWs observe and face different occupational injuries and hepatitis cases which initiate themselves to take the vaccine. Furthermore, in Ethiopia till now there is no trend for vaccination of the health care providers before and after recruitment to work. In addition, to cover the cost of the vaccine working for some years has been needed especially for mid and low-level HCWs. The above-mentioned reasons may contribute for the dalliance of vaccination.

Those HCWs working in the delivery room and ward were two times more likely to be vaccinated as compared compared to those who worked in the outpatient department, emergency and others. There is no study that supports this evidence but it might be due to the fact that labor, delivery, and wards are the working departments where the health care providers and the clients close contact and overcrowded areas that increase the rate of transmission of the disease.

In this study, 63.2% of the study participants were knowledgeable about HBV vaccination. This is in line with the study conducted in Bahir Dar where 62% of the HCWs were knowledgeable about HBV vaccination (Abeje and Azage, 2015). However, this result is lower than the study conducted in Gondar university hospital where 73% of the study participants were knowledgeable about hepatitis B virus transmission, progress and vaccination (Ayalew et al., 2016). This study also revealed that those participants who were knowledgeable about HBV  vaccination  were  two times more likely to be fully vaccinated. This is could be due to the fact that if an individual is clearly aware of the disease, its mode of transmission, and prevention mechanisms, the probability of adhering with the solution is very high.

In the current study, 56% of the study participants had  favorable attitude about HBV vaccination. Those participants who had favorable attitude were two times more likely to receive a full dose of HBV. This is in line with previous studies despite they did not calculate the overall attitude; majority of the questions used to measure the attitude of the health care providers about hepatitis B virus and its vaccination (Ahmed and Alanee, 2012; Akibu et al., 2018). This might be developed secondary to considering their job as hazardous and or risky, adequate information about the vaccine and considering it as one of the safety to prevent themselves from the disease. Generally, this study tries to determine the HBV vaccination status, knowledge and attitude of HCWs about HBV and its vaccination, and factors associated with full vaccination status using a comprehensive tool adopted from different literatures.

Vaccination of health care workers against HBV was low at Wolayita Sodo Hospitals, Southern Ethiopia. Receiving a complete series of hepatitis B vaccine varied by sex, the length of years in service, working department, knowledge, and attitude of the health care providers about hepatitis B vaccination. Hospital administrators in collaboration with the ministry of health and other stakeholders must implement policies and education practices, facilitating hepatitis B virus vaccination coverage among health care workers.

The authors have not declared any conflict of interests.

The authors would like to acknowledge Arba Minch University and the study participants for their invaluable support for this study.