Knowledge, perception and practices of Suez Canal University students regarding Hepatitis C Virus infection risk and means of prevention

1Department of Pediatrics, Faculty of Medicine, Suez Canal University, Ismailia, Egypt 2Social Research Center, American University, Cairo, Egypt 3Department of Infectious and Endemic Diseases, Faculty of Medicine, Suez Canal University, Ismailia, Egypt 4Department of Infectious and Endemic Diseases, Faculty of Medicine, Suez University, Suez, Egypt 5Department of Rheumatology and Rehabilitation, Faculty of Medicine, Suez Canal University, Ismailia, Egypt 6Department of Pediatrics, Faculty of Medicine, Suez Canal University, Ismailia, Egypt 7Medical Microbiology & Immunology Department, Faculty of Medicine, Suez Canal University; 41111 ring road, Ismailia, Egypt 8Faculty of Education, Suez Canal University, Ismailia, Egypt 9Social Research Center, American University, Cairo, Egypt


Introduction
The global prevalence of Hepatitis C virus (HCV) is a major health problem in Egypt as it`s prevalence is reaching 13% of the population. Also, it is considered a serious social and economic problem that needs a lot of effort to eradicate it [1]. Liver related death, liver cirrhosis and hepatocellular carcinoma (HCC) are the end results of untreated HCV patients [2].
In 2015, the burden of HCV on the Egyptian economy was estimated around $3.81 billion due to consumption of the health facilities and indirectly due to disability and loss of life [3].
Health care providers (HCP) such as physicians, nurses, laboratory staff and medical students are usually at great risk of exposure [4]. Among these, HCV is transmitted through contaminated surgical instruments, needles [5], skin prick, injection drug use [6] and blood transfusion [7]. Also, HCP infected with HCV are at great risk of discrimination and stigmatization at their work by their colleagues and even by their family members due to poor knowledge and lack of awareness of viral transmission [8,9]. In order to eliminate the infection with this major health public issue, it is important to be strict with the infection control guidelines [10].
In Egypt, a survey was conducted on 278 universities where 1,319,525 undergraduate students enrolled. But due to the asymptomatic characteristics of HCV infection, university students who are infected could easily infect others without knowing that [11].
Promoting insightful awareness of university students toward this major health problem will gradually help in eliminating this problem. If students do not have access to information about the disease, then they are not likely to have suf icient knowledge or be concerned of contracting it. The state should aim to raise a generation of students, aware of the burden of HCV infection in Egypt, and who will be willing to accept responsibility to expend their efforts in the future to limit HCV infection.
The aim of this study is to measure the level of knowledge of university students and their perception regarding HCV infection, and means of its prevention, in order to adequately plan an intervention program to reduce the risk of infection and thus lower the infection rates.

Statistical analysis
Data collected through the questionnaire was coded, entered and analyzed using Microsoft Excel software. Data was then imported into Statistical Package for the Social Sciences (SPSS version 18.0) software for analysis.
Chi square test for qualitative variables, paired t test, and one-way ANOVA with least signi icance difference. Multiple regression analysis was used to test relationship between different dependent and independent variables were used and specify what they were used for just as the multiple regression. P value will be set at <0.05 for signi icant results.

Ethical consideration
The Ethics Committee in Faculty of medicine Suez Canal University approved this work according to the declaration of Helsinki. Also, the Research Ethical Committee of Egyptian Ministry of Health and Population Central Directorate for Research and Health Development approved the study. Consent for an interview was taken from each participant, who was assured about the con identiality of his/her information.

Materials and Methods
A cross sectional study conducted in Ismailia at Suez Canal University from April 2015 till February 2018 on 698 university students in 5 faculties: Education, Nursing, Medicine, Pharmacy and Dentistry. This sample size is a strati ied cluster sample with clusters representing the 5 faculties and from each faculty sample random sample was drawn.
The data were collected through a self-administered questionnaire composed of 45 questions to determine the demographic, social and behavioral characteristics of the studied population. Also their knowledge and perception of the possible social and behavioral risk factors for HCV infection and its transmission were queried.
As well as the method of HCV prevention the infection control procedures which include questions about the sterilization and disinfection, hand washing, care of sharp, needle stick injury and ways to deal with it, dealing with blood spoilage, regular checkups and HB virus vaccination. All the data were kept con idential throughout the steps of work and were only accessible to the team members.

Results
This cross sectional study was carried out on 698 students from the faculties of Medicine, Pharmacy, Dentistry, Nursing and Education in Suez Canal University to determine the knowledge, perception and practices of those students regarding HCV infection and means of prevention. Table 1 shows that the mean age of the participants was 20.74± 1.31. 52% of the sample was in the age group 19-21 years. Table 2 shows that 98.4% of the students have heard about hepatitis C, and 95.6% of them know that it is prevalent in Egypt. Table 3 shows the proportion of correct answers toward each Hepatitis C knowledge question. There was a statistically signi icant difference regarding the knowledge about the symptoms, diagnosis, complications and routes of transmission among the different faculties.    Table 4 shows the proportion of students that were exposed to blood products, spilling and needle stick injuries. Table 5 shows that there was a signi icant difference regarding receiving infection control training, using protective gloves during risky procedures and complying with hand washing practices, with the highest percentage among nursing students. Table 6 shows that there was no statistically signi icant difference among the different faculty students regarding engaging in dangerous practices that may lead to hepatitis C transmission.    Table 7 shows that there was no signi icant difference between males and females regarding knowledge about hepatitis C. There was a statistically signi icant difference between different faculties as well as between different years (p<0.001).
Students receiving infection control trainings had a statistically higher mean knowledge score than those who did not attend trainings. Table 8 shows that Stepwise backward regression analysis model of signi icance best-itting predictors of knowledge about hepatitis C, were Faculty of Medicine (t=8.9, p<0.001), Faculty of education (t= -8.4, p<0.001), Age (t=3.6, p<0.001).

Discussion
The present study shows that the mean level of knowledge among university students was generally low. With the exception of faculty of medicine, students from all other faculties displayed lack of knowledge regarding the symptoms, diagnosis, routes of transmission and complications of the disease. There was positive correlation between the faculty of Medicine and good knowledge about hepatitis C. Also, there were signi icantly lower knowledge scores among students of the faculty of education, as well as a negative correlation between knowledge and the faculty of education.
In a report by [11], in Pakistan, the survey showed fair level of knowledge among university students regarding hepatitis B and C, but gaps in knowledge were identi ied which need to be strengthened in students especially in non-biological sciences group. These results agree with those found in a survey in Iran where the knowledge of students with respect to the type of hepatitis (A, B, C, D and E) was very weak [12].
Our results showed that medical students had the highest knowledge score, followed by nursing students due to their basic knowledge .In a survey by [13]. On the knowledge of health care workers about HCV, the mean knowledge level score was acceptable and doctors were the most knowledgeable group too.
There was no signi icant difference between males and females regarding knowledge or dangerous practices [14], also found that there was no signi icant difference between genders regarding knowledge, however, in their study it was shown that female students had more positive attitudes than male students towards risk taking and prevention of hepatitis C.
Knowledge among dental students in our study was found to be low. This is contrary to the results found in a study by [15]. In Bulgaria on dental medicine students, where the majority of participants in the study showed high or average rate of knowledge concerning HCV route of transmission and prevention. Similar results were found in previous studies assessing Hepatitis knowledge in dental students and dentists worldwide [16][17][18].
Unlike the present study, where the proportion of dentistry students complying with hand washing and using protective gloves was lowest, in Todorova's work, it was found that students in the faculty of Dental Medicine were relatively aware of current risk posed by hepatitis in dental practice and knew how to protect themselves and patients from hepatitis spread. As the knowledge of this group about the prevention and transmission of hepatitis was not high, it is predictable that they do not follow preventive strategies completely. In a study in a teaching hospital in Lahore, it was determined that lack of awareness was the commonest reason for not being vaccinated against hepatitis B [19].
In our study, less than half of the students with different faculties received hepatitis  vaccination. This indicates lack of knowledge about the means of prevention of infection. Also in the Pakistan survey, knowledge about hepatitis B vaccine was not satisfactory among study groups [11]. This is contrary to the indings of [13]. Who found that the majority of the medical students (97.2%) had received Hepatitis B vaccination.
Our results show that there is a positive correlation between age and the degree of knowledge, and that the 4 th year students had the highest mean knowledge score. In a study conducted by [20]. On medical students of Delhi to measure their level of information about hepatitis A and B, a questionnaire including information on hepatitis B vaccine, its transmission, symptoms and prevention, was distributed among the irst, third and last year students. The results showed that senior students had the highest level of information compared with other two groups [21].
We conclude that knowledge and attitude of university students in our region is partial too weak in those groups of students of non-biological sciences who have less close contact with the patients.

Financial support
The study was carried out under the Research Grant Agreement (TC/4/Health-2010-hep-3271) between Science and Technology Development Fund (STDF) of Egypt and the Faculty of Medicine, Suez Canal University.