Status of Household Transmission Prevention among Individuals with Chronic Hepatitis B: a Cross-sectional Study in Ethiopian Tertiary Care Setting

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Higher disease related knowledge among Hepatitis B patients improves the practice of transmission prevention and screening of household contacts. This study aims to assess the knowledge and practice of household transmission prevention among people with chronic hepatitis B attending a liver clinic at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. Methods A single center cross-sectional study among 229 hepatitis B patients visiting liver clinic for follow up service was undertaken in 2021. Data were collected using a structured interviewer guided questionnaires and analyzed using descriptive and inferential statistical methods in SPSS 26. Results Mean age of respondents was 40 years, 68% were male, 65% of respondents scored ≥75 (defined as a high knowledge). In adjusted linear regression, age 3 years were associated with higher knowledge score (R2= 0.106, F=8.936, P<0.001). Only 38.6% of participants scoring ≥6 (defined as good prevention practice). In Adjusted logistic regression, factors associated with poor practice were; low level of education (OR: 5.218; 95%CI: 1.34-20.23; p=0.017), being on anti HBV treatment (OR: 3.582; 95%CI: 1.04-12.33; p=0.043) and duration of follow up at TASH <2 years (OR: 2.93; 95%CI: 1.14-7.55; p=0.025). Conclusion In contrast to overall good knowledge, largely poor implementation of prevention practices and misunderstandings about transmission through air, kissing, and eating utensils were seen in a significant proportion of participants. Based on the results, any educational programs planned for this population should give special attention to the implementation of recommended prevention practices than simple awareness creation, with priority given to those with low education, <2 years on follow-up, and those on anti-hepatitis B treatment. 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F1000Research 2025, 14 :538 ( https://doi.org/10.12688/f1000research.163718.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Status of Household Transmission Prevention among Individuals with Chronic Hepatitis B: a Cross-sectional Study in Ethiopian Tertiary Care Setting [version 1; peer review: awaiting peer review] Liban Dida Godana https://orcid.org/0000-0001-7563-8402 1 , Henok Bahru https://orcid.org/0009-0001-6374-1098 2 , Hiwot Belachew 2 , Galgalo Abagudo 3 , Galgalo Abduba 4 , Neway Fekede 5 Liban Dida Godana https://orcid.org/0000-0001-7563-8402 1 , Henok Bahru https://orcid.org/0009-0001-6374-1098 2 , [...] Hiwot Belachew 2 , Galgalo Abagudo 3 , Galgalo Abduba 4 , Neway Fekede 5 PUBLISHED 30 May 2025 Author details Author details 1 Department of Internal Medicine, Moyale Primary Hospital, Moyale, Oromia, Ethiopia 2 Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia 3 Department of Surgery, Moyale Primary Hospital, Moyale, Oromia, 0000, Ethiopia 4 Department of Obstetrics and Gynecology, Moyale Primary Hospital, Moyale, Oromia, Ethiopia 5 Department of Internal Medicine, Goba Referral Hospital, Madda Walabu University, Robe, Oromia, Ethiopia Liban Dida Godana Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Henok Bahru Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Hiwot Belachew Roles: Data Curation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Galgalo Abagudo Roles: Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Galgalo Abduba Roles: Data Curation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Neway Fekede Roles: Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW Abstract Background The significance of household transmission of hepatitis B virus infection has been identified in different studies. Higher disease related knowledge among Hepatitis B patients improves the practice of transmission prevention and screening of household contacts. This study aims to assess the knowledge and practice of household transmission prevention among people with chronic hepatitis B attending a liver clinic at Tikur Anbessa Specialized Hospital (TASH), Ethiopia. Methods A single center cross-sectional study among 229 hepatitis B patients visiting liver clinic for follow up service was undertaken in 2021. Data were collected using a structured interviewer guided questionnaires and analyzed using descriptive and inferential statistical methods in SPSS 26. Results Mean age of respondents was 40 years, 68% were male, 65% of respondents scored ≥75 (defined as a high knowledge). In adjusted linear regression, age 3 years were associated with higher knowledge score (R2= 0.106, F=8.936, P<0.001). Only 38.6% of participants scoring ≥6 (defined as good prevention practice). In Adjusted logistic regression, factors associated with poor practice were; low level of education (OR: 5.218; 95%CI: 1.34-20.23; p=0.017), being on anti HBV treatment (OR: 3.582; 95%CI: 1.04-12.33; p=0.043) and duration of follow up at TASH <2 years (OR: 2.93; 95%CI: 1.14-7.55; p=0.025). Conclusion In contrast to overall good knowledge, largely poor implementation of prevention practices and misunderstandings about transmission through air, kissing, and eating utensils were seen in a significant proportion of participants. Based on the results, any educational programs planned for this population should give special attention to the implementation of recommended prevention practices than simple awareness creation, with priority given to those with low education, <2 years on follow-up, and those on anti-hepatitis B treatment. READ ALL READ LESS Keywords Chronic hepatitis B, Household contacts, sexual partners, transmission, prevention Corresponding Author(s) Liban Dida Godana ( [email protected] ) Close Corresponding author: Liban Dida Godana Competing interests: No competing interests were disclosed. Grant information: The fieldwork in this project was supported by Addis Ababa University. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in drafting the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Dida Godana L et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Dida Godana L, Bahru H, Belachew H et al. Status of Household Transmission Prevention among Individuals with Chronic Hepatitis B: a Cross-sectional Study in Ethiopian Tertiary Care Setting [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :538 ( https://doi.org/10.12688/f1000research.163718.1 ) First published: 30 May 2025, 14 :538 ( https://doi.org/10.12688/f1000research.163718.1 ) Latest published: 30 May 2025, 14 :538 ( https://doi.org/10.12688/f1000research.163718.1 ) Introduction Hepatitis B Virus (HBV) infection is a significant public health problem with a global prevalence of 3.5%. 1 World health organization estimates that 296 million people were living with chronic hepatitis B infection in 2019, with 1.9 million new infections each year. In the same year, hepatitis B resulted in an estimated 820 000 deaths, mostly from cirrhosis and hepatocellular carcinoma (primary liver cancer). According to the world health organization (WHO) report, the Western Pacific and African regions accounted for 68% of the overall global burden, with an estimated prevalence of 6.2% and 6.1% respectively. 2 , 3 recent systematic review and Meta-analysis of the prevalence of HBV in Ethiopia showed that the overall pooled prevalence of HBV was 6%. 4 In most countries where HBV is endemic, perinatal transmission remains the most important route and cause of chronic infection. In comparison, horizontal transmission (i.e., household contacts, particularly child-to-child transmission) after exposure to infected body fluids is an important route of infection in areas of intermediate prevalence. 5 , 6 The significance of household transmission of HBV infection has been identified in different studies that at least half of HBV infection in children could not be attributed to vertical transmission, and in many endemic regions, prior to the introduction of neonatal vaccination, peak prevalence was seen in children between 7-14 years of age. 7 Similarly, in another study that involved household members of CHB patients, about 14-60% of them had serological evidence of resolved HBV infection, while 3-20% had a chronic infection, with the highest risk for infection among sexual partners and children living in the household of a person with chronic HBV infection. 8 In a study conducted in Taiwan, the HBV infection rate was 65 percent among neonates born to HBsAg-negative mothers and HBsAg-positive fathers. Most of these transmissions are believed to result from close contact of the unprotected infant with the infected blood and body fluids of the father. 9 One study in Ethiopia also found that non-perinatal transmission was a highly prevalent route of transmitting the infection and has an important role in maintaining the high infection rate in Ethiopia. 10 In addition to universal vaccination, American Association for the Study of Liver Disease (AASLD) guidelines recommend vaccination for individuals who are not immune to HBV and are at high risk of exposure or a poor disease outcome. This includes; household and sexual contacts of persons with chronic hepatitis B (CHB,) HIV-infected persons, persons who inject drugs (PWID), men who have sex with men, sex workers, healthcare workers, individuals with underlying chronic liver disease, and immunocompromised individuals. 11 Ethiopia also adopted the recommendation to offer the HBV screening and vaccination to its populations at increased risk of acquiring or transmitting the virus, especially key populations such as healthcare workers. 12 Therefore screening family members, sexual partners, and household contacts is an efficient way of identifying additional people with HBV who can benefit from treatment and monitoring. 13 However, most individuals with chronic hepatitis B are unaware of their infection and thus will benefit less from clinical care, treatment, and interventions designed to reduce onward transmission and disease progression. 14 One report showed that; in Africa, less than 1% of adults who tested positive for HBsAg at the community level had been previously tested and were aware of their diagnosis. 15 One explanation for the under-diagnosis of CHB and poor access to clinical care is a lack of awareness about the virus among people with or at greater risk of hepatitis B infection. 14 This hypothesis is supported by improvements in healthcare-seeking behavior among people with CHB following educational interventions. 16 , 17 The studies have shown that patients’ good knowledge regarding transmission, prevention, and treatment of Hepatitis B infection results in; improved screening and vaccination of high-risk groups, limited the spread of the infection to the community, early detection and linkage to care for many undiagnosed cases, and lowered the risk of developing related complications and death among CHB patients. 18 , 19 However, data regarding the awareness and practice of CHB patients toward preventing disease transmission is scarce worldwide, particularly in Africa. Thus, assessing the knowledge and practice of chronic hepatitis B patients regarding transmission prevention would provide crucial information for the prevention and control of HBV infection and in achieving its elimination goals. To date, there are only a few studies done targeting similar topics and populations worldwide. In almost all of these studies, the practices of preventing HBV transmission to others were not adequately assessed. The status of household transmission prevention among people with chronic hepatitis B in Ethiopia is unknown. Therefore, this study aimed to assess the level of knowledge and practice towards prevention of household transmission among people with CHB attending a liver clinic at Tikur Anbessa specialized hospital, Addis Ababa University, Ethiopia. Methods Study design and setting A single center cross-sectional study was conducted in July-December 2021 at Tikur Anbessa specialized hospital (TASH), the main tertiary referral center in Addis Ababa, Ethiopia. TASH gastroenterology and hepatology unit runs 3 days weekly outpatient clinic, and on average, up to 30-40 CHB patients are expected to visit the clinic weekly as newly referred cases or for follow-up. 507 CHB patients had visited the TASH liver clinic at least twice in the 12 months (i.e., from January 2020- January 2021). Study participants The study population for this study was all CHB patients attending the TASH liver clinic for follow-up service during the data collection period. The study included; (1) patients with confirmed diagnosis of CHB infection (HbsAg-positive persistence for more than 6 months) and had at least two visit at the TASH liver clinic, (2) aged 18 years and above, (3) able to speak and understand either English, Amharic or Afan Oromo languages, and (4) understood the study objectives and voluntary to be interviewed. Patients with known cognitive or mental disorders and those who are seriously ill were excluded from the study. Sample size calculation and sampling procedure The sample size was calculated using single proportion formula with the assumptions of confidence interval = 95%, critical value (Zα/2) = 1.96, and degree of precision (d) = 0.05. The population proportion (p) = 50% was used since no research was done in the same setting concerning knowledge and practice for preventing HBV household transmission. n = ( Z 2 × p × q ) / d 2 Where n = sample size, p = population proportion rate = (50%), since the proportion of patients coming to the clinic was unknown, Z = standard normal variable at the confidential level of 95%, d = margin of error, which is 5%, and q = 1-p. n = ( 1.96 2 × 0.5 × 0.5 ) / 0.05 2 n = ( 3.8416 × 0.25 ) / 0.0025 n = 0.9604 / 0.0025 n = 384.16 ≈ 384 Since the source population is less than 10,000, the sample size was adjusted using the correction formula; Nf = ni/(1 + ni/N) where ni = initial sample size, Nf = new sample size, N (total population) = 507. Therefore; Nf = 384/(1 + 384/507) Nf: 384/1.76 = 218 Nf = 218 Then 10% of the new sample size was added by considering for non-response rate. → (10/100) × 218 = 22. Therefore, the sample size for this study is approximately 22 + 218 = 240. A simple random sampling method was used to recruit 240 adult patients with confirmed chronic hepatitis B infection from those who visited the TASH liver clinic during four months periods of data collection. Study variables Independent variables were; the participant’s demographic details and clinical data that might influence the dependent variables. These includes; Age, sex, marital status, occupation, level of education, region, disease duration, duration of follow up at TASH, treatment status and if anybody else in the household is infected. Dependent variables were; the level of knowledge of transmission and prevention of HBV and the level of practices towards household transmission prevention of HBV. Knowledge is defined as the fact or condition of being aware of something. 20 In this study, it was used to assess patients’ awareness of modes of HBV transmission and how to prevent it. The overall knowledge of respondents was assessed using fourteen questions regarding HBV transmission and prevention. Each of the 14 knowledge questionnaires had three possible responses: yes, no, or don’t know. The responses were scored by assigning a value of 1 to correct answers and a value of 0 to wrong answers and don’t know. A total knowledge score was presented on a scale of 100, and to categorize knowledge score, the total score was dichotomized as high (≥75 out of 100 (≥11 out of 14)) and low to intermediate if <11(75%) using a top quartile score as the cut of point. 21 , 22 Practice is defined as; to carry out, to apply or to do or perform often, customarily, or habitually. 23 In this study, it was used to assess the degree of implementation of recommended measures to prevent HBV transmission within the household. The practice of individual respondents regarding household transmission prevention of HBV was assessed by seven ‘yes’ or ‘no’ questions. Each correct response was given a score of “1” while an incorrect answer was given a score of “0”. The total score was categorized using a top quartile score, as good for a score between 6 and 7 points and fair to poor if <6(75%). Data sources/measurement A standardized questionnaire was developed adopting items from previously validated tools used in studies on Knowledge of hepatitis B transmission and prevention. 18 , 21 , 24 The Original questionnaires were reviewed, and contextually relevant modifications were made to align with the Ethiopian health care setting and cultural context. The questionnaire was prepared in English and translated into Amharic and Afan Oromo Languages. A structured questionnaire containing 31 items with 3 sections, covering the socio-demographic and clinical characteristics of the patients (10 questions), patients’ knowledge related to HBV transmission and prevention (14 questions), and (7 questions) to assess the practice towards prevention of HBV household transmission were used for data collection. The questionnaire was validated by doing a pre-test on 10% of the sample before the actual data collection period. A necessary modification of the questionnaires was carried out based on the pre-test feedback. Furthermore, the reliability of the questionnaires was checked, and their using SPSS Cronbach Alpha value was 0.93 and 0.729 for questions of knowledge of transmission and prevention and prevention practice, respectively. The nurses who had access to patient’s medical record numbers were asked to select CHB patients and give their lists to the data collectors after routinely taking their vital statistics. A simple random sampling method selected the participants from the lists. Then Patients were invited to participate in the research while they were waiting for his/her turn at the follow-up clinic or after being seen by their doctors. The data collectors were the investigator and staff nurses, and medical interns. Adequate orientation was given to data collectors on the aim of the research, the content of the questionnaire, and the data collection process. The data was collected three days/week (i.e., during the clinic’s weekly service). The investigator also supervised the data collection processes regularly during the whole data collection period. The collected data was checked every day by the investigator for its completeness and consistency. A copy of full questionnaires used in this study has been uploaded as Extended Data. Statistical analysis Data were analyzed using SPSS version 26 statistical packages. Descriptive variables were expressed as frequency, percentages, mean, standard deviation, and abnormally distributed variables as the median. Bivariate analyses (independent t-test, chi-square & ANOVA) were conducted to test the associations between dependent and independent variables. The association was further assessed using regression analysis for the variables that showed significance in bivariate analysis. A P-value < 0.05 was considered to be statistically significant in all cases. Participants with missing data for the main outcome were not included. Ethical approval and consent to participate Ethical approval for this study was obtained on 1 st of September 2021, from Addis Ababa University Collage of Health Sciences Department of Internal Medicine Ethics Committee located at Addis Ababa, Ethiopia. The study protocol was reviewed and approved by departmental research and ethics committee under supervision of Dr. Dawit Kebede and Dr. Abdurezak Ahmed. Although no formal reference number was issued initially due to internal record keeping practices, a documented approval was granted prior to commencement of the study and the most recent renewal was approved on April 29, 2025 under the reference number IMD/941/25. All study participants were adults aged 18 years and above, with no known mental or cognitive disorders. Participants’ involvement in the study was voluntary, and a written informed consent was obtained from all participants after providing detailed information about the study’s objectives, procedures, risks and benefits. The Consent process was conducted in accordance with ethical approval granted by the ethics committee of the department. No personal identifiers were used on the data collection form. Collected data were only accessed by the investigators and confidentiality was be maintained at all levels of the study. Results Demographic characteristics of respondents Of 240 sampled and eligible for interviews, only 229 chronic HBV patients were included in this study, making the response rate 95 percent. 156(68.1%) respondents were male and 73(31.9%) were female. Participants had a mean age of 39.8(±11) years. 183(79.9%) of them were married and 41(17.9) were single. The majority (71.1%) of respondents have had at least attended secondary education. 125(54.6%) participants were either government or private employed while 28(12.2%) had no job. About 2/3rd of participants (69%) were residents of Addis Ababa, while 21.8% were from Oromia regional state. The mean duration of illness from the time of diagnosis was 4.8(±4.2) years, and the mean duration of follow-up at TASH was 3.2(±2.7) years. Most of them (69%) have never received any specific treatment for HBV, and 92.1% of the participant had no additional household member infected with HBV. Knowledge of HBV transmission and prevention The mean total knowledge score of 14 questions for HBV transmission and prevention was 79.1 (11.14(SD: ±2.6)), showing a high level of hepatitis B knowledge among participants. Nearly 2/3rd of participants (65%) showed a high level of knowledge. 90% percent of respondents knew HBV could be transmitted by having unprotected sex with a person infected with hepatitis B, while 28% of them were unaware of vertical transmission. Nearly 2/3rd of participants (65%) were aware of four main routes of HBV transmission (i.e., vertical, sexual contact, sharing injecting equipment, sharing toothbrushes or razor blades), and only 3 patients were unaware of any of the transmission routes. The three questions that were least likely to be answered correctly were about possibilities of transmission by; touching a person with hepatitis B (69%), by kissing a person with hepatitis B (52%), and through the air when a person with hepatitis B coughs or sneezes (67%). Most of the participants (96.5%) were aware that people with hepatitis B should tell their family members to get tested as Summarized in Table 1 . Table 1. Proportion of CHB patients who answered correctly to questions about knowledge of hepatitis B transmission and prevention. Knowledge of hepatitis B transmission and prevention (correct answer) Total n = 229 Transmission routes Number Percent By having unprotected sex with a person with hepatitis B (True) 205 89.5 Through mother to child at birth (True) 166 72.5 By sharing toothbrushes or razor blades (True) 198 86.5 By sharing injecting equipments, e.g. needles used in tattooing, body piercing or drug use (True) 190 83 By touching a person with hepatitis B (False) 158 69 By kissing a person with hepatitis B (False) 120 52.4 Through the air when a person with hepatitis B coughs or sneezes (False) 154 67.2 By eating food prepared by a person with hepatitis B (False) 198 86.5 By sharing eating utensils (False) 194 84.7 By sharing foods (False) 204 89.1 Prevention knowledge People with hepatitis B should use condoms when having sex * (True) 174 76 People with hepatitis B should tell their family members to get tested (True) 221 96.5 There is a vaccination to prevent hepatitis B (True) 183 79.9 Newborn of Hepatitis B infected mothers should receive vaccine at birth (True) 187 81.7 * Not applicable if partner is vaccinated or is naturally immune. Practices towards prevention of household transmission Mean total practice score of seven questions used to assess the practices towards prevention of household transmission was 4.7(SD: 1.79). Since some of questions were not applicable to some patients, only participants for whom all of question assessing practices were included to calculate mean practice score and to categorize practice. The total practice score was dichotomized as good (6-7) or fair to poor (<6). Accordingly, 39 (38.6%) patients were within the good practice range whereas 62 (61.4%) showed fair to poor practice towards HB prevention. When queried about specific preventive practices, most of the respondents (87%) answered they had disclosed their status of HBV infection to their spouse; about 2/3rd of participants said they encouraged their household members or sexual contacts to get tested; only a half of the respondents said they recommended HBV vaccination to identified unvaccinated household members and/or sexual contacts. Fifty-three (26%) respondents said they always use condoms when having sex with unvaccinated/unimmunized partners. Twenty-six (11%) said they had ever shared personal items (razors, toothbrushes, and/or nail scissors) with household members, while 109(83%) said they always cover their wounds as Summarized in Table 2 . Table 2. HBV transmission prevention practices reported by respondents. HBV transmission prevention practices assessment items Number Percent Disclosed his/her HBV status to spouse a No 27 12.6 Yes 187 87.4 Encouraged any of household members to undergo HBV testing b No 72 32.4 Yes 150 67.6 Ever recommended HBV testing to sexual contacts c No 67 30.5 Yes 153 69.5 Recommended HBV vaccination to identified unvaccinated household members and/or sexual contacts d No 95 46.3 Yes 110 53.7 Always use condom when having sex * e No 151 74.0 Yes 53 26.0 Ever shared personal items (razors, toothbrush, and/or nail scissors) with household members f Yes 26 11.4 No 203 88.6 Always cover his/her open wounds or cuts g No 23 17.4 Yes 109 82.6 a Data available for 214 respondents. b Data available for 222 respondents. c Data available for 220 respondents. d Data available for 205 respondents. e Data available for 204 respondents. f Data available for 229 respondents. g Data available for 132 respondents. * Not applicable if partner is vaccinated or is naturally immune. Factors associated with knowledge of hepatitis B transmission and prevention Specific socio-demographic characteristics were associated with hepatitis B knowledge among participants. Bivariate analyses (independent t-test, chi-square & ANOVA) were conducted to test the associations between socio-demographic data and mean knowledge score of respondents. Three variables; age group, duration since diagnosis, and presence or absence of additional infected household members showed significant association with knowledge score. Significant predictors of knowledge were assessed using standard multiple regression. The three variables identified as significant predictors of mean knowledge score (age, duration since diagnosis, and other infected household members) were further analyzed by standard multiple regression. The results indicated that the younger age group, presence of additional infected household members, and longer duration since diagnosis as significant predictors of higher knowledge score (R2 = 0.106, F = 8.936, P 75%) among respondents. Adjusted multiple linear regression Variables B t p value R R Square Adjusted R Square F Sig. Duration since diagnosis (years) 0.099 2.532 0.027 .320 a 0.106 0.095 8.936 .000 b Age group dichot. (years) -0.770 -2.293 0.012 Other infected household member -2.028 -3.267 0.001 a Dependent Variable: Total knowledge score. b Predictors: Any infected household member, duration since diagnosis dichotomized (years), Age group dichotomized (years). Factors associated with associated prevention practices Factors associated with practice regarding HBV transmission prevention in the bivariate analyses were assessed using logistic regression ( Table 4 ). In Adjusted logistic regression, factors associated with the poor practice were; low level of education (OR: 5.218; 95%CI: 1.34-20.23; p = 0.017), being on anti-HBV treatment (OR: 3.582; 95%CI: 1.04-12.33; p = 0.043) and duration of follow up at TASH < 2years (OR: 2.93; 95%CI: 1.14-7.55; p = 0.025). Table 4. Socio-demographic and clinical characteristics of respondents associated with fair to poor practice of transmission prevention. Variables Unadjusted binary logistic regression Adjusted logistic regression Sig. Exp(B) 95% C.I. for EXP(B) Sig. Exp(B) 95% C.I. for EXP(B) Lower Upper Lower Upper Level of education Low level of education 0.015 5.617 1.401 22.509 0.017 5.218 1.346 20.238 High level of education 1.0 1.0 Treatment status On antiviral 0.041 3.666 1.055 12.738 0.043 3.582 1.041 12.330 Not started antiviral 1.0 1.0 Other infected household member Yes 0.069 9.045 0.839 97.480 No 1.0 Follow up duration at TASH (years) ≤ 2 years 0.009 3.750 1.390 10.117 0.025 2.943 1.146 7.557 >2 years 1.0 Discussion Our study identified that higher mean knowledge (11.14 or 79%) of hepatitis B transmission and prevention among respondents and 2/3rd of respondents have high level of knowledge. The finding is consistent only with the results of a study done in Australia, in which 79% of respondents have high over all knowledge score and mean knowledge score of transmission and prevention was (78%; IQR: 67,100) and (80%; IQR: 80,80) respectively. 24 However, in this study mean duration of follow-up was higher (7.2 years), and patients with limited English language proficiency were excluded. These factors could contribute to a higher level of knowledge seen in the study. The finding was inconsistent with other studies from Australia and Pakistan, where low knowledge levels were identified. This could be explained by the lack of access to health care (immigrants) and some differences in data collection tools as well as scoring methods used in these studies. 21 , 22 In the current study, the respondents have better knowledge of transmission routes, as 65% know four main routes. In contrast, only 35% of respondents were aware of four main routes (i.e., vertical, sexual contact, sharing injecting equipment, and sharing toothbrushes or razor blades) in the Australian study. 24 A community-based study that assessed the Hepatitis B Virus (HBV) infection knowledge status of uninfected persons across three states in Nigeria identified overall poor knowledge but still higher than the figures reported in both Australian and Pakistan studies. 24 The difference may be related to the high prevalence of HIV in sub-Saharan Africa, including Ethiopia contributing to better awareness, as most participants said, “The transmission routes are the same as that of HIV” in response to the questions about transmission routes. Despite the context of a high mean knowledge score, still, a significant knowledge gap was seen as more than a quarter of the participants were unaware of vertical transmission and also the necessity of newborn vaccination against HBV. In addition, respondents in this study said they don’t know about the availability of an effective HBV vaccine (20%) and should use condoms when having sex unless the partner is vaccinated or naturally immune (24%). The results from other studies showed relatively better knowledge when compared to the finding of our study, suggesting important areas that require attention to halt household transmission of HBV. 21 , 22 Misunderstanding about the transmission of hepatitis B through kissing (50%), air (coughing, sneezing), touching an infected person, and sharing eating utensils was identified among participants and reflects the findings of other studies. 18 , 21 , 24 The implications of this mistaken information could be significant considering Ethiopian cultures of sharing food, with the likely marginalization of people with CHB leading to unnecessary actions taken by the patients, which would disrupt their daily living and affect the overall quality of life. This study also identified that the younger age group (3 years) predicted higher knowledge of HB transmission and prevention among participants. In addition to a high level of education and English language proficiency, similar findings were reported in other studies as significant predictors of high knowledge in this population. 18 , 21 , 22 , 25 , 26 These findings indicate a priority for the interventions designed to improve knowledge should be given to older age groups, recently diagnosed patients, and to those without additional infected household members. Our study showed that the respondents have overall fair to poor practice towards preventing HBV household transmission based on the mean total practice score. The finding aligns with the results of some previous studies. 18 , 26 In response to specific questions, although most respondents (87%) said they had disclosed their status to their spouse, around 2/3rd of them encouraged testing, while only half recommended vaccination to identified unvaccinated household members and/or sexual contacts. The available literature findings are consistent with the current results regarding disclosure. However, with regard to the practice of recommending testing and vaccination, compared to the current study, higher practices were seen in a study done in Malaysia and Turkey, while a study in San Francisco by Nishimura. et.al reported lower practice despite higher knowledge among respondents. 24 , 26 , 27 This finding highlights that, high knowledge alone cannot result in good prevention practices. This could be due to fear of the potential social stigma associated with revealing their HBV status even the more knowledgeable cases may have been reluctant to encourage testing and vaccination among their close contact. 24 Respondents with low education, <2 years of follow-up, and those on anti-hepatitis B treatment were identified as significant predictors of poor prevention practice among the participants. This association was not analyzed in any of the previous studies. Thus, we hypothesize that patients on anti-hepatitis B treatment may think as if their infection is controlled and no more transmissible to others, thus making them reluctant to implement recommended prevention practices. Again, the finding suggests priority groups whenever interventions designed to improve practice are planned. Strength and limitations of the study The findings of this study are subject to some limitations. It is not possible to exclude the possibility of selection bias based on willingness to be interviewed or of response bias based on respondent self-report that could not be verified by other means. The study was done on outpatients in a single public tertiary hospital, usually approached by low to middle-income populations. The high-income group usually uses these facilities in emergencies only. Hence the results of our research may not represent the entire population. Besides, the participants were recruited in clinical settings, and the result may over-represent people with CHB who are sufficiently motivated to seek clinical care for their infection. However, the high interview response rate for knowledge questions and random sampling are strengths of our study that should minimize selection bias. Conclusion This study identified good overall knowledge of hepatitis B transmission prevention. However, misunderstandings about transmission through air, kissing, and eating utensils were identified in the majority of respondents. Furthermore, age >40 years, recently diagnosed patients (<3 years), and those without additional infected household members were identified in this study as priority populations for the interventions designed to improve the knowledge gap and correct wrong impressions about transmission. Regarding practice towards prevention of HBV transmission, our study showed that the respondents have overall poor practice. In particular, poor practice was identified in encouraging or recommending testing and/or vaccination to household members and sexual contacts. A lower level of education, follow-up duration <2 years, and being on anti-hepatitis B treatment were identified in this study as significant predictors of poor prevention practices. Higher practice about disclosure of HBV status to spouses identified in this study may be due to response bias. If response bias occurred, it would have biased the results to show better knowledge and preventive practices, so the gaps in knowledge and practice may be even larger than what we found in our study. Recommendations We recommend comprehensive educational interventions using strategies and techniques shown to increase health literacy (by clinicians at outpatient clinics or Mass Media) are needed to improve the knowledge gap and misconception about HBV transmission identified in people with CHB infection. Any educational programs planned for this population should give special attention to the implementation of recommended prevention practices than simple awareness creation, with priority given to those with low education, <2 years of follow-up, and those on anti-hepatitis B treatment. What is already know on this topic 1. Enhanced disease-related knowledge among Hepatitis B patients will improve practice towards prevention of transmission and facilitate screening of their sexual partners and household contacts. 2. This will help identify more Hepatitis B patients who can benefit from monitoring and treatment. 3. However, no study has assessed this population’s knowledge and practice status in Ethiopia. What this study adds 1. Overall, good knowledge of HBV transmission-prevention was identified in this study. 2. In contrast, largely poor implementation of recommended prevention practices and misunderstandings about transmission were seen in a significant proportion of participants. 3. Educational interventions for this population should focus on implementing specific prevention practices and target misunderstandings about transmission, with priority given to those with low education, <2 years of follow-up, and those on anti-hepatitis B treatment. Preregistered data analysis The authors declare they did not preregister the research. Data availability statement Figshare: Status of Household Transmission Prevention among Individuals with Chronic Hepatitis B: a Cross-sectional Study in Ethiopian Tertiary Care Setting- Dataset. https://doi.org/10.6084/m9.figshare.28664648.v3 30 The project contains the following underlying data: Data modified 2. (Anonymised answers to questionnaire, correct answers – 1, incorrect answers – 0, level of knowledge and practice were included by scoring method). Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). 30 Acknowledgements The authors are sincerely grateful to the patients who offered to participate in the study. The authors are thankful for the support given by the staff of Addis Ababa University department of Internal Medicine. Authors would also like to acknowledge Addis Ababa University for funding this study. 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Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 May 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Internal Medicine, Moyale Primary Hospital, Moyale, Oromia, Ethiopia 2 Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia 3 Department of Surgery, Moyale Primary Hospital, Moyale, Oromia, 0000, Ethiopia 4 Department of Obstetrics and Gynecology, Moyale Primary Hospital, Moyale, Oromia, Ethiopia 5 Department of Internal Medicine, Goba Referral Hospital, Madda Walabu University, Robe, Oromia, Ethiopia Liban Dida Godana Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Henok Bahru Roles: Data Curation, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Hiwot Belachew Roles: Data Curation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Galgalo Abagudo Roles: Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Galgalo Abduba Roles: Data Curation, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Neway Fekede Roles: Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The fieldwork in this project was supported by Addis Ababa University. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in drafting the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 30 May 2025, 14:538 https://doi.org/10.12688/f1000research.163718.1 Copyright © 2025 Dida Godana L et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. 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