Knowledge of HBV
This study found that there were gaps in the knowledge with regards to HBV among individuals with chronic HBV infection. HBV patients in Malaysia were found to have poorer knowledge compared to those in Singapore
 and Chinese Canadians
. The majority of participants of this study were aware of the three significant complications of chronic HBV infection, namely chronic inflammation of liver, cirrhosis and liver cancer. However, participants were less aware of the symptoms of liver disease. While more than half of the respondents were able to respond correctly to two of the items (jaundice and tiredness), awareness of other symptoms such as nausea and vomiting, abdominal discomfort/pain and abdominal distension were less known. Studies have also shown that many HBV patients did not know that chronic HBV can be asymptomatic and may pass on the virus
, and even would remain asymptomatic when the disease became much more severe or in early diseases such as liver cancer
[19, 21]. Sometimes the symptoms may be mistaken for other minor medical health conditions such as indigestion and are usually treated with over-the-counter medication. This is of concern as those who experience these symptoms may not be aware of the severity of the condition and thus may cause delay in seeking treatment. Early detection of the complication of HBV is important so that appropriate treatment can be given before the disease progresses. In addition, patients should also be made aware that cirrhosis and liver cancer are usually asymptomatic.
The misperception that sharing eating and drinking utensils could transmit HBV seemed to prevail among patients of this study. This misperception is also reported in Asian HBV patients
[18, 19, 21] and general public in Singapore, San Francisco, Washington and Australia
[23–25]. Such misperceptions could evoke anxiety in individuals with HBV and may create a barrier in their social interaction for fear of transmitting the virus to others. In addition, patients with HBV were found to be apprehensive about disclosing their disease status for fear of social rejection and yet they feel guilty about hiding their health condition
. This may hinder the timely diagnosis and treatment of the disease and its complications
This study identified patients of age group 30–39, with tertiary education level and longer duration of HBV diagnosis as independent factors contributing to a higher knowledge score. Younger individuals have better opportunity to be educated and also have better access to information especially through the internet. Besides this, people with a high education level have higher health literacy which makes understanding of health information easier. In many studies, high educational level attainment has been reported to be associated with better HBV knowledge
[7, 11, 19]. Individuals equipped with knowledge and education have been shown to be more likely to practice preventive measures such as getting screened for HBV and getting their children vaccinated for HBV
. Having longer duration of HBV diagnosis was also found to be associated with better knowledge of HBV. Having lived with HBV infection and in regular contact with healthcare professionals enable the patients to seek more information with regard to HBV. Perhaps this also explains why patients of aged 50–59 in this study have high knowledge. Patients without cirrhosis were found to be more knowledgeable with regards to hepatitis B. Perhaps, these patients were diagnosed with HBV early and equipped themselves with HBV knowledge and undertook necessary precautions to prevent the development to cirrhosis.
Attitudes towards HBV
Majority of study participants were concerned of spreading HBV to family members and friends. In addition, most patients also showed positive attitudes regarding disclosure of disease status to family and health care providers. The reason could be that they are worried of their family getting infected as well especially from them. By informing their family members of the disease status, steps can be taken by their family members to go for screening which could lead to early diagnosis and treatment or vaccination for prevention. Besides, informing family members and healthcare providers could also enable both parties to take necessary precaution to avoid virus transmission since family members could be living with the patient while and healthcare providers have close proximity with patients when giving out health treatment which could increase the risk of transmission.
In contrast to disclosure of their HBV disease status to family and healthcare providers, participants reported feeling embarrassed to reveal their disease status to the public. This may indicate that there is an attached stigma to being HBV positive. Perhaps there are fears of social rejection. A qualitative study revealed that fear of rejection and stigma at personal and community level is a barrier for those with HBV to disclose their disease status as the revelation would lead to segregation from family and community
Participants in this study were also found to be not empathetic towards people living with HBV infection. A third agreed that people with HBV should not be working in the food industry. This may be attributed to the misconception that HBV could spread by food. Demystifying these beliefs is necessary to prevent social isolation of and discrimination against people with HBV infection. These myths could be dispelled by patient and public health education.
Patients who reported feeling worried of spreading HBV to family and friends and worried since the diagnosis of HBV were of younger age group, Malay ethnicity, and had shorter duration of diagnosis. Reasons could be that HBV patients of younger age or those more recently diagnosed are worried as they may not have come to terms with the diagnosis of HBV infection and also were unsure of the characteristics of the disease, which explains the fear of transmission to others. While for some patients who might be knowledgeable, the worry may be stemmed from the knowledge of the consequences of long standing infection.
HBV patients were more likely to worry about spreading HBV infection to family and friends and worry ever since the diagnosis with increasing age. For those who received therapy for HBV, they were less likely to be worried after diagnosis. Early intervention is crucial for HBV patient just recently diagnosed such as in educating HBV patients with regards to their disease and also in initiating therapy for those who are eligible in order to prevent fears or anxiety in them.
Lifestyle practices related to HBV prevention
With regards to lifestyle practices and HBV prevention, participants modified their lifestyles and adopted activities that would prevent virus transmission to others. The majority of patients undertook the necessary preventive measures to reduce the risk of HBV transmission, namely avoid sharing of personal items such as razors and toothbrushes, and also not participating in blood donation. In addition, they have also encouraged family members to screen for HBV. All the Indians who reported ever drinking alcohol had reduced or stopped drinking. However, it should be noted that there are only total of 3 Indians reported in this study who have ever drink alcohol. The small sample size of Indian in this study reflected the low prevalence of HBV among Indians in Malaysia due to lower genetic susceptibility to HBV as they originate from Southern India
. High proportion of Chinese also reported stopped or reduced drinking alcohol following their HBV diagnosis.
Approximately half or more of the participants avoided sharing eating and drinking utensils. This may stem from the misconception that sharing eating and drinking utensils could infect others. Those who are elderly, of Indian ethnicity and with cirrhosis were significantly found to not share their eating and drinking utensils. Older age groups may be less educated due to lack of education opportunity, understanding and access to health information. Most patients of Indian ethnicity who did not share eating and drinking utensils could be due to them worried of spreading HBV to their family and friends. This may be due to erroneous knowledge on viral transmission, which caused them to be worried of spreading to others and thus, adopting unnecessary behavior such as avoid sharing eating and drinking utensils. This finding highlighted the need for specific education intervention to be made targeted particularly to those of Indian ethnicity. Those with cirrhosis were also not sharing eating and drinking utensils. This again could be due to erroneous knowledge on viral transmission and especially when the symptoms of cirrhosis are much more obvious, thus may caused apprehension of both patient and others to share eating and drinking utensils with each other. Therefore, there needs to be more public health campaign to focus on the route of transmission of HBV.
This study found that patients with higher HBV knowledge were worried ever since diagnosed with HBV. In contrast to the logical assumption that people with higher knowledge should be less worried. Perhaps patient of this study, who felt worried ever since diagnosis sought more information with regards to the diseases and hence, more knowledgeable. However, studies have shown that knowledge does not necessarily enhance attitude and behavior in healthcare.
In Malaysia, nationwide campaigns are conducted to provide screening for hepatitis B, vaccination, and public forums to increase public awareness of the disease. Mass hepatitis B screening and vaccination have been found to decrease social stigma surrounding HBV
. A survey was carried out in 2000 in Malaysia to assess the effectiveness of Hepatitis Day and it revealed that although awareness of hepatitis is high in the public (95%), but it is only higher among those with higher level of education and income
. Perhaps different strategies can be employed to reach out to those from lower educational and socio economic background in terms of creating awareness and making preventive and treatment options more accessible. While this campaign has contributed greatly to increasing the awareness of HBV, in terms of reaching its target to educate public on symptoms, there is still room for improvement as evidenced by the findings from the current study. Hence, dissemination of information particularly on symptoms and modes of transmission of HBV needs to be intensified as knowledge pertaining to these two aspects are still lacking. This is pertinent as misconceptions on modes of transmission could potentially lead to stigma, unnecessary actions which would disrupt daily living and overall quality of life.
This study adds to the scanty research of Hepatitis B in the local context. However, this study was conducted in a hospital setting and may not be generalized to the wider population in the community.