Knowledge, attitudes, and practices toward hepatitis B virus infection among hepatitis-B patients in Qinghai Province, China

Abstract

Background

Patients with hepatitis B virus (HBV) infection are more prone to developing cirrhosis and liver cancer and can transmit the virus to others. Improving the knowledge, attitude, and practice (KAP) of HBV among patients is of great significance in delaying the progression of hepatitis B and reducing its transmission. This study aimed to assess the KAP of HBV among patients with HBV infection as well as the associated factors.

Methods

A cross-sectional study was conducted between June and July 2023 among patients with hepatitis B from two public hospitals in Qinghai Province, China. KAP regarding hepatitis B was assessed using a prevalidated questionnaire. Descriptive statistics were used to determine the participants’ demographic characteristics. A score above the median indicated adequate knowledge, positive attitudes, and good practices. Multivariate logistic regression analyses were used to identify factors influencing KAP among patients.

Results

Among 263 patients, 51.3%, 74.5%, and 67.3% had adequate knowledge, positive attitudes, and good practices, respectively. Junior high school or higher [odds ratio (OR) = 0.10, 95% confidence interval (CI):0.04–0.24] was associated with knowledge. Female (OR = 0.46, 95%CI:0.23–0.93), junior high school or higher (OR = 0.35, 95%CI:0.14–0.87), possible duration of disease ≥ 10 years (OR = 2.49, 95%CI:1.30–4.77) were associated with attitudes. Agro-pastoralism (OR = 2.28, 95%CI:1.06–4.92) was associated with practices.

Conclusion

In this study, patients had average knowledge of HBV, and most of them displayed a positive attitude and good practices toward HBV. Targeted intervention measures based on KAP-influencing factors should focus on improving patients’ knowledge of HBV and on continuously enhancing their positive attitudes and practices toward HBV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-28036-2.

Introduction

Hepatitis B is a serious and common infectious liver disease. It is a major global health problem. It can cause both acute and chronic infections and puts people at a high risk of death from cirrhosis and liver cancer [1]. One in four people with chronic HBV infection is at risk of premature death from cirrhosis or liver cancer [2]. The World Health Organization (WHO) has proposed the goal of eliminating hepatitis B by 2030, which includes ambitious targets for a 90% reduction in the incidence of viral hepatitis, 80% treatment uptake by eligible patients, and a 65% reduction in mortality [3]. China has made good progress in reducing the incidence of HBV infection in the past few decades. A systematic literature review and meta-analysis of 3740 studies and 231 million people reported that HBsAg seroprevalence in the general population decreased from 9.6% in 1973–1984 to 3.0% in 2021 [4]. However, China still has the world’s largest burden of HBV infection. Therefore, reducing the incidence of hepatitis B in China is crucial to achieving the WHO’s goal of reducing viral hepatitis cases by 90% by 2030 [5].

Knowledge, attitude, and practice (KAP) surveys are representative of a specific population and are used to collect information on what is known, believed, and done on a particular topic [6]. These are the most frequently used tools in health-seeking behavior research [6]. To reduce the prevalence of hepatitis B, many studies investigate the KAP of HBV among medical staff [7], students [8], and the healthy population [9]. However, only a few studies have focused on patients with hepatitis B infection. A study from Pakistan investigated the KAP of patients with hepatitis B but did not analyze the factors influencing KAP [10]. Another study from the Gambia used only univariate analysis to examine the factors influencing knowledge and attitudes among patients with hepatitis B [11]. Therefore, there is a need for more accurate measurements of the factors influencing KAP in patients with hepatitis B.

Improving the KAP of patients with hepatitis B is very important for several reasons: (1) Patients with hepatitis B who have a low KAP are not only prone to increasing disease burden but may also transmit HBV to others. (2) Most people who are newly infected with HBV remain asymptomatic and do not know their hepatitis status for many years [12]. Only some individuals infected with HBV exhibit symptoms (acute hepatitis) [13]. As a result, some patients diagnosed with hepatitis B may neglect to take care of their health and control their condition. (3) Most patients who begin hepatitis B treatment must continue the treatment for life. During antiviral treatment, patients with hepatitis B may experience varying degrees of decline in disease cognition and coping ability, poor treatment compliance, and decreased emotional regulation, which are not conducive to improving the efficacy of antiviral treatment and the quality of life of patients. (4) Although medical insurance coverage in China has reached over 95% of the population [14], it can only reimburse a portion of expenses [15], with the remaining costs being borne by individuals. Patients with hepatitis B who require long-term or even lifelong medication face a continuous economic burden [16]. Improving the KAP of patients with hepatitis B helps in better disease management and delays disease progression, thereby reducing the frequency of hospitalizations and preventing costly complications such as liver cancer.

Qinghai Province is located on the Qinghai-Tibet Plateau in western China, covering an area of 722,300 square kilometers, and has a population of 5.94 million in 2023 (with its capital Xining housing 2.48 million people) [17]. Due to its limited health and educational resources, Qinghai faces significant challenges in the control of infectious diseases [18]. One study indicates that the prevalence of hepatitis B in the Qinghai-Tibet Plateau exceeds 10%, which is markedly higher compared to the prevalence in other regions of China [19]. From 2011 to 2021, Qinghai had the highest average annual incidence of hepatitis B, reaching 178.00 per 100,000 people [20]. Therefore, this study aimed to explore the level of KAP in HBV among patients with hepatitis B and to identify the influencing factors. This can provide a basis for formulating more precise and effective intervention measures to improve the KAP levels in patients with hepatitis B.

Methods

Study design and setting

This cross-sectional study was conducted between June and July 2023 in Xining City, Qinghai Province, China. A multistage sampling technique was used to select the samples. First, using convenience sampling, one infectious disease specialty hospital and one general hospital were selected in Qinghai Province. These are the Infectious Diseases Hospital of Qinghai Province (the 4th People’s Hospital of Qinghai Province) and the Qinghai Provincial People’s Hospital, which together handle the largest number of patients with hepatitis B in Qinghai Province. Second, all liver disease departments in the Infectious Diseases Hospital of Qinghai Province and the gastroenterology department in Qinghai Provincial People’s Hospital (departments that admitted patients with hepatitis B) were selected. Third, using cluster sampling, face-to-face interviews were conducted with all patients with hepatitis B who met the inclusion criteria in the selected department. The inclusion criteria for our survey participants were patients aged 15 years and above, patients with a confirmed diagnosis (HbsAg-positive) of hepatitis B, and patients who voluntarily agreed to participate in the survey. Patients with comorbidities, those from other provinces, and pregnant women were excluded [10].

The sample size was calculated using an online sample size calculator (http://www.raosoft.com/samplesize.html) [21]. The prevalence of HBV in China is 5–8% [22], and the prevalence rate in Qinghai Province is higher than the national average [19]. The sample size was estimated based on a population size exceeding 20,000 individuals, with a 95% confidence interval (CI), 5% margin of error, and 80% response distribution [21]. The sample size required for this study was 243 patients with hepatitis B. A total of 268 patients with hepatitis B from two hospitals were invited, and 263 (98.1%) returned the questionnaire. Five questionnaires were excluded because the patients withdrew midway, resulting in missing critical variables (knowledge, attitudes, and practice).

Study instruments

A self-designed questionnaire was developed based on a previously validated tool that was used to evaluate the KAP of patients with hepatitis B, according to a literature search [10, 23, 24]. A team comprising 15 experts in related disciplines (physicians who provided clinical care for patients with hepatitis B, staff members in charge of hepatitis B prevention and control at the Center for Disease Control and Prevention (CDC), researchers familiar with hepatitis B prevention and control, and health education in universities or research institutions) was invited to evaluate the questionnaire on its appropriateness, accuracy, and relevance, as well as to critically assess its content. To assess the degree of consistency among the various items within the measurement tool, we conducted a pilot survey using a convenience sampling method among 15 patients with hepatitis B and measured the Cronbach’s alpha coefficient, which was 0.80, suggesting a good degree of internal consistency. Data collected from the pilot questionnaires were excluded from the analysis. Cronbach’s alpha coefficient for this survey was 0.83.

The questionnaire comprised four parts (see Supplementary File): (1) Basic demographic characteristics and health-related behaviors of patients with hepatitis B, including sex, age, ethnicity, education level, region, monthly income per person, marital status, occupation, and possible disease duration (in years). (2) hepatitis B-related knowledge, with 21 items encompassing basic knowledge of hepatitis B, modes of transmission, symptoms, risks, and preventive measures. (3) Attitude towards hepatitis B, consisting of nine items that address attitudes towards hepatitis B vaccination, actions taken upon learning about HBV infection, etc. (4) Hepatitis B-related behaviors were made up of nine items inquiring about practices such as sharing toothbrushes or razors with family members, adhering to doctors’ instructions for timely check-ups, or regular medication.

Each correct KAP item was awarded one point, with incorrect answers receiving 0. Aggregate scores for each domain were calculated to determine the total KAP score. Adequate knowledge, positive attitude, and good practice were defined as scores at or above the median, whereas less knowledge, negative attitude, and poor practice were defined as scores below the median [25]. The scores ranged from 0 to 21 for knowledge, 0 to 9 for attitude, and 0 to 9 for practice. In this study, cutoff levels were set at 14 for knowledge, six for attitude, and six for practice to classify responses as adequate/positive/good or poor/negative/bad.

Statistical analysis

SPSS version 21 was used for data analysis. Descriptive statistics were used to illustrate participants’ demographic characteristics. Categorical variables are described as percentages. The variance inflation factor (VIF) is used to assess the extent of multicollinearity. In this study, all variables had a VIF value of less than 10, indicating that there was no significant multicollinearity. Multiple imputations using chained equations were performed to address missing data [26, 27]. Multivariate logistic regression analyses were used to identify factors influencing KAP in patients with hepatitis B infection. Odds ratios (ORs) were presented with 95%CI, and P < 0.05 was considered statistically significant.

Results

Participants’ characteristics of the study

Table 1 shows the distribution of sociodemographic characteristics. Among the 263 patients, 175 (66.5%) were men, 52.5% were over 50 years old, and 81.7% were married or cohabiting. Almost half of the patients had a junior high school or higher education level (49.0%), and more than half were ethnic minorities (56.3%). Of the participants, 38.4% were from cities, 32.7% were from pastoral areas, and they were mainly agro-pastoralists (62.7%). Of the participants, 52.1% had a monthly family income of < 3000 Chinese Yuan. 52.5% of participants had a history of hepatitis B for 10 years or more (Table 1).

Table 1.

Basic sociodemographic information of the participants (N = 263)

Characteristic	Categories	n	%
Sex	Male	175	66.5
	Female	88	33.5
Age, (years)	≤ 50	125	47.5
	> 50	138	52.5
Marital status	Married or cohabiting	215	81.7
	Single	48	18.3
Education level	Illiteracy and semiliterate	68	25.9
	Primary school	66	25.1
	Junior high school or higher	129	49.0
Ethnicity	Han	115	43.7
	Ethnic minorities	148	56.3
Region	City	101	38.4
	Agricultural area	60	22.8
	Pastoral area	86	32.7
	Missing data	16	6.1
Occupation	Others	98	37.3
	agro-pastoralist	165	62.7
Monthly income per person, (CNY)	< 3000	137	52.1
	3000–5000	61	23.2
	> 5000	65	24.7
Possible duration of disease, (years)	< 10	104	39.5
	≥ 10	138	52.5
	Missing data	21	8.0

CNY Chinese Yuan

Knowledge of HBV

Table 2 describes the current knowledge status of patients with HBV infection. Knowledge was assessed by asking questions about the signs and symptoms, transmission, and preventive measures against hepatitis B. The two questions with the highest accuracy rate of answers are “What is the most recognized mean of diagnosis for hepatitis B virus?” (87.1%) and “Do patients with hepatitis B need to quit drinking༟” (83.7%). Four questions with an answer accuracy rate below 50% were: “Hepatitis B can only be transmitted when symptoms are present” (36.5%), “Can hepatitis B be transmitted when you get your hair cut, ears pierced, or get a tattoo?” (40.3%), and “Can hepatitis B be transmitted through unprotected sex?” (40.7%), and “Pregnant women infected with hepatitis B can give birth to healthy babies” (41.8%). The rate of adequate knowledge was 51.3% (see Table 2).

Table 2.

Proportion of participants who provided correct answers for knowledge questions regarding hepatitis B (N = 263)

Questions		Correct answers	n	%
Basic knowledge about hepatitis B
K1	Can hepatitis B be transmitted?	Yes	150	57.0
K2	What is the most recognized mean of diagnosis for hepatitis B virus?	Blood tests	229	87.1
K3	What is the most important measure to prevent hepatitis B?	Hepatitis B vaccination	176	66.9
Symptoms and hazards
K4	Can hepatitis B affect liver function?	Yes	208	79.1
K5	Can hepatitis B cause cirrhosis or liver Cancer?	Yes	206	78.3
K6	Jaundice is one of the common symptoms of hepatitis B?	Yes	187	71.1
K7	Fatigue, nausea, and loss of appetite are common symptoms of hepatitis B	Yes	138	52.5
Transmission Routes
K8	Hepatitis B only be transmitted when symptoms are present	No	96	36.5
K9	Can hepatitis B be transmitted by contaminated blood and blood products?	Yes	181	68.8
K10	Can hepatitis B be transmitted when you get your hair cut, ears pierced, or get a tattoo.	Yes	106	40.3
K11	Can hepatitis B be transmitted through unprotected sex?	Yes	107	40.7
K12	Can hepatitis B be transmitted through from mother to child at birth?	Yes	151	57.4
K13	Can hepatitis B be transmitted through handshake、embrace, or kiss?	No	159	60.5
K14	Can hepatitis B be transmitted through sneezing or coughing?	No	152	57.8
K15	Can hepatitis B be transmitted by contaminated water/food prepared by person suffering with these infections?	No	133	50.6
K16	Can hepatitis B be transmitted by un-sterilized syringes, needles and surgical instruments?	Yes	173	65.8
Prevention Measures
K17	Do you think healthy individuals should be vaccinated against hepatitis B༟	Yes	209	79.5
K18	How many doses of the hepatitis B vaccine are usually required for the entire course?	3	134	51.0
K19	Hepatitis B vaccine is free for newborns in China	Yes	166	63.1
K20	Pregnant women infected with hepatitis B can give birth to healthy babies	Yes	110	41.8
K21	Does hepatitis B patients need to quit drinking༟	Yes	220	83.7
Adequate knowledge Rate	-	-	135	51.3

Attitude towards HBV

As shown in Table 3, each question was labeled with a positive or negative attitude. The two questions with the most positive attitudes are “What worries you most after you were diagnosed with hepatitis B?” (96.6%) and “Who did you talk to about your illness?” (95.8%). The three questions with the most negative attitudes are “When you had symptoms of hepatitis B, at what stage did you come to the health facility?” (14.8%). “Have you ever thought you could get hepatitis B?” (20.9%), and “What was your reaction when you found that you have hepatitis B?” (30.4%). The rate of positive attitude was 74.5% (Table 3).

Table 3.

Proportion of participants with positive/favorable attitudes towards hepatitis B (N = 263)

Questions		Answers	n	%
A1	Have you ever thought you could get Hepatitis B?	yes*	55	20.9
		no	208	79.1
A2	What was your reaction when you found that you have Hepatitis B?	Fear*	80	30.4
		Shame	16	6.1
		Surprise	71	27.0
		Sadness	96	36.5
A3	Who did you talk to about your illness?	Physician	142	54.0
		Spouse	69	26.2
		Parents	21	8.0
		Child	14	5.3
		Other relatives	6	2.3
		Friends	0	0.0
		No one#	11	4.2
A4	What did you do when you knew that you have symptoms of Hepatitis B?	Go to a regular hospital to see a specialist for reasonable treatment*	180	68.4
		Pay attention to roadside advertisements and seek treatment at private clinics	8	3.0
		Self-purchase of medication for treatment based on information in online media	13	4.9
		Failure to treat initially without symptoms	62	23.6
A5	When you had symptoms of Hepatitis B, at what stage you came to the health facility?	Own treatment fails	178	67.7
		After 3–4 weeks of the appearance of symptoms	46	17.5
		Soon as I realize the symptoms are of Hepatitis B*	39	14.8
A6	How expensive do you think is the diagnosis and treatment of Hepatitis B?	Free	26	9.9
		Reasonable	58	22.1
		Somewhat expensive	72	27.4
		Expensive	40	15.2
		Don’t know#	67	25.5
A7	What worries you most after you diagnosed with Hepatitis B	Fear of death	132	50.2
		Fear of disease spreading to family	68	25.9
		Cost of treatment	54	20.5
		Isolation from the society#	9	3.4
A8	Are you active in your treatment and visit the hospital regularly	Yes*	226	85.9
		No	37	14.1
A9	Will you persuade your family and friends to get hepatitis B vaccination?	Yes*	243	92.4
		No	6	2.3
		I’m indifferent	14	5.3
Positive attitude rate	-	-	196	74.5

*Positive attitude, #Negative attitude

Practice towards HBV

The results of the practices towards HBV are presented in Table 4. The four questions with the most correct responses were, “Do you share a toothbrush or razor with your family?” (91.6%), “Do you follow the doctor’s advice to take your medication regularly and on time?” (89.7%), “Do you follow the doctor’s instructions to go to the hospital for a check-up on time?” (89.7%) and “Do you refuse to interact with people because you have hepatitis B?” (88.6%). The three questions with the poorest behaviors were “Do you engage in unsafe sex?” (30.4%), “Do you ask for sterilized equipment or replace with a new one when required for ear piercing, tattooing, or eyebrow tattooing?” (39.5%), and “Have you ever participated in a health education program related to hepatitis B?” (55.9%). The rate of good practices was 67.3% (Table 4).

Table 4.

Proportion of participants for practice items on hepatitis B (N = 263)

	Questions	Answers	n	%
P1	Have you been transfused with blood products such as albumin and plasma?	Yes	78	29.7
		No*	185	70.3
P2	Have you ever received surgical treatment?	Yes	98	37.3
		No*	165	62.7
P3	Do you ask for sterilized equipment or replace it with a new one when required for ear piercing, tattooing, or eyebrow tattooing?	Yes*	104	39.5
		No	159	60.5
P4	Do you share a toothbrush or razor with your family?	Yes	22	8.4
		No*	241	91.6
P5	Do you refuse to interact with people because you have hepatitis B?	Yes	30	11.4
		No*	233	88.6
P6	Do you follow the doctor’s advice to take your medication regularly and on time?	Yes*	236	89.7
		No	27	10.3
P7	Do you follow the doctor’s instructions to go to the hospital for a check-up on time?	Yes*	236	89.7
		No	27	10.3
P8	Do you engage in unsafe sex?	Yes	183	69.6
		No*	80	30.4
P9	Have you ever participated in health education program related to hepatitis B?	Yes*	147	55.9
		No	116	44.1
Good practice Rate	-	-	177	67.3

*Good practice

Influencing factors of KAP of HBV

Table 5 shows OR for factors associated with KAP for HBV. The results of multivariate logistic regression analysis showed that educational level (junior high school or higher, OR = 0.10, 95%CI: 0.04–0.24) was associated with knowledge score; the result showed sex (female, OR = 0.46, 95%CI:0.23–0.93), educational level (junior high school or higher, OR = 0.35, 95%CI: 0.14–0.87), and possible duration of disease (≥ 10 years, OR = 2.49, 95%CI:1.30–4.77) were associated with attitude score; occupation (agro-pastoralist, OR = 2.28, 95%CI:1.06–4.92) was associated with practice score.

Table 5.

Analysis of factors associated with knowledge, attitudes, and practices regarding hepatitis B virus

Variables	Categories	Knowledge		Attitudes		Practices
		OR(95% CI)	P	OR(95% CI)	P	OR(95% CI)	P
Sex	Male(Ref.)
	Female	0.87(0.45–1.67)	0.67	0.46(0.23–0.93)	0.03	1.17(0.63–2.16)	0.63
Age	≤ 50(Ref.)
	> 50	1.61(0.85–3.05)	0.14	1.30(0.68–2.48)	0.43	1.12(0.62–2.03)	0.71
Region	City(Ref.)
	Agricultural area	0.87(0.37-2.00)	0.73	0.56(0.24–1.30)	0.18	0.65(0.30–1.43)	0.28
	Pastoral area	1.55(0.70–3.43)	0.28	0.967(0.44–2.11)	0.93	0.92(0.43–1.96)	0.82
Marital status	Married or cohabiting(Ref.)
	Single	1.64(0.74–3.61)	0.22	1.51(0.67–3.39)	0.32	0.92(0.43–1.96)	0.83
Ethnicity	Han(Ref.)
	Ethnic minorities	1.66(0.82–3.39)	0.16	1.48(0.70–3.12)	0.30	1.39(0.70–2.77)	0.35
Education level	Illiteracy and semiliterate(Ref.)
	Primary school	0.58(0.25–1.35)	0.20	1.03(0.47–2.27)	0.94	1.57(0.70–3.54)	0.27
	Junior high school or higher	0.10(0.04–0.24)	< 0.01	0.35(0.14–0.87)	0.02	1.97(0.83–4.64)	0.12
Occupation	Others(Ref.)
	agro-pastoralist	1.15(0.53–2.49)	0.72	1.23(0.55–2.77)	0.62	2.28(1.06–4.92)	0.04
Monthly income per person (CNY)	< 3000(Ref.)
	3000–5000	1.07(0.47–2.42)	0.87	0.81(0.33–1.96)	0.63	1.11(0.51–2.43)	0.80
	> 5000	0.55(0.20–1.49)	0.23	0.66(0.23–1.88)	0.44	0.77(0.29–2.037)	0.60
Possible duration of disease (years)	< 10(Ref.)
	≥ 10	0.83(0.45–1.52)	0.54	2.49(1.30–4.77)	0.01	1.08(0.59–1.96)	0.81

Abbreviations: OR Odds ratio, CI Confidence interval, Ref. Reference

Values in bold indicate statistically significant difference at P < 0.05

Discussion

The degree of patient knowledge about HBV is important for interrupting disease transmission and maintaining the health of the population. This study investigated the level of KAP and its influencing factors among patients with hepatitis B, providing a basis for proposing health education strategies to help patients form correct HBV prevention and control knowledge, strengthen health beliefs, and improve health behaviors.

Knowledge of HBV

In this survey, only 51.3% of the participants had adequate knowledge. Most patients with HBV infection in this study knew the most recognized diagnostic methods for HBV infection and the need to quit drinking. This is because they had already been diagnosed with hepatitis B and received medical treatment, so they had a preliminary understanding of hepatitis B. However, patients with hepatitis B have a low awareness of the transmission routes of the infection, which may reduce the overall level of hepatitis B knowledge among patients and easily lead to the spread of the virus. Patient knowledge of HBV is crucial because it helps detect and identify patients who need treatment [28] and reduces the spread of the virus. The low adequate knowledge rate of HBV may be due to low educational levels. In this study, only 49% of patients had a junior high school education or higher. In addition, Qinghai Province, characterized by a vast territory and sparse population, has a predominantly agricultural population with relatively backward economic and medical conditions, leading to low coverage of hepatitis B prevention and health education [29], which may impact the HBV knowledge level of patients.

Attitudes towards HBV

Although the rate of positive attitudes in this study was 74.5%, these attitudes still need to be improved. Our data showed that only 14.8% of individuals opted for prompt medical consultation, which may be attributed to the fact that nearly half of the patients perceived the cost of treatment to be high (42.6%). This is probably because although health insurance reimburses medical expenses, it still poses a significant financial burden on those who need long-term antiviral and other medications [30]. Of these patients, 67.7% indicated that they did not visit a health facility until their treatment failed. Owing to the relatively low level of health literacy among residents in Qinghai Province [31] or considerations of medical expenses, some patients may purchase medications for hepatitis B based on their judgment, and they regard seeking treatment at a formal hospital as a last resort. This result is in line with that reported in Pakistan [10]. A delay in seeking medical treatment leads to further deterioration of the condition and can cause the spread of infections to other healthy individuals. We also found that before being diagnosed with hepatitis B, the majority of patients believed that they could never be infected (79.1%). This may reflect a lack of knowledge among patients about the transmission routes of hepatitis B. If people do not have much understanding of the transmission routes of hepatitis B, they may not be able to accurately assess their own infection risk and, therefore, are unlikely to consider themselves susceptible to the disease. This cognitive deficiency may cause patients to neglect preventive measures in their daily lives, thereby increasing their risk of infection [32]. In this study, only 30.4% of the patients exhibited positive emotional reaction (fear), and 69.6% exhibited negative emotional reactions after diagnosis, such as shame, surprise, or sadness. This may be due to incorrect perceptions of hepatitis B, such as the stigma associated with being HBV-positive [33]. Fear is one of the basic emotions of human beings and helps humans avoid danger [34]. After being infected with hepatitis B, patients’ awareness of disease risks increases, which motivates them to actively seek medical assistance, learn about the disease, and take preventive measures to reduce the risk of the disease. In contrast, negative emotions, such as shame, surprise, and sadness, can plunge patients into negative moods, impair mental health, and hinder treatment [35, 36]. Therefore, a timely intervention is necessary.

Practice towards HBV

In this study, although the good practice rate was 67.3%, the accuracy rates of the three behaviors were low and needed improvement. First, 69.6% of the patients reported engaging in unsafe sexual behaviors, which is consistent with a previous study in Pakistan (60%) [10]. This phenomenon may be correlated with the low educational levels of patients with hepatitis B [37]. Second, only a small number of patients requested sterilized equipment or replaced it with a new one for ear piercing, tattooing, or eyebrow tattooing. This reflects poor practices among the participants and poses a danger to other healthy individuals in society. A study on the KAP of HBV among college students in Nepal showed that 87.3%–96.2% of the participants reported asking for a new blade for shaving or hair cutting, a new syringe for injection, and sterile equipment for ear and nose piercing [38]. This was because their study targeted medical students with educational backgrounds and basic medical skills that were broader than those of our population. Third, less than 60% of the patients (55.9%) had participated in health education programs related to HBV infection. This is likely because of Qinghai’s sprawling geography and limited health resources, which make health education less accessible to the populace [29].

Influencing Factors of KAP

The results of this study showed that junior high school or higher education was a protective factor for knowledge and attitudes toward HBV among patients with hepatitis B. The effect of education on HBV knowledge has been reported in previous studies [23, 39, 40]. Hepatitis B is a complex disease with variations in its natural history, progression, and clinical management. Individuals with low levels of education may have difficulty understanding and lack effective access to health information related to hepatitis B. Conversely, patients with higher education have greater access to information related to hepatitis B from various sources [25]. A previous study also found that people who are better educated are more concerned about their health [41]. Education equips individuals with the necessary knowledge and awareness so that they can make wise decisions about hepatitis B, take a positive attitude towards it, and make them aware of the importance of prevention, detection, and support [39].

In this study, females were more likely than males to have a positive attitude toward hepatitis B. One study reported that in China, women may experience more discrimination associated with HBV than men [42], which could result in women having a higher risk perception than men. Pregnancy contributes to the development of positive attitudes [43]. During pregnancy, through screening and participation in childhood hepatitis B vaccination programs, women have the opportunity to gain an in-depth understanding of the vast amount of information related to hepatitis B. This enhances their awareness about hepatitis B, improves their attitudes, and positively influences their behaviors. Therefore, women should adopt a more proactive attitude towards the prevention and treatment of hepatitis B. In addition, higher attitude scores among women may stem from their greater focus on health [44] coupled with the fact that women tend to exhibit healthier lifestyles than men [45]. Another reason for knowledge or influence on behavior is based on exposure or information on hepatitis B during pregnancy and testing and through the hepatitis B vaccination schedule for children.

The results of this study indicate that patients with a longer disease duration (over 10 years) were more likely to exhibit negative attitudes. Newly diagnosed patients with hepatitis B tend to be eager to acquire disease-related knowledge and self-care skills, thereby enhancing their sense of control over the disease and mitigating the intensity of negative emotions. However, as the disease progresses or deteriorates, it may lead to increased physical pain and financial stress, which can readily precipitate negative attitudes [46].

Our data also showed that agro-pastoralists were more likely to engage in poor practices. This may be related to the fact that they have long lived in farming and pastoral areas, where transportation is inconvenient, medical conditions are poor, health promotion is limited, and the living habits are unhealthy [47, 48].

Limitations

The study is not without its constraints. First, the data were self-reported, which may introduce recall bias, thereby affecting data accuracy. Second, this study, which was conducted in a hospital setting, may not be generalizable to a wider population of patients with hepatitis B residing in the community. Third, the cross-sectional design did not allow us to ascertain causality between KAP and its influencing factors. Fourth, the investigators were staff members of the CDC. There may be a distinction between their roles and those of physicians who primarily focus on treating illnesses in hospital settings, which may lead to a social likeability bias. Fifth, this study had a relatively small sample size. Although the findings provide valuable insights into KAP levels and influencing factors among patients with hepatitis B, the generalizability of these results may be limited due to the modest number of participants. Finally, the study participants were hospitalized patients with hepatitis B who may have had more severe conditions than those who were not hospitalized. Therefore, the generalizability of these results is limited.

Implications

Based on the findings of this study, the following suggestions are proposed to improve the KAP for HBV among patients with hepatitis B: (1) Comprehensive health education specifically tailored for patients with hepatitis B, particularly those with low educational levels, is of utmost importance. This education should emphasize in-depth knowledge dissemination on the various transmission routes of the virus. The focus should be on addressing patients’ concerns and alleviating them by providing clear information on blocking transmission and understanding the natural history of chronic HBV infection. (2) To improve the timely medical treatment rate and mental health of patients with hepatitis B, publicity efforts and psychological counseling are necessary. Special attention should be paid to male patients, those with low educational levels, and those who have been diagnosed with the disease for an extended period. Efforts should also address how to promptly diagnose and treat patients to further alleviate anxiety. (3) Effective intervention measures should be formulated to encourage healthy lifestyles in patients with hepatitis B. Strengthening the accessibility of health education activities is crucial, particularly for agro-pastoralists. These measures should not only focus on lifestyle changes but also continue to emphasize the importance of understanding HBV and seeking timely medical attention. (4) Raising disease awareness among patients with hepatitis B is an important and complex task that involves the shared responsibility of many parties, including government departments, public health agencies, medical professionals, the CDC, and educational organizations.

Conclusions

In this study, patients with hepatitis B had average knowledge, and most of them displayed a positive attitude, and good practices towards HBV. Hepatitis B patients with a junior high school education or above have better knowledge and attitudes towards HBV; female patients hold more positive attitudes towards HBV; patients with a longer possible duration of disease have more negative attitudes towards HBV; and patients who being a agro-pastoralist exhibit poorer behavior towards HBV. Targeted intervention measures based on KAP-influencing factors should focus on improving patients’ knowledge of HBV and on continuously enhancing patients’ positive attitudes and practices towards HBV. Early intervention is crucial for recently diagnosed patients with hepatitis B, such as educating patients about their disease and initiating therapy for those who are eligible to prevent fears or anxiety.

Abbreviations

CI

Confidence interval

CNY

Chinese Yuan

HBV

Hepatitis B virus

KAP

Knowledge, attitude, and practice

OR

oodds ratio

Ref

Reference

VIF

Variance inflation factor

Authors' contributions

ZL, CF, and KA contributed to the study design. ZL and YZ contributed to the data collection. ZL and CF contributed to the data analysis. ZL and CF wrote the main manuscript text. CF and ZL revised the manuscript. All authors read and approved the final manuscript.

Funding

This study is funded by the Chinese Foundation for Hepatitis Prevention and Control (YGFK20210044).

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to agreements with participants who restricted data sharing but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The Ethics Review Committee of Qinghai Provincial Center for Disease Control and Prevention approved the study protocol (No: 2023002). Patients were assured of the confidentiality of their responses. All subjects gave their informed consent for inclusion before participating in the survey. All methods in the present study were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.