Determinants of Overall Knowledge and Health Behaviors Towards Hepatitis B and C Among Ever- Married Women in Pakistan: Evidence Based on Demographic and Health Survey 2017–18


 Background: In 2019, around 5 million and 10 million people were affected by hepatitis B virus (HBV) and hepatitis C virus (HCV) respectively in Pakistan. On World Hepatitis Day 2019, Pakistan’s Government announced the Prime Minister’s Plan to eliminate HBV and HCV from the country by 2030. In order to achieve this goal, adequate knowledge about HBV and HCV regarding mode of transmission, symptoms of the disease, and awareness about available treatments and vaccines is imperative. The present study aims to investigate the determinants related to overall knowledge about and behaviour in relation to HBV and HCV amongst married women in Pakistan.Methods: Secondary data analysis was carried out using the Pakistan Demographic and Health Survey (PDHS) 2017–18. A series of questions regarding women’s knowledge about how to avoid HBV and HVC and their health behaviour in relation to HBV and HCV were posed to 12,364 ever-married women of reproductive age (15–49 years). Bivariate and multivariable logistic regression was applied to examine the effects of socio-demographic characteristics and covariates on women’s overall knowledge and health behaviour regarding HBV and HCV.Results: The findings highlight that the majority of women (88.3%) have heard of HBV and HCV. Nonetheless, only 34.8% had comprehensive knowledge about how to avoid HBV and HCV. Few women (11.3%) had been tested for HBV or HCV during the year preceding the survey. Furthermore, the results indicated that women from Sindh, living in urban areas, aged 35 years and over, having more than 10 years of schooling, belonging to the richest wealth quintile and working as professionals or in clerical/sales & service jobs reported better knowledge and health behaviours regarding HBV and HCV.Conclusion: This study provides evidence that women’s socio-demographic characteristics create differences in their overall knowledge about and attitudes towards HBV and HCV. This research emphasized that there is a need to create awareness about the causes and prevention of HBV and HCV in order to achieve the goal of eliminating these diseases in Pakistan by 2030.

cases of hepatitis B and C by 10% and 30%, respectively [2,5]. In addition to this, on World Hepatitis Day 2019, Pakistan's Government also announced the Prime Minister's Plan to eliminate HBV and HCV from the country by 2030. Through this plan, the federal government aims to facilitate provincial governments in providing leadership and coordination to scale up preventive, testing and treatment services for hepatitis [2].
Despite the governmental efforts and commitment, HBV and HCV are still serious public health challenges in Pakistan. Adequate knowledge about HBV and HCV, regarding mode of transmission, symptoms of disease and awareness about available treatments and vaccines is very important for encouraging a favourable attitude towards seeking treatment and avoiding the spread of infections [6,7]. A previous study conducted in Pakistan indicated that married women had poor and incorrect knowledge about the causes, prevention and treatment of HBV [8]. It is evident through research ndings that pregnant women are more at risk, if infected, of transmitting viral hepatitis B and C via sexual, vertical (mother to child during childbirth) and horizontal routes (e.g., blood transfusions and contaminated injections). Therefore, married women's knowledge about HBV and HCV is crucial for controlling the disease [9,10].
In light of the above context, there is a dire need for research to understand the determinants of overall knowledge about HBV and HCV among married women. Women who have adequate knowledge about the causes, prevention and treatment of HBV and HCV can be expected to take precautionary measures to avoid the spread of disease and to access treatment services. Previous studies suggest that, in Pakistan, hepatitis B patients lack information about attitudes and practices regarding the prevention of disease [6], and that women have less knowledge about HBV and HCV than men [11]. However, the ndings of a study conducted among medical students in Pakistan revealed that female students have more diagnostic knowledge about HBV and HCV than male students [12]. The ndings of another study with male respondents revealed that respondents have low levels of knowledge about HBV and HCV, which leads to unfavourable attitudes towards the practising of preventive measures [13].
The studies referred to above with reference to Pakistan were carried out with small sample sizes and lacked evidence of married women's knowledge and behaviour regarding HBV and HCV. Hence, the present study aims to bridge this research gap, based on a larger sample that is representative of the population of Pakistan. Its prime objective is to investigate various determinants affecting overall knowledge and behaviour relating to HBV and HCV amongst married women in Pakistan.

Theoretical framework
The theoretical foundation of this research draws upon knowledge, attitude, practice (KAP) theory, which combines aspects of knowledge, attitudes and practice [14], and the WHO's framework of social determinants of health [15].
The assumptions of KAP theory indicate that modi cations occur in the health behaviour of individuals after seeking health education and knowledge. It provides a rational model linking health education and behavioural changes [16]. The core postulate of KAP theory emphasizes three successive stages through which an individual's behaviour passes in order to adapt to changes. These stages are: acquisition of related knowledge, attitude modi cation and formation of behaviour. Furthermore, KAP theory postulates that acquiring su cient knowledge regarding symptoms, causes and ways to prevent disease inculcates positive attitudes among individuals about following preventive methods and seeking medical care. Several previous studies have reported that individuals' KAP level was signi cantly linked to addressing false perceptions, management of illness, seeking healthcare services and embracing disease-preventive behaviour [17][18][19][20][21].
Furthermore, the social determinants of the health framework emphasize the role of individuals' sociodemographic factors in determining their health. It indicates that individuals' health status may vary depending upon their sociodemographic characteristics [22]. The ndings of past studies indicate that low socioeconomic strata are linked with low levels of treatment compliance, the inaccessibility of healthcare facilities and insu cient ability to afford medical treatment [23][24][25][26]. The literature also reveals that gender, age, level of education and income affect an individual's knowledge and behaviour in terms of seeking good health [27,28].
Based on the postulates of KAP theory and the social determinants of health framework, this research explored the social factors linked to the knowledge and behaviour of ever-married women in Pakistan regarding HBV and HCV.

Study design
This research conducted secondary data analysis, using the fourth and latest Pakistan Demographic and Health Survey (PDHS) 2017-18. Currently, PDHS 2017-18 provides the largest national representative estimates of demographic and health indicators in Pakistan. Furthermore, it provides the largest dataset of variables related to HBV and HCV knowledge among the general population. PDHS 2017-18 is a cross-sectional survey, adopting a strati ed two-stage sample design. The strati cation was based on urban and rural areas, and a total of 16 strata were obtained, consisting of eight strata each for urban and rural areas. During the rst stage, 580 clusters consisting of enumeration blocks were selected, while in the second stage, 16,240 households (28 households per cluster) were selected, using a probability systematic selection process.
PDHS 2017-18 collected data on different types of questionnaires. In the present study, data obtained through the women's questionnaire was used. The women's questionnaire was administered to 12,364 ever-married women of reproductive age (15-49 years). This women's questionnaire included questions regarding women's knowledge and behaviour regarding hepatitis B and C.

Outcome variables
In this study, women's awareness, knowledge/health beliefs about HBV or HCV, and health behaviour are taken as outcome variables. Initially, women' awareness was explored, if they had ever heard of illnesses called HBV or HCV ("Yes"/"No"). Women who replied "yes" were asked further questions to inquire about their knowledge and health behaviour regarding HBV or HCV.
Women's overall knowledge or health beliefs about HBV or HCV was inferred from the following question: "Is there anything a person can do to avoid getting HBV or HCV?" ("Yes"/"No"/"Don't know"). Women who replied "yes" were further asked: "What can a person do to avoid getting HBV or HCV?" Possible responses to this question included six options: "practice safe sex", "safe blood transfer", "use disposable syringe", "avoid contaminated food/water", "avoid contact with infected person", and "ensure dentists' instruments properly sterilized". Respondents who replied correctly were coded as 1, while those who replied incorrectly or "don't know" were coded as 0. Hence, the score for women's knowledge about HBV or HCV ranged from 0 to 6. This score was dichotomized into no knowledge (score 0) vs. some knowledge (score 1-6).
Health behaviour was determined through the following question: 1) "Have you ever been tested for HBV or HCV?" ("Yes"/"No"). 2) Respondents who reported "yes" were asked about their recent test: "How many months ago was your most recent test for HBV or HCV?" ("Within the last year"/"More than one years ago").

Independent variables
In this study, women's healthcare decision-making autonomy, exposure to mass media to access information, health insurance coverage and the accessibility of distant healthcare facilities were taken as independent variables, which may in uence women's knowledge and behaviour about HBV or HCV.
Women's healthcare autonomy measures their overall contribution towards decisions about healthcare ("Who usually decides about your healthcare?"). Possible responses were: "respondent alone", "husband/partner alone", "respondent and husband/partner jointly", "respondent and other person", and "someone else or others". For this study, responses to the above question were dichotomized into one of two categories: whether the woman has "a say at all" (either alone or jointly with her husband/partner or jointly with another person) or whether she has "no say at all" (in cases where her husband/partner alone, someone else or others make the decisions). Exposure to mass media to access information measures the women's frequency of reading a newspaper, watching TV or listening to the radio, and was grouped into two categories ("Yes"/"No"). Furthermore, women were asked about health insurance coverage ("Yes"/"No") and the accessibility of distant healthcare facilities for seeking medical services ("big problem"/"not a big problem").
Statistical analysis SPSS version 21 was used for the data analysis. We applied sampling weights for all analyses. Descriptive statistics were employed for sociodemographic characteristics. Measures of women's awareness, overall knowledge and health behaviour regarding hepatitis B or C, women's healthcare decision-making autonomy, exposure to mass media and health insurance coverage were compiled in the form of frequencies and percentages. Multicollinearity between variables was examined using a variance in ation factor (VIF). However, no multicollinearity (VIF ≥ 10) was observed.
Bivariate and multivariable logistic regression models were applied to investigate the effect of sociodemographic characteristics and further independent variables on women's overall knowledge related to HBV and HCV. The results are presented as odds ratios (OR) and adjusted odds ratios (AOR) with 95% con dence intervals (CI). Table 1 describes the sociodemographic characteristics and covariates of the sample of 12,364 evermarried women. The majority resided in rural areas (63.2%) and belonged to the age group 25-34 years (40.1%). With reference to educational status, the majority of respondents (49.2%) had no formal schooling, while 21.2% had completed 6-10 years of schooling, and only 13.1% had attained more than 10 years of schooling. The majority of respondents (80.1%) were unemployed. Most of the respondents (66%) had access to mass media and half (50.5%) reported that they had autonomy in making healthcare decisions. Furthermore, a signi cant percentage (42.0%) of respondents reported that the accessibility of distant healthcare facilities for seeking medical services was a problem, and almost all respondents (98.6%) had no health insurance coverage. Awareness, overall knowledge and health behaviour

Sociodemographic characteristics and covariates
The majority of respondents (88.3%) were aware of HBV and HCV. With reference to women's knowledge of HBV and HCV, it was found that more than half of respondents (57.4%) were aware of various ways to avoid HBV and HCV. However, only some of the respondents (34.8%) were found to have comprehensive knowledge about how to avoid HBV and HCV (Table 2). Upon probing, the results showed that less than one-fth of women reported contaminated water and food (17.9%) or use of an infected syringe (12.8%) as the main risk factors for HBV and HCV. Furthermore, some of the women were also found to be aware of safe sex practices (6.8%), safe blood transfusion (9.4%), and refraining from contact with an infected person (7.9%) to avoid HBV and HCV (Fig. 1).

Bivariate and multivariable logistic regression
The results of the bivariate and multivariable logistic regression analysis of women's overall knowledge (Table 4) and health behaviour (Table 5) regarding HBV and HCV related to sociodemographic characteristics and covariates are presented below.  Furthermore, some of the women were also aware of safe sex practices, safe blood transfusions and avoiding contact with infected persons to avoid HBV and HCV. Since the reported percentage of women's awareness is low, these ndings highlight the importance of increasing awareness campaigns among the general public and to encourage people to go for testing in order to implement Pakistan's Government Plan to eliminate HBV and HCV by 2030 [2]. These ndings are in line with previous research conducted in Ethiopia, which reported that the majority of women had never been screened for HBV [29]. The ndings from a study in Ghana revealed that slightly fewer than half of the women surveyed reported knowledge about HBV [30]. Another small-scale study conducted in Pakistan reported that the majority of both men and women (75.4%) have poor knowledge regarding HBV and have never gone through HBV testing (96.9%) [6].
With reference to the association between women's overall knowledge and health behaviour regarding HBV and HCV and sociodemographic characteristics, the present study indicated that women living in urban areas, with higher age, better education, higher income and employed in the group of professional, clerical, sales & services reported better overall knowledge and health behaviour regarding HBV and HCV. These results are comparable with other studies carried out in Pakistan [11,31], India [32], Uganda [33] and Poland [34]. Furthermore, these ndings are also in line with the framework of social determinants of health, which emphasizes that an individual's socioeconomic position is (positively or negatively) associated with their knowledge and health behaviour [22].
In addition to sociodemographic factors, the ndings of this study revealed that exposure to mass media and autonomy to make decisions about personal healthcare were positively associated with good health behaviour related to HBV and HCV. These ndings are consistent with the results of previous studies conducted in Poland [34] and Pakistan [35], which highlighted women's autonomy and the positive effect of the media on knowledge and awareness about disease prevention. Here, it is also important to note that the media has two important responsibilities in order to play its part in disease prevention. Firstly, it is responsible for creating awareness regarding the causes of disease, available treatments and measures to prevent the disease. Secondly, it is responsible for countering infodemics by avoiding misinformation regarding any health-related issue [36].
Summing up, the ndings highlight the importance of obtaining accurate and comprehensive knowledge regarding the prevention and treatment of HBV and HCV. Regarding knowledge and awareness, it is important that reliable and valid knowledge is imparted to married women to bring about change in their attitudes and behaviour in relation to disease [37,38]. It is evident from various studies that accurate and reliable knowledge helps to reduce myths and doubts associated with HBV and HCV [39][40][41]. Similarly, reliable sources may be used to disseminate information and knowledge regarding HBV. This information may help in shaping and moulding the attitudes and behaviour of individuals. Therefore, suitable and effective health education programmes and behaviour-change strategies at a community level should be launched in order to reduce misconceptions and help women to access services.

Limitations
Despite the strengths of this study, such as the large sample size and nationally representative data, one needs to consider several limitations when interpreting the data. A major limitation is the fact that the analysis is based on secondary data, which does not include all the items relevant to a holistic view on the determinants of knowledge and behaviour related to HBV and HCV. Furthermore, the assessment does not distinguish between HBV and HCV and combines these two diseases. Additionally, it is a crosssectional design which does not allow for the investigation of causal relationships.

Conclusion
This study provides evidence that women's sociodemographic characteristics are associated with knowledge and behaviours relating to HBV and HCV. There is a need to create awareness about the causes and prevention of HBV and HCV among women residing in rural areas and having less education. In order to achieve the goal to eliminate HBV and HCV in Pakistan by 2030, the government needs to launch comprehensive media campaigns, particularly in rural areas, to provide adequate information about HBV and HCV regarding mode of transmission, symptoms of disease and awareness about available treatments and vaccines in order to inculcate favourable attitudes towards seeking treatment and to reduce the spread of infections.
Abbreviations AOR: Adjusted odds ratio CI: Con dence interval