Introduction

Hepatitis B virus is a major clinical issue because of its high infectious rate and ability to proceed from acute liver damage to chronic liver disease [1]. It is considered one of the most ubiquitous bloodborne viruses globally, with around 468 million cases recorded in 2016 [2]. HBV prevalence is highest in the Western Pacific, followed by Africa [3]. In 2017, the estimated incidence of HBV in Jordan was about 2.4%, and the prevalence of HBV among patients in dialysis units was 6% [4, 5]. HBV-related liver transplants accounted for 17% of all liver transplants done at King Hussein Medical Center. [6] The incidence of HBV infection among dialysis patients in Western Europe, Japan, and the United States is around 6.6%, while it ranges from 1.3% to 14.6% in the Asia-Pacific region [7, 8]. Extrahepatic symptoms of HBV can be seen in both acute and chronic infections, affecting up to 20% of HBV-infected cases in Jordan [9]. It is generally understood that HBV is transferred during pregnancy and through contact with contaminated blood or bodily fluids [10]. In reality, hemodialysis patients are at increased risk of contracting HBV not only because of the transmission mechanism but also because of uremia-related immune weakness and dysregulation [11]. Clinical manifestations of HBV include acute hepatitis, chronic hepatitis, cirrhosis, hepatocellular carcinoma, hepatic failure, and other consequences [1]. In dialysis patients, liver disease has a discrete clinical course, moving from moderate hepatic inflammation to severe fibrosis [12]. Furthermore, HBV infection has been linked to an increased risk of hepatocellular diseases and a lower chance of kidney transplantation [13]. Researchers have extensively explored the relationship between HBV infection and glomerular diseases [14]. Recent study has demonstrated significant correlations between chronic hepatitis B and renal function impairment, as well as an increased chance of acquiring a low glomerular filtration rate (GFR) [14]. When determining HBV severity in dialysis patients, depending exclusively on liver enzymes such as serum ALT is inadequate since they do not necessarily correspond with disease severity. Furthermore, higher serum ALP levels can be linked to the related parathyroid Furthermore, there is little research on the relationship between viral loads and illness severity. Consequently, liver biopsy appears to be the only definitive approach to evaluate disease activity in dialysis patients [15]. Vaccination against HBV has shown to be efficient, producing 98% to 100% protection in the general population. Since its introduction in 1995, the HBV vaccine has resulted in a considerable drop in infection rates [6]. The most effective technique for providing immunological protection against HBV infection in dialysis patients is to provide the vaccination before they reach end-stage renal failure. This is because the reaction to the vaccination declines in proportion to the degree of renal damage [16]. A study conducted in Jordan in 2020 examined general knowledge of HBV found that public understanding of HBV was typically low to moderate. Awareness of factors such as disease prevalence, etiology, transmission, and high-risk populations was found to be low [6]. Therefore, this highlights the need to conduct further studies regarding HBV in the local population. Based on previous literature and the scarcity of local studies on this matter, this study aims to assess the awareness of HBV among hemodialysis patients in Jordan.

Materials and methods

A cross-sectional descriptive study was conducted among hemodialysis patients in different Jordanian hospitals with hemodialysis units. Multiple governmental hospitals in Jordan that had dialysis units and one university-based hospital were included in the study; AL-Hussein / Salt Hospital, Al Basheer Hospitals, Princess Basma Hospital, AL-Nadeem Hospital, Al Zarqa Hospital, Prince Hamza Hospital and Jordan University Hospital. The data for this study were collected in the period between July and December 2022. Participants were recruited from lists provided by dialysis units, each list included all regular patients who had scheduled sessions for hemodialysis, then patients were approached before or after the session, according to their preferences if they were willing to participate in the study. The inclusion criteria for the study were as follows: 1) hemodialysis patients who were above 18 years of age. 2) patients who accepted to participate in the study. Those who met the inclusion criteria and agreed to participate were invited to complete a face-to-face interviews-based survey, after providing informed consent. A total of 398 hemodialysis patients participated in the study, which exceeds the minimum sample size required. The sample size calculation was based on a 5% marginal error and a 50% prevalence rate [17]. Exclusion criteria for the study included patients who were not conscious or unable to provide informed consent, patients below the age of 18, and patients who refused to complete the questionnaire.

Results

Demographics of survey participants

The sociodemographic characteristics of participants are summarized in Table 1. Data was collected from 398 participants who agreed to be involved in the study. The percentage of male participants in our study was 61.3% (n = 244). Half of the participants were older than 50 years old 50% (n = 199), 30.7% (n = 122) were between 38–50 years old and the remaining 19.3% (n = 77) were between 18–37 years old. Almost four- fifths (n = 324) of participants were married. Regarding the educational level, (71.1%, n = 283) had a lower level of education. Around half of the participants (55.3%, n = 220) have no job. Only (3.3%, n = 13) were from the medical study field, (35.7%, n = 142) were non-medical. Almost three-fourths (n = 294) were city residents. The majority of participants (95.7%, n = 381) had no personal history of Hepatitis B infection, and (83.7%, n = 333) had no family history either.

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Table 1. Demographics of survey participants.

https://doi.org/10.1371/journal.pone.0312226.t001

Associated factors associated with knowledge level toward HBV infection

The significant associations between knowledge and sociodemographics are shown in Table 2. In the univariate logistic regression analysis, significant associations were found between the level of knowledge and the following variables: education level (OR = 1.888, CI = 1.207–2.954, p<0.005), work (OR = 1.772, CI = 1.165–2.694, p<0.007), medical study field (OR = 8.963, CI = 1.913–41.987, p<0.005), non-medical study field (OR = 0.659, CI = 0.426–1.022, p<0.062), history of hepatitis B virus infection in family (OR = 3.424, CI = 1.981–5.917, p<0.000). While in the multi variate logistic regression analysis, significant associations were found between the level of knowledge and the following variables: education level (OR = 1.490, CI = 0.878–2.528, p<0.140), work (OR = 1.589, CI = 0.819–3.082, p<0.171), medical study field (OR = 8.568, CI = 1.761–41.688, p<0.008), non-medical study field (OR = 0.959, CI = 0.467–1.970, p<0.909), history of hepatitis B virus infection in family (OR = 3.822, CI = 2.157–6.771, p<0.000), as shown in Table 3.

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Table 2. Association between socio-demographic factors and knowledge level.

https://doi.org/10.1371/journal.pone.0312226.t002

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Table 3. Logistic regression analysis between knowledge, and socio-demographics factor toward HBV infection.

https://doi.org/10.1371/journal.pone.0312226.t003

Discussion

Hepatitis B Virus (HBV) infection represents a global health challenge, affecting approximately 300 million individuals worldwide [1]. Among Hemodialysis patients, the risk of HBV infection is higher [16]. This risk stems from the frequent need for blood transfusions, the procedure itself, and the potential exposure to contaminated blood products and contact with healthcare personnel which favors infections in addition to their compromised immune status [21]. Thus, emphasizing the importance of increasing patient awareness regarding these risks. Implementing stringent infection control measures is a vital step in maintaining the health and well-being of hemodialysis patients. This hospital -based cross national study aimed to investigate the knowledge, attitude. and practices of hemodialysis patients towards hepatitis B virus. Data was gathered from a cohort of 398 participants, with a predominance of middle-aged to old individuals, and 61% were male participants. Notably, only 4.3% of the participants had reported a history of HBV infection.

Higher levels of knowledge and attitudes were observed among patients with higher educational levels, and among patients who already work in the medical field. On the contrary, a previous study reported limited knowledge among those with higher educational backgrounds [22]. The majority of the participants were already familiar with the term hepatitis, and 60% were aware of subtype B, with only half of the participants recognizing it as a viral infection. Furthermore, 70% of participants didn’t know that it can present early on with flu-like symptoms while more than half of them were aware that it presents with jaundice, nausea, and vomiting. The overall knowledge about potential consequences such as the risk of developing liver cancer was poor. Regarding transmission route, results were satisfactory in which majority of the participants know that it can be transmitted through the use of unsterilized syringes, surgical needles (72.1%) and blades (59%), and through blood and blood products (76.1%). This was correlated with what resulted in the practice assessment section where the majority followed protective measures against the transmission of HBV by these routes. However, half of the participants were unknowledgeable about its transmission through unsafe sexual intercourse (51%) and vertical transmission from mother to child (48.2%). Moreover, most participants (79.6%) have a misconception that having a drink or food from an infected person can increase the risk of acquiring the infection and this also can explain why two-thirds of participants avoid meeting with positive patients. In comparison to other studies, the level of knowledge of the disease presentation, transmission routes, and related complications, among the different populations were similar to our study [18, 23, 24]. Moreover, improving public and healthcare providers’ awareness of hepatitis B should be sought out by health policymakers to minimize discrimination against infected persons, reduce transmission, improve early detection and treatment, and prevent complications [25, 26]. In regards to attitudes, the majority of participants expressed a sense of vulnerability to infection (75%) and indicated that they would promptly seek medical attention (67.8%) if they suspected they were infected. Remarkably, half of the participants were unsure of the financial implications associated with the diagnosis and treatment of Hepatitis B, whereas 37.4% thought it would be expensive or somewhat expensive. Additionally, 62.3% expressed concern about the possibility of transmitting the infection to their families. These findings indicate that the majority of the participants are aware of the seriousness of the disease but lack sufficient knowledge and confidence in the treatment process or to address the disease’s impact on their daily lives, social interactions, and financial situation. Patients with chronic kidney disease must be vaccinated early, as their ability to achieve immunological protection with the HBV vaccine decreases with disease progression [27]. It is important to note that participants exhibited a positive result towards vaccination, with 61.6% being aware of the available vaccine, and 64.3% reported having already been vaccinated. Additionally, a majority expressed willingness to undergo further investigations and adhere to safety practices. However, 92.5% have never participated in HBV-related health education programs. In the quest for controlling HBV infections regionally and worldwide, lack of knowledge and understanding of HBV transmission dynamics among the public, highly susceptible groups, medical students, and healthcare professionals due to misconceptions in knowledge about HBV should be identified and further awareness must be spread and advocated [25, 26]. A similar cross-sectional study was done among Vietnamese Americans focused on HBV screening and vaccinations stating that only one third of the participants were aware of the availability of screening and vaccination against HBV [28]. Thus, implementing Community awareness campaigns, universal vaccination, targeted outreach programs for high-risk groups, patient education, and healthcare provider training can significantly decrease the spread of HBV and promote public health awareness in general.

Conclusion

In conclusion, overall knowledge of HBV and its symptoms and mode of transmission were deficient. On the contrary, participants showed positive attitudes and practices to mitigate disease transmission. More efforts should be taken to raise awareness of HBV and other transfusion-transmissible pathogens among hemodialysis patients. Additionally, more studies should be conducted to investigate patient awareness, knowledge, and behaviors related to infection control which could help guide interventions.

Supporting information

Acknowledgments

We wish to express our gratitude to all administrative staff and data collectors from Jordanian medical schools for their support in the distribution of the survey.