DOI: https://doi.org/10.

53350/pjmhs22169288
ORIGINAL ARTICLE

A Kap Study of Hepatitis Among Hepatitis Positive Patients Presenting to

a Tertiary Care Hospital in Southern Punjab, Pakistan
MUHAMMAD MEHWAR ANJUM1, MOHAMMAD HAMZA BIN ABDUL MAIK2, MUHAMMAD RIZWAN3, MUHAMMAD AWAIS BIN ABDUL
MALIK4, RIDA SALEEM5, FAIZA KHALID6
1
Third Year MBBS Student at Sheikh Zayed Medical College, Rahim Yar Khan
2
Final Year MBBS student at Services Medical College, Lahore
3,4,5,6
Third Year MBBS student at Sheikh Zayed Medical College, Rahim Yar Khan
Corresponding author: Muhammad Mehwar Anjum, Email: [email protected], Cell: 0347-1460050

ABSTRACT
Objective: To study prevalence and assessment of knowledge, attitude, and practice regarding hepatitis in patients presenting
to a tertiary care hospital in Southern Punjab.
Method: The study was conducted at the medicine wards of Sheikh Zayed medical hospital, Rahim Yar Khan for three months
from July till September 2021. The data was collected through a physical questionnaire which was divided into three sections
relating to prevalence, prevention along with control and risk factors. The collected data was then analysed using SPSS version
26.
Results: Out of 219 patients, there were 83 females (38.42%) and 133 males (61.57%). The mean age of the population was
found to be 51.74 (15.51). Hepatitis C (86.1%) was found in the highest prevalence. 128 patients (59.2%) were chronic cases
while 88 (40.7%) were acute. Regarding co-morbidities, 32.9% patients had diabetes type II (DM-II) and 31.5% of the patients
had pre-existing primary hypertension (HTN). In terms of awareness, it was found that 122 (56.5%) attendants/patients were
able to correlate their presenting symptoms with hepatitis. 129 (59.7%) of attendants showed some understanding about
vaccination. Only the association between the attitude score among males and females was found to be statistically significant
(p-value= .003).
Conclusion: Despite increasing vaccination trends, hepatitis cases are still prevalent as the most common cause is HCV which
has no vaccination. Good prognosis of HCV requires early detection which is rare as the public still lacks knowledge on its
disease course and a proactive attitude.
Keywords: KAP, Hepatitis C, Pakistan, South Punjab, Hepatitis B, Hepatitis Vaccination, Awareness, Vertical transmission,
Hepatitis

INTRODUCTION consent of the head of departments of the concerned wards. An

Hepatitis is a cause for concern among certain countries like informed written consent was taken from patients on a separate
Pakistan and its underdeveloped areas of Punjab due to their high form, every patient remained anonymous and voluntarily became a
population distributions [1]. Hepatitis C virus (HCV) is one of the part of the research with the right to withdraw. The associations
causes of chronic hepatitis and the most prevalent form of the virus between different variables along with the frequencies and
in Pakistan [2]. Some factions of the society segregated based on percentages of all the questions asked of patients, or their
gender or age are more prone to be hepatitis positive than the attendants are reported. The data was collected through a physical
others. Pakistan has not seen a decline in hepatitis cases: this is questionnaire which was divided into three sections: dealing with
due to multiple causes like a poor sewage system, reused prevalence (including age, gender, occupation, and comorbidities),
syringes, shaving at barbers and lack of awareness about the prevention and control (including data about presenting complaint,
prevention and control of the virus, its symptoms for early how long after did the patient present to the hospital, whether they
diagnosis, and its spread [3]. The vaccination programs have been were aware they had hepatitis or if it was a recurrent infection,
going on for decades and have been met by resistance from the family history, usage of homeopathic medicine and knowledge of
people. The summation of all these factors makes hepatitis a general vaccination as well as the status of hepatitis vaccination
constant and lingering problem in Pakistan [4]. among family members), and risk factors (including socio-
Accordingly, there is a need to understand the demographics economic living conditions, hygiene, animal handling, water
in the general population as well as those presenting to the hygiene, past medical history, and needle stick injuries). Questions
hospital with varying complaints associated with hepatitis. No were inclusive of all viral hepatitis, keeping in mind their varying
studies have been performed previously in South Punjab of presentations and risk factors.
Pakistan, delineating the percentages of distinct types of hepatitis The hepatitis positive patients presenting to the Medicine
patients among hospital medicine wards. This study intends to ward of the hospital with related symptoms were considered as the
pinpoint the social groups and enlist the portions of society that population of the study and a rough estimate using hospital data
need further awareness of hepatitis symptoms and their control was taken as at least 200 for the size of the study. It was
strategies. Considering the recent pandemic and increase in performed over a span of three months i.e., July, August, and
general vaccination awareness among people, the study is the first September 2021, with the collection of data in regular intervals
of its kind to happen in the Sheikh Zayed Hospital Rahim Yar Khan from the sample. The sample was taken using the clustered
to highlight the need for patient/attendant increased awareness in random sampling technique. The participants all presented to the
combating hepatitis. A previous study was conducted in the same same health care unit but there were no further bias-inducing
hospital regarding the seroprevalence of different markers of criteria to hand-pick a few of them for this study. Inclusion criteria
Hepatitis [5]. This study builds up on that by finding groups that consisted of all hepatitis patients of the ward who gave written
need particular focus for prevention and control. consent. While the exclusion criteria consisted of those who
withdrew consent, were less than 14-year-old and chronic HCV
patients who had presented with systemic complaints not of the
SUBJECTS AND METHODS
liver or GIT (like seizures, malaria, or stroke).
This study quantifies the Knowledge, Attitude and Practice through
Questionnaires were distributed among the six researchers
KAP scores of Hepatitis positive patients presenting to the
who ran a trial test of the questionnaire for a couple of days,
Medicine Ward in Sheikh Zayed Hospital Rahim Yar Khan and
improvised and then continued. Then the researchers would
reports their prevalence. This study was conducted after obtaining
periodically go to different Medicine wards to physically fill out the
written permission from the Hospital’s research board and verbal
questionnaire. There is a probability of a small bias in the study

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here, as people who are in a hospital setting are more accepting of Table 3 shows the practice score among the patients. Out of
medical interventions, especially prophylactic ones, than those a total score of 6, the mean was 3.740. Patients and attendants
outside. The interview of questions per patient lasted for 5-10 showed great willingness to get their close family members
minutes and was conducted in the patient’s language. Firstly, the vaccinated (70.4%) and there was an increased trend seen in
LFTs of patients were checked. Then viral markers were verified to awareness of unsafe needle usage as well as shaving at barber.
decide the type of viral hepatitis. In some cases, other medical The biggest contributor to a low score was the excessive use of
reports like CT scan and PCR were checked too to ensure the homeopathic medicine among hepatitis patients.
patient was rightly diagnosed and to prevent any selection bias or Of the 216 patients, 79 (36.57%) had known cases of
confounder meddling with the result. When the questions regarding hepatitis in the family. Out of these, 30 (37.97%) were present in
the vaccination status and its awareness were asked, in case of siblings of the patient, 23 (29.11%) in offspring, and 14 (17.72%) in
negative replies, the attendants were briefed on how vaccinations parents. There was no statistically significant association between
worked, their advantages and facilities where they could easily get the occurrence of Hepatitis C and the knowledge of symptoms of
vaccinated. Upon filling of questionnaire, the data points were hepatitis within any strata of days in which the patient was
added into a Google Form. This helped the researchers visualize admitted to the hospital. 80 (37.03%) patients presented to the
the data in the end and help the entry of data points into an hospital within a week of symptoms, 65 (81.25%) of these patients
automatically generated spreadsheet. When the period of the data were HCV patients and only 33 (50.76%) of HCV positive ones
collection was over, the spreadsheet was inspected and highly were aware their symptoms corresponded with those of hepatitis
variable responses like reasons for not getting vaccinated and C.
presenting complaints were streamlined under various broader There was no statistically significant association between
categories to help in the analysis and better reporting of the data. vaccination status and the usage of homeopathic medicines (p-
This also helped against sensitivity analysis. The data values were value=.19) but there was a significant association between the
analyzed using IBM’s Statistical Package for Social Sciences. The knowledge of vaccines in general and hepatitis B vaccination
improvised spreadsheet was converted into a database. Type for awareness (p-value= 4.72E-18). Additionally, the most common
each variable was adjusted by the software but the Likert scale reason that around 71 (33%) patients or attendants cited for not
data were treated as ordinal categorical as there was an order to getting vaccinated for hepatitis was a complete lack of awareness
the range of answer scales present in the questionnaire. on how to get vaccinated.
Descriptive statistics of all the variables with their frequency was The data of the socioeconomic conditions of the patients is
calculated and is reported below. The statistical significances were reported in Table 4, with a special focus on the association
calculated using parametric tests like the Mann-Whitney U Tests between the poverty line and hepatitis patients. Questions related
and then one-tailed Spearman correlated (where applicable), with to food, water and hygiene are relevant to Hepatitis A and E while
the p-value= .05. There was no missing data found. others are for blood-borne ones. The findings in risk factors among
hepatitis positive demographic show most patients were below the
RESULTS poverty line and the socio-economic parameters like the number of
A total of 219 patients and their attendants were interviewed over rooms and number of people in house support this claim.
the period of three months, out of which the data points from three In Table 5, the associations between various demographics
of them were voided due to withdrawal of consent midway. All of patients are shown with their respective KAP scores. Only the
other 216 participants had values for all variables. There were 83 association between the attitude score among males and females
females (38.42%) and 133 males (61.57%). The most common was found to be statistically significant. The Mann Whitney U Test
type of viral hepatitis among the patients was Hepatitis C with 186 was only run within the house-wife demographic within the
patients (86.11%) followed by 36 Hepatitis B patients (16.66%). occupation tab.
Out of the 36 people who had Hepatitis B, 9 had coinfection with Using the one-tailed Spearman correlation, a significant
Hepatitis C and 2 had a recently diagnosed superinfection with association between Knowledge score and Attitude score (p-
Hepatitis D. 5 (2.31%) patients also had HCC secondary to viral value= .017), as well as Knowledge score and Practice score (p-
hepatitis. Not enough cases of Hepatitis A and Hepatitis E value= .004). Thus, making it a vital area of focus to combat
presented to make any meaningful comment of their prevalence. against this disease in the community.
The mean age for HCV positive patients was 53.74 (14.32) while
the mean age for non-HCV positive hepatitis patients was 39.3
(17.07) with a confidence level of 95%, which corroborates earlier
mean ages of HBV and HCV. Of the 133 males, 33 (24.81%) were
retired, 30 (22.55%) were farmers or property owners and 28
(21.07%) percent were skilled and unskilled laborer. The rest were
varying professions. There were only two barbers and no
healthcare workers. Most of the females, 67 (80.72%), were stay-
at-home spouses.
The most common presenting complaint among patients is
visualized in Figure 1.
The questions pertaining to the knowledge of hepatitis
patients are listed and scored in Table 1. Results show a good
understanding of hepatitis and its symptoms among patients once
they get it. The mean score of Knowledge was 2.583, the main
contributor to this low score being a lack of knowledge of Hepatitis Figure 1: Frequency of various presenting complaints in Hepatitis positive
B vaccine prior or even after infection. patients
The results delineating attitude of patients of hepatitis is
given in Table 2. The low mean score of 5.120 reflects a delay in (ALOC: Altered Level of Consciousness)
bringing hepatitis positive patient to the hospital on time. Moreover Figure Legend: Figure 1 shows the frequency of most
27 (12.5%) of patients had either a hepatitis positive mother or common presenting complaints among Hepatitis. Y-axis shows the
offspring, thus showing vertical transmission. Unclean water number of patients, X-axis shows the presenting complaint. Blue
consumption (69.9%) was the biggest factor of a subpar living denotes ascites, orange shows abdominal pain, grey shows
standard among hepatitis patients, although it affects Hepatitis A melaena, yellow shows weakness, cyan shows hematemesis and
and E more, which were not prevalent cases here. green represents altered level of consciousness.

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A Kap Study of Hepatitis Among Hepatitis Positive Patients

Table 1: Questions to determine knowledge score among Hepatitis patients

Knowledge
Question Score Result
1. Knowledge of diagnosis of Hepatitis 1 Yes No
122 (56.5%) 94 (43.5%)
2. Correlation of disease with previous symptoms of Hepatitis 1 Yes No
155 (71.8%) 61 (28.2%)
3. Aware of general vaccines 1 Yes No
129 (59.7%) 87 (40.3%)
4. Aware of Hepatitis B vaccine 2 Yes No
76 (35.2%) 140 (64.8%)
Total Score for Knowledge is 5
Mean Score for Knowledge: 2.5833 ±0.21833

Table 2: Questions to determine attitude scores among Hepatitis patients

Attitude
Question Score Result
1. Time taken to come to hospital 0 : More than a month 32 (14.8%)
1: More than 2 weeks 6 (2.8%)
2: More than a week 22 (10.2%)
3: Within a week 80 (37.0%)
4: As soon as possible 76 (35.2%)
2. Change in lifestyle based on family history 0: No change regardless 135 (62.5)
1: Distant relative; somewhat 51 (23.6%
2: Close family; great affect 30 (13.9%)
3. Subpar hygienic practices like eating outside too much, 1: Ill-prepared commercial food 8 (3.7%)
sharing toothbrushes, water cleanliness, animal handling 1: Toothbrush sharing 24 (11.1%)
1: Unclean water consumption 151 (69.9%)
1: Unsafe handling of animals 80 (37.3%)
Total Score for Attitude is 10
Mean Score for Practice: 5.1204 ±0.2337

Table 3: Questions to determine practice score among Hepatitis patients

Practice
Question Score Result
1. Usage of homeopathic medicine 2 Yes No
166 (76.9%) 50 (23.1%)
2. Vaccination status for Hepatitis B 2 Yes No
152 (70.4%) 64 (29.6%)
3. Hygienic practices during shaving 1 Yes No
202 (93.5%) 14 (6.5%)
4. Unsafe syringe usage 1 Yes No
213 (94.0%) 13 (6.0%)
Total Score for Practice is 6
Mean Score for Practice: 3.7407 ±0.1739

Table 4: Socioeconomic conditions of patients presenting with Hepatitis

Frequency Percentage
Poverty line Above 89 41.20
Below 127 58.87
Parameters People Number % Rooms Number % Bathrooms Number %
<3 24 11.11 <3 99 45.83 0-1 136 62.96
3-6 58 26.85 3-5 94 43.50 2-3 71 32.87
6< 134 62.03 5< 23 10.64 3< 9 4.16

Table 5: Association of various demographic groups with KAP scores

Demographic Characteristic Knowledge Score P-value Attitude Score P-value Practice Score P-value
Gender
Male 2.6541 0.380 4.8496 0.003 3.7820 0.510
Female 2.4699 5.5542 3.6747
Occupation
Farmer 2.7692 4.3462 3.6923
Housewife 2.4627 0.400 5.4179 0.086 3.7612 0.930
Retired 2.2381 5.15 3.4500
Labourer 2.8250 4.3810 3.9048
Comorbidities
Hypertension 2.7941 0.148 5 0.432 3.7206 0.852
Diabetes 2.8028 0.145 5.2254 0.491 3.8451 0.401

DISCUSSION Hepatitis B vaccine were not much. This trend only increased as
In our study, we found an unexpectedly substantial number of our study progressed and can be attributed to the current
people who knew about how vaccinations worked in all coronavirus pandemic, due to which the government has
socioeconomic subgroups even if the people who knew about implemented restrictions for non-vaccinated citizens. The influx of

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knowledge through social media has also helped the case of existing old cross-sectional studies in other regions of the country.
awareness [6]. People resorting to homeopathic medicines were The study proved how considering the global pandemic, the public
aware of vaccinations and were willing to get vaccinated proves viewpoint of vaccinations has improved with greater awareness
this too. So, rather than a distrust of the medical system, the and less reluctance. However, it also showed an urgent need to
barrier is a lack of state apparatus to inoculate them. Awareness diagnose HCV infections on time to curb the increasing number of
programs should target the prompt vaccination of children for serious cases. Using the findings of this study, medical
Hepatitis B as mother-to-child transmission (MTCT) during practitioners of this area can be on the lookout for the tell-tale
pregnancy is the leading form of transmission. Vaccination later in symptoms in high-risk individuals and provide them with effective
life does not help much while the risk of MTCT is reduced by healthcare. This should help the knowledge and attitude of
prompt neonatal HBV vaccination through the EPI and the population in this area towards hepatitis improving mortality as
administration of hepatitis B immunoglobulin after birth in high-risk well.
infants [7].
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