Knowledge, attitudes and practice of primary health care physicians towards hepatitis B virus in Al-Jouf province, Saudi Arabia

Hepatitis B virus (HBV) represents important, yet clinically silent public health significance worldwide[1]. World health organization (WHO) data estimate serologic evidence of past or present HBV infection among two billion persons globally, while over 350 million people are carriers of chronic hepatitis B (CHB) worldwide[1, 2]. The virus is transmitted in the blood and fluids which can be diagnosed during acute and chronic stages[3]. Acute infection may cause nonspecific symptoms or fulminant hepatitis that may die or requires urgent liver transplantation[3]. Chronic infection with HBV causes death associated with cirrhosis, liver failure, or hepatocellular carcinoma, and has a negative impact on health-related quality of life (HRQOL)[2–4]. HBV ranks second, after tobacco, on the list of known carcinogenic agents affecting humans and the tenth leading cause of death globally[5, 6]. Costs associated with HBV are therefore substantial; it creates a significant economic burden to the health care services[1, 4, 7].

PHC physicians will be in the forefront of managing patients with chronic hepatitis B infection and most hepatitis B infections are identified at the primary care level[8, 9]. It is assumed that physicians practicing in our community are lacking the important knowledge about and the appropriate attitudes toward HBV. Although, many studies in different countries have evaluated the knowledge level, attitudes, and practice among PHC physicians towards HBV[9–11]. There have been a very few attempts to identify a specific impact of this condition among physicians practicing in Saudi Arabia, a country with the highest high endemicity of HBV[12]. Hence, the main reasons of this study are to evaluate the knowledge base, attitudes, and to explore practice patterns of PHC physicians towards HBV. The data and information obtained from this study will identify weaknesses and help to improve healthcare system in managing this serious disease in the primary care setting.

When asked about what would they do if a patient with HBV presents to their office, we found only 30.8% (n = 45) of the physicians responded that they will achieve continuity of care for HBV; whereas 62.9% (n = 100) of the participants will refer HBV immediately or later to the specialists. Four males and three female physicians (4.4%) were not sure what should be done for HBV.

When inquired about whether the PHC physicians are capable to achieve a major role in the management of HBV; 85 (53.5%) agreed, 43 (27.1%) strongly agreed, 13 (8.2%) disagreed, 4 (2.6%) strongly disagreed, and 12 (7.7%) were not sure.

Regarding the possible modes for HBV transmission, 142 (89.3%) physicians reported through wound-to-wound, 140 (88.1%) sexual contact, 127 (79.9%) during delivery from the infected mothers to their infants, 110 (69.2%) maternofetal, 83 (52.2%) through saliva followed by 81 (50.9%) breast milk. While, 130 (81.8%) physicians considered hugging, 136 (85.5%) shaking hands or 123 (77.4%) sharing foods with infected persons as a safe practices.

When asked about the main sources of their knowledge about HBV; textbooks were ranked first among 139 (85.5%) physicians, followed by internet 15 (9.4%), whereas medical journals were the main sources among 8 (5.0%) physicians.

Hepatitis B virus is a challenging infectious disease for all of the health care professionals throughout the world[1–3]. Fortunately, infection with this virus is not only treatable, but also preventable[2–5]. PHC physicians are, thus, expected to achieve a major role in the diagnosis, prevention, and referral of HBV, as a means of controlling HBV[7–11]. The current study is, to the best of the author’s knowledge, the first comprehensive PHC setting-based survey carried out in Saudi Arabia (alJouf province) to evaluate knowledge, attitudes and practice of PHC physicians regarding management of HBV in the PHCCs. We believe that our sample was representative of the PHC physicians and accounted for approximately 80% of all the PHC physicians practicing in alJouf province. More than half the physicians under this study had low to moderate experience in PHC setting (≤10 years).

This study, clearly, proves that physicians practicing in our community were aware of magnitude of HBV in Saudi Arabia[12]. It is found, most of the physicians 102 (64.2%) perceived that HBV at level of public health significance in the country; and 131 (82.4%) suggested the need of catch-up vaccination for all Saudi older age groups, including adolescents and adults. Also, 143 (89.9%) suggested “educational strategies about HBV with special attention to Saudi citizens of lower education levels and lower socio-economic classes”. Our findings are in agreement with, and support, recommendations and reports of CDC about HBV[13]. The referred recommendations and reports demonstrate that more actions should be offered to HBV in the highly endemic areas like Saudi Arabia where HBV prevalence is ≥8%[12, 13].

It is well documented that most patients with chronic HBV are identified in the primary care level and only those with chronic active HBV are selected for specialist care[9, 10, 14]. Unfortunately, we found only 45 (28.3%) physicians surveyed will carry a continuity of care for HBV patients; whereas, 99 (62.3%) will refer HBV to the specialists. However, an effective referral is needed only for those who are eligible for sophisticated diagnosis and antiviral therapy[9, 10, 14]. Our findings are in agreement with those practical difficulties in the management of HBV in Asia-Pacific[7]. The referred reports have demonstrated that PHC physicians may show a reluctance to treat HBV patients, because of incomplete knowledge about hepatitis B, resulting in the referral of numerous patients to specialists[7]. Also, lack of suitable approach or confidence with lack of diagnosis facilities all contribute to referral[7, 11].

This study shows inadequate knowledge among PHC physicians regarding HBV, but this not necessarily reflects the picture of PHC physicians who are practicing in other parts of Saudi Arabia. This study has shown that, only 69 (43.4%) physicians were able to interpret HBV seromarkers and only 67 (42.1%) recognized the incubation period of HBV[13]. Also, 97 (61%) of the physicians were unaware of the risk of HBV chronicity which is inversely related to age[2, 3, 13]. Attributable reasons could be inadequate training programs about HBV. Our findings are not dissimilar to those reported in a recently study carried out in Australia to evaluate the knowledge and educational needs of GPs about viral hepatitis[15]. The referred study has identified limitations in knowledge among GPs concerning certain aspects of viral hepatitis[15].

Health education is of crucial significance for persons with HBV[6–9, 11, 13]. Those individuals should be educated about the risk of transmission, needle exchange programs, condom use, and avoidance of sharing toothbrushes, razors, etc.[11, 13]. It was interesting to find most of the physicians 142 (89.3%) had interest to involve the family on education and management of HBV patients. As such, educational skills about HBV could optimize care and management of patients and increase the doctor-patient relationship[1, 4, 6, 7].

Hepatitis B is one of the most highly infectious diseases without seasonal distribution[6]. Our findings show a high rate of misconceptions regarding infectivity patterns of HBV. It was found, only 37 (23.3%) physicians recognized that HBV could be an infectious agent in the environment and more than 45% were not aware of its transmission through needlestick which is 50–100 times higher in comparison with HIV[2, 3, 6, 13]. Misconceptions and confusion that persist among PHC physicians in these aspects could interfere with patients’ education and the safety of household contacts[2, 6, 13]. The possible explanation could be that, during an undergraduate study the infectious diseases, such as HBV are given only a small share in comparison to other medical subjects. In addition, textbooks were the main source of knowledge among the physicians surveyed and most textbooks are not updated, all of these issues could contribute to a lack of knowledge about HBV.

The most effective method of preventing HBV is through vaccination[2, 4–6, 13]. Interestingly, the vast majority of the physicians believed that vaccination is the mainstay to address HBV, and more than 81% of them recognized that the vaccine is safe for people of all ages[2, 6, 13]. Our cross-sectional study has shown adequate knowledge among PHC physicians regarding modes of HBV transmission. For specific modes of transmission (for example hugging, sharing food, maternofetal, breast milk) there were misconceptions[2–4, 13]. This might be due to the controversy of these issues and the lack of the solid evidence. It is observed that maternofetal transmission is the dominant route of HBV transmission in high prevalence endemic areas such as South-East Asia[16]. Breast-feeding seems to be an additional mode by which infants acquire HBV; however, the risk associated with breast-feeding is negligible compared with that of exposure to maternal blood and body fluids at birth[6, 16, 17].

In the area of follow-up, we found 100 (62.9%) physicians suggested it is more appropriate for CHB patients with [HBeAg-ve, liver enzymes within normal limits] to be followed in the primary care. Whereas, nearly all the participants 150 (94.3%) reported it is more appropriate for those with (HBeAg + ve, elevated liver enzymes) to be referred to the specialists. Our findings are in agreement with several international strategies regarding prevention, care, and follow-up of HBV[18, 19]. The referred strategies have demonstrated that patients in inactive carrier stage do not need treatment, because the progression of their liver disease is slow, if at all[18, 19]. Only those patients who have CHB (active HBV replication with high viral load and ongoing necro-inflammation) qualify for treatment[18, 19].

This study has revealed that only minority of the PHC physicians 25 (15.7%) considered that, PHCCs are a suitable places to manage HBV patients. Our findings and those internationally revealed that lack of investigation facilities in the PHCCs contribute further to poor management of HBV patients in the PHCCs[11]. It was found, the proportion of private physicians who considered PHCCs suitable places to manage HBV is more than that found among those governmental administered physicians (25.0% vs 17.0%; p < 0.05). Attributable reasons could be adequate facilities at the private health care centers in comparison with that available in public PHCCs[11].

This study shows more suitable attitudes among PHC physicians toward HBV. It was found, 101 (63.7%) physicians reported that, persons with HBV can participate in all activities including contact sports, and 119 (75.1%) believed that they should not be excluded from the daycare or school participation and should not be isolated from other children. Also, 106 (66.7%) physicians did not have concern on shaking hands and did not feel uncomfortable hugging a person who has HBV. Our findings are in agreement with those internationally which demonstrate that no evidence exists of HBV transmission by causal contact in the workplace, and HBV is not spread by kissing or hugging[13].

This study has revealed that the vast majority of the physicians were in favour to establish “Saudi guidelines for diagnosis and management of hepatitis B virus”. This finding is in agreement with, and supports, those recommendations regarding management of CHB in resource-poor countries. The referred recommendations revealed that guidelines for primary care physicians should be published and existing ones should be updated to keep physicians informed on changes in CHB management[1].

Strengths of this study including a high response rate (88.3%), also, targeting PHC physicians that have been involved as a “gatekeepers” to the primary protective and curative health services, moreover, to the best of our knowledge, no similar study has been carried out among PHC physicians in Saudi Arabia. Despite of the study findings, we acknowledge its limitations, actually all the information are reported which may not be reflective of the actual situation in the primary care, also, all the questions in the questionnaire are close-ended which may hinder some important points on knowledge and practice of the participating physicians.

In conclusion, suitable attitudes with lack of knowledge were found and practice of PHC physicians regarding HBV appears inappropriate among the majority of PHC physicians in Al Jouf province of Saudi Arabia. This may be due to lack of structured training programs concerning HBV. A well planned CME programs must be conducted to increase their knowledge and correct erroneous ideas regarding HBV. PHCCs should be technically supported to facilitate the diagnosis of HBV. Further studies are also required to identify other factors underlining the less than optimal preventive and management of HBV in the primary care setting.