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Table of Contents
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 93-98

Knowledge, awareness, and risk prevention among hepatitis patients attending a tertiary care hospital in Delhi

1 Department of Planning and Evaluation, The National Institute of Health and Family Welfare, New Delhi, India
2 The National Institute of Health and Family Welfare, New Delhi, India

Date of Submission26-Jan-2022
Date of Decision06-May-2022
Date of Acceptance13-Jul-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Dr. V K Tiwari
Department of Planning and Evaluation, The National Institute of Health and Family Welfare, New Delhi - 110 067
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcfm.ijcfm_9_22

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Introduction: People living with chronic viral hepatitis in India often lack awareness on risk factors and prevention. Moreover, due to fear of stigma and discrimination, they often delay appropriate and timely treatment, resulting in chronic treatment and impoverishment. The objective of this study is to assess knowledge, awareness, and prevention regarding risk factors among viral hepatitis-infected patients attending a super-specialty hospital in Delhi.
Material and Methods: Data were collected from 389 patients using systematically random sampling using a pretested, structured interview schedule from patients attending Institute of Liver and Biliary Sciences, New Delhi.
Results: Findings revealed that 90.7% of the respondents believed that hepatitis B virus/hepatitis C virus (HBV/HCV) can be transmitted through sexual contact with a person who is infected, 94.3% said that it can be transmitted by transfusion of infected blood, 90% reported that it can be spread from infected mother to child during child birth, 93.8% responded that it can be transmitted if a person uses a razor, pierced ear ring, needle, or syringe used by an infected person, 83% believed that HBV/HCV can cause cancer in 90% of the respondents in long run, and more than 35% believed that HBV/HCV is curable. Results also show that 7.2% of the respondents have been vaccinated for HBV infection in the past, 20.8% of the respondents have screened their families for hepatitis B infections, and 77.9% of the respondents have received antiviral medications.
Conclusion: HBV/HCV-infected patients had less knowledge about various facts regarding disease and continue to experience emotional disturbances, stigma, and discrimination.

Keywords: Discrimination, hepatitis B virus, hepatitis C virus, knowledge and awareness, risk prevention, stigma

How to cite this article:
Tiwari V K, Balsundaram P, Raj TP. Knowledge, awareness, and risk prevention among hepatitis patients attending a tertiary care hospital in Delhi. Indian J Community Fam Med 2022;8:93-8

How to cite this URL:
Tiwari V K, Balsundaram P, Raj TP. Knowledge, awareness, and risk prevention among hepatitis patients attending a tertiary care hospital in Delhi. Indian J Community Fam Med [serial online] 2022 [cited 2023 Jun 4];8:93-8. Available from: https://www.ijcfm.org/text.asp?2022/8/2/93/366555

  Introduction Top

Viral hepatitis takes a heavy toll on lives, communities, and health systems. It is responsible for an estimated 1.4 million deaths per year from acute infection and hepatitis-related liver cancer and cirrhosis – a toll comparable to that of HIV and tuberculosis. Of those deaths, approximately 47% are attributable to hepatitis B virus (HBV), 48% to hepatitis C virus (HCV), and the remaining to hepatitis A virus (HAV) and hepatitis E virus (HEV).[1]

Globally, an estimated 1.4 million cases of HAV infection occur annually.[2] The proportion of young adults at risk for HAV infection is very low in India. HEV is the most important cause of epidemic hepatitis, though HAV is more common among children. Most acute liver failures diagnosed in India are attributable to HEV, and HEV is the most common cause of hepatitis during pregnancy. Both HAV and HEV are transmitted through the fecal-oral route, due to ingestion of sewage-contaminated and inadequately-treated water.[3]

Chronic hepatitis B can lead to serious health issues, such as cirrhosis or liver cancer. At least 15%–25% of chronically HBV-infected people will die due to liver disease caused by HBV, and this constitutes nearly one million people each year.[4] The best way to prevent hepatitis B is by getting vaccinated.[5] The WHO recommends universal hepatitis B vaccination for all infants and that the first dose should be given as soon as possible after birth.[6] Treatment of chronic hepatitis B infection can slow the progression of cirrhosis, reduce the incidence of liver cancer, and improve long-term survival. However, many people are diagnosed only when they already have advanced liver disease and die within months of diagnosis.[7]

Hepatitis C is a blood-borne virus, and most people become infected with the HCV by sharing needles or other equipment to inject drugs. There is no vaccine for hepatitis C. The best way to prevent hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs.[8] Population prevalence of chronic HCV infection in India is around 1%. The prevalence of hepatitis C has been observed to be relatively higher in Punjab, Haryana, Andhra Pradesh, Puducherry, Arunachal Pradesh, and Mizoram, compared to other states.[9],[10],[11],[12],[13]

A national programmer for viral hepatitis has been launched in 2014 laying focus on blood safety, laboratory strengthening, and information, education, and communication. In view of the infection and health consequences, raising awareness and prevention are the best strategies. No many studies are conducted on awareness, health promotion, and preventive aspects of HBV/HCV in the country. A cross-sectional study conducted by Verma et al. determined 22.3% incidence of hepatitis C in Ratia block of Fatehabad district, Haryana, India. The study emphasizes the need for public awareness campaigns at various levels and prevention of HCV infection.[10] A retrospective study in Punjab found that high proportions (44.8%) of the patients included in the study were incidentally detected with hepatitis C infection on routine screening.[14] A study conducted among male people who inject drugs (PWIDs) in Delhi found that a tenth of the participants were HBsAg positive and suggested targeted intervention programs to make HBV/HCV testing, prevention, and care more accessible for PWIDs. Awareness of HCV infection status is expected to influence risk behaviors.[15]

In view of above background, a study was conducted among patients attending a government tertiary care hospital in Delhi to assess their knowledge, awareness, and risk prevention practices regarding HBV and HCV infections.

  Material and Methods Top

The present descriptive study was conducted by the National Institute of Health and Family Welfare (NIHFW), an autonomous organization, under the Ministry of Health and Family Welfare, Government of India. The study was carried out at the Institute of Liver and Biliary Sciences (ILBS), which is an apex tertiary care government hospital in Delhi, during October 2016–January 2017. Ethical approval was taken from the Institutional Ethics Committee of NIHFW as well as the Institutional Review Board of the hospital. The inclusion criteria were patients diagnosed with HBV or HCV infections for more than 6 months and aged 18 to 75 years. Patients with acute viral hepatitis, hepatitis B/C with cancer, or in coma were excluded from the study.

As the prevalence of awareness about hepatitis B and C in India is unknown, the sample size was calculated assuming a prevalence of 50% which gives the maximum sample for all statistical calculations. With the confidence level of 95%, and 5% allowable error, the calculated sample size was 384 patients.[16] Considering 10% nonresponse, a sample size of 422 patients were taken in the study.

Systematic random sampling was used, and sampling interval was calculated. It was observed that around 50 patients were attending outpatient department daily. It was decided to collect ten patients randomly each day. Thus, starting randomly between 1 and 5 patients, next 5th patient was selected till we completed 10 interviews. Out of 422 patients, 33 interview schedules were excluded from the sample as these had incomplete data. However, after scrutinizing for accuracy and completeness of data, a total of 389 (350 outpatients and 39 in-patients) interview schedules were analyzed using the IBM SPSS Statistics for Windows, Version 23. (Armonk, NY, IBM Corp.).

  Results Top

Out of 389 patients, 299 (77%) were males and 90 (23%) were females. Minimum age was 18 and the maximum was 75 years, with a mean age of 41.8 years. About 30% of the patients were in the age group of 36–45 years, 28% in 26–35 years, and 22% in 46–55 years. About 78% came from urban area and 22% from rural area. In the sample, 62.5% were graduate and above, 20.6% were secondary or a senior secondary, and merely 7% were primary or a below primary level. Most of the respondents had government/private job (50%), followed by business people (17.7%). About 54% had an income of more than Rs. 30,000/month, about 30% had between Rs. 16,001 and Rs. 30,000/month, and around 14.9% of them had an income between Rs. 6001 and Rs. 16,000/month. The median household yearly income is Rs. 360,000/year. About 4% of the respondents had below poverty line card.

Study reveals that 85% of the respondents believed that even though the liver function test is normal, a person can continue to have HBV/HCV; 91% believed that even though there were no signs or symptoms, one can continue to be infected with HBV/HCV; 83% reported that HBV/HCV can cause cancer in 90% of the respondents in long run; and 85% believed that by treating HBV/HCV adequately, one may be able to completely cure or delay the advancement of cirrhosis or cancer. 89.5% of the respondents were aware of hepatitis B vaccination. Although there is no vaccine for HCV, 9.3% of the respondents believed that there may be vaccine for the prevention of HCV infection. More than 90% had knowledge about route of transmission of infection [Table 1].
Table 1: Knowledge about modes of transmission of hepatitis B virus/hepatitis C virus (n=389

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While knowledge about routes of transmission was quite high, at the same time, many myths were also prevailing. The analysis revealed that 42.7% of the respondents believed that HBV/HCV can be transmitted by drinking contaminated water and 14.1% reported as transmitted by eating contaminated food, about 16.5% reported as spread using towels used by infected persons, 5.4% said that it can be transmitted by sharing the same tableware, 8.5% said that it can be transmitted through sharing utensils, 19.3% believed that it can be transmitted by eating together, 2.8% respondents thought that it can spread while shaking hands with infected persons, and 43.7% believed that it can spread when a person slightly kisses an infected person. Many such myths such as using towels used by infected persons (16.5%) and eating together (19.3%) may lead to discrimination in family [Table 2].
Table 2: Myths about modes of transmission of hepatitis B virus/hepatitis C virus (n=389)

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Majority of the respondents were aware of the consequences of viral hepatitis and vaccination for HBV, and only 36% were aware that HCV is curable.

In spite of visiting super-specialty hospital, around 10% believed that there is vaccine for the prevention of HCV infection. About 30%–40% believed that HBV and HCV are curable and insignificant difference exists between responses from male and female patients. Relatively, few (20%) respondents said that liver cirrhosis is curable [Table 3].
Table 3: Awareness about consequences of viral hepatitis (n=389)

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Awareness about the fact that ' HBV/HCV infection can cause liver cancer' and 'even without any signs and symptoms, one may continue to be infected with HBV/HCV' was very high(>80%) and such awareness increased with the level of education among patients. When enquired about knowledge regarding availability of vaccine to prevent HBV infection, 60%–90% at different educational levels were aware and the awareness consistently increased with the level of education. We found that 20%–40% of the patients in different educational categories were familiar with the fact regarding curability of HBV/HCV. Education did not have an association with all the above outcome variables.

The best way to prevent hepatitis B is by getting the hepatitis B vaccine. The results show that 7.2% of the respondents have been vaccinated for HBV infection in the past, 20.8% of the respondents have screened their families for hepatitis B infections, and 77.9% of the respondents have received antiviral medications [Table 4].
Table 4: Practices of respondents for tackling viral hepatitis (n=389)

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Our findings show no significant gender difference (7.4% males, 6.7% females) among patients getting vaccinated against HBV infection in the past. Higher female percentage (19.4% males, 25.6% females) respondents had screened their families for hepatitis B infections and have received antiviral medications (76.3% males and 83.3% females).

Majority (89%) of the respondents received knowledge about viral hepatitis through the doctors, followed by friend or relatives among 29.8%. Just 9.5% of the respondents received knowledge through health staff and 27.5% of the respondents browsed the Internet to know about viral hepatitis. Very few of them replied source of information as television (TV) (2.3%) and radio (0.8%). When enquired about adequacy of information about the disease and treatment, only two-fifths (40.5% males, 37.8% females) of the respondents told that they got information adequately. In our study, almost 50% of the patients responded that doctors did not provide information about the disease.

Due to the poor awareness about the diseases, many patients had to bear stigma in their surroundings. In our study, 46.8% of males and 43.3% of females were worried about chronic infection, while only 15.1% of males and 14.4% of females said not at all. Further, 29% of the males and 31% of the females said that they felt “isolated and lonely” due to chronic liver infection. One-third of the male and female patients suffered from “low self-esteem” due to the disease, while 81.3% of males and 76.7% of female reported that carrying a chronic liver infection had an impact on their lifestyle. Among males, 7% mentioned that they quit smoking and 13.4% quit alcohol. However, 83.9% of males and 72.2% of females were worried of transmitting the disease to others.

Within family stigma was also faced by the patients. Some isolated themselves from family because of fear of spreading disease to them (8.7%), family members were hesitant to share things such as towel and utensils (26%), spouses of the infected partner were afraid (42%) that the infection may be transmitted to their children in case they get closer to the infected partner, so keeping children away from the infected partner. Due to fear of infection, 3% pateints informed that their conjugal and sexual relationship were adversely affected.

  Discussion Top

More than 90% of the burden of Hepatitis is due to the infections with the HBV and HCV. Prevention can reduce the rate of new infections, but the treatment can prevent deaths in the short and medium term.[17] When Hepatitis B patients lack a basic understanding of infection control and management, it can result in the further spread of hepatitis B infection. Our study was conducted in hospital setup where patients are also counseled on various aspects. A mixed pattern emerged regarding various aspects of awareness. A very high percentage of them (75%–90%) believed that HBV/HCV can cause cancer in long run, even though the liver function test is normal a person can continue to have HBV/HCV, even though there are no signs or symptoms one can be infected with HBV/HCV, by treating HBV/HCV adequately one may be able to completely cure or delay the advancement to cirrhosis or cancer. We found marginal difference in the level of awareness among male and female patients probably because of hospital-based study. In spite of visiting super-specialty hospital, one-tenth believed that there is vaccine for the prevention of HCV infection.

Our study found high awareness regarding transmission routes of HBV/HCV infection. Higher percentage of males (92.3%) than females (82.2%) reported that the infection can be transmitted from mother to child during pregnancy. Further, the study found that education has a significant relationship with the knowledge of transmission of the disease. The result was in line with the studies conducted in Vietnam and Pakistan.[18],[19]

Some noteworthy misconceptions such as 'HBV/HCV can spread through consumption of contaminated water and food (42.7%)', eating together (19.3%), and by sharing the same tableware (5.4%) also prevailed among patients. Gender, place of residence, and education were found to have a statistically significant effect on all of the above myths related variables (P < 0.05). Lack of awareness and misconception are also reported from many other studies. A study conducted in the United States among four Asian-American–migrant groups – Vietnamese, Hmong, Korean and Cambodian – found that large proportions of all groups incorrectly believed it could be transmitted by coughing, sharing food and drink, and eating utensils.[20]

Awareness about consequences, vaccination of HBV infection, and treatment is important. We found that HBV/HCV infection can cause liver cancer and even without any signs and symptoms, one may continue to be infected with HBV/HCV, and awareness was very high (>80%) and also increased with level of education.

The percentage of awareness about the facts that 'inspite of normal Liver Function Test, one may be infected with HBV/HCV' and by 'treating HBV/HCV adequately, one may be cured/delay the advancement of liver cirrhosis/cancer' ranged between 60-80%. Knowledge regarding availability of vaccine to prevent HBV infection was existing among all educational level among patients and it consistently increased with the level of education. However, awareness was low on some facts such as curability of HBV/HCV. This result is in line with the study conducted in at Haramaya University, a statistically significant association was observed between the field of study and knowledge of HBV.[21] Awareness about the fact that HBV and HCV are curable ranged between 30% and 45% and difference between rural and urban areas was not much.

Immunization programs are highly effective, clearly protect populations and individuals at risk. The hepatitis B vaccine is safe and is usually given as 3–4 shots over a 6-month period. The complete vaccine series induces protective antibody levels in more than 95% of infants, children, and young adults. Protection lasts at least 20 years and is probably lifelong. Thus, the WHO does not recommend booster vaccination for persons who have completed the three-dose vaccination schedule. Hepatitis B vaccination is the mainstay of hepatitis B prevention.[22] The present study reveals that just 7.2% of the respondents had been vaccinated for HBV infection in the past, and 20.8% of the respondents had screened their families for hepatitis B infections. A community-based study conducted in Vietnamese corroborates our study findings.[18] Hepatitis B continues to spread in endemic areas where universal vaccination has not yet been achieved.[23] The availability of vaccine and its use in preventing neonatal transmission as well as the increasing use of suppressive therapies should yield greater gains in the eradication of hepatitis B in upcoming generations.[23]

A diagnosis of hepatitis B and C is an opportunity for healthcare providers to create awareness about the disease and to encourage patients in their commitment to treatment and self-care. In our study, regarding information about the disease and treatment, 40% of the respondents got adequate information, and 59% got only “some information.” The inadequate information among service providers and patients in hospital often result in stigma and discrimination and psycho-social problems.[24],[25] Stigma creates many problems among patients and also results in delayed and inappropriate treatment. Stigma can significantly affect the patients' quality of life.

In our study, about 40% of those who were illiterate/just read and write, 45% of those who attended primary or a secondary school, and 46.4% of those attended senior secondary school/college said that they were highly worried about the disease status. Our study reported that fear of transmitting infection to others by sharing things such as eating utensils, cups, glasses, and towels was expressed by respondents. Similar to our results, study conducted by Hilsabeck et al. at Rawalpindi, Pakistan, found that changes in lifestyle were reported by 75% of the participants in their study. This was either due to weakness (fatigue) or emotional disturbances (mood swings, anxiety, irritability, depression, etc.), which is consistent with previous reports.[26],[27] Change in patients' daily life has been attributed to worries and uncertainties associated with hepatitis due to its slow and silent nature as well as a lack of proper information about its transmission, prognosis, and treatment.[28],[29]

  Conclusion and Recommendations Top

Even though knowledge about the disease course and transmission was good among the participants, proportion of immunized was less. There were some myths that were prevalent among them. There was a need to create awareness among the general population by using various communication strategies such as education, communication, and social media. Electronic media such as TV, radio and print media such as newspapers and magazines can also be used for health promotion. Adequate health education should be provided to the patients in the hospital as well as in community settings for control and management of the disease.


Authors are grateful to Director, ILBS, for granting permission to conduct the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]


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