Prediction of Preventive Behaviors of Hepatitis B among Nurses; Insights from the Theory of Planned Behavior

Background Hepatitis B is the cause of the majority of acute and chronic infections, liver cirrhosis and liver cancer in the world. The purpose of current research was to investigation the hepatitis B (HB) preventive behaviors in nurses in west of Iran by using the theory of planned behavior (TPB). Methods This cross-sectional research was conducted on 330 nurses from ve teaching and treatment hospitals in Kermanshah who were randomly selected. Data were collected by self-report questionnaire. Data were analyzed in the SPSS-16 software by using bivariate correlation, t-test, ANOVA, and linear regression statistical tests. Results The mean score for the prevention behaviors of HB was 3.14± 1.45, and the participants achieved 62.8% of the maximum obtainable score for the prevention behaviors of HB. TPB constructs were accounted for 22% of the variation in prevention behaviors of HB, F= 42.351, P< 0.001 and among the TPB constructs, attitude and perceived behavior control were the most inuential predictors of doing prevention behaviors of HB. Conclusions This research provides a foundation for planning health promotion program to increase the prevention behaviors of HB. It seems our ndings are useful in planning health promotion programs aimed at increasing attitude and perceived behavior control to increase the prevention behaviors of HB.

predictors of doing prevention behaviors of HB. Conclusions This research provides a foundation for planning health promotion program to increase the prevention behaviors of HB. It seems our ndings are useful in planning health promotion programs aimed at increasing attitude and perceived behavior control to increase the prevention behaviors of HB.

Background
Hepatitis B (HB) is the second common cause of acute hepatitis and the HB virus (HBV) is the causes of cirrhosis and Hepatocellular carcinoma (1). In the world, about 360 million people are suffering from chronic HB infection, and near 90% of the carriers living in developing countries and more than 600,000 people die annually in the world (2). Iran is a country with a moderate prevalence of chronic infection of HB, and near 30% of the Iranian population have a history of HBV infection and about 1.5 to 2.5 percent of them are chronic carriers (3). HB is the most common occupational health problem in health care workers and its annual incidence in hospital staff is 0.1%, which is about ten times higher than in the normal population (4). The health care worker who deal with the blood and body uids of the infected patients are more at risk, and the risk is about 33% in injuries caused by shading and sharp objects (5).
HBV transmitted through coetaneous damage, contact with blood products, saliva, semen, tears and other contaminated infections of the body (6). Most cases of chronic HB are asymptomatic, and most people are not aware of their disease, therefore it's a silent epidemic (7). HB creates a huge nancial burden, but the infection can be prevented (8). According to the high prevalence, serious consequences and costs of disease, it seems that developing and implementing prevention programs are necessary (9).
The most important methods to the prevention of HB include; providing educating and vaccination the atrisk groups (10). Therefore, situation analyses and understanding the preventive behaviors of HB among the at-risk group are necessary for the starting of planning programs, and previous research indicated that the most effective programs are evidence and theory-based which rooted in behavior change science (11). In this regard, the theory of planned behavior (TPB) was used in behavior change analyses; this theory presented by Ajzen and Fishbein, and according to TPB, the primary determinant of behavior is behavioral intention, which expresses "the individual's motivation for adopting a behavior" and the behavior intention predicted by three determinants of 1) attitude 2) subjective norms; and 3) perceived behavioral control (12). The TPB has been used in many studies in various elds, such as prevention behaviors of HB (13)(14)(15)(16)(17)(18)(19)(20).
Therefore, considering the importance of understanding effective determinants in the adoption of preventive behaviors of HB in the development, implementation, and evaluation of preventive programs, the purpose of the current research was to investigate the HB preventive behaviors prediction in nurses based on TPB constructs.

Participants and procedure
This cross-sectional research was conducted on 330 nurses from ve teaching and treatment hospitals in Kermanshah who were randomly selected. Data were collected by self-report questionnaire. Considering the various hospitals (Imam Reza, Imam Ali, Imam Khomeini, Farabi, Taleghani) as clusters, samples were chosen randomly based on the probability proportional to the size of each cluster. The nurses who work in Kermanshah hospitals were eligible to participate in this study.

Measures
The data collection questionnaire consisted of three parts, which are described below. Five items were designed to measure attitude towards preventive behaviors of HB (e.g. "If I performed prevention behaviors of HB, it would help me to the prevention of HB"). Three items were designed for subjective norms towards preventive behaviors of HB (e.g. "If I performed prevention behaviors of HB, my family will con rm it."). Three items were designed to measure perceived behavior control regarding preventive behaviors of HB (e.g. "I believe that I can manage myself to performed preventive behaviors of HB"). The behavioral intention to preventive behaviors of HB was measured by ve items (e.g., I intend to uptake the HB vaccine). In order to facilitate participants' responses to the items, attitude, perceived behavior control, and behavior intention items were standardized to a ve-score Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Subjective norms items were standardized to a yes (1) or no (0) scale.
The third part included a question regarding the prevention behaviors of HB. To assess whether or not the nurses had performed HB preventive behaviors, we used their responses ve questions about the HB prevention behaviors, such as uptake HB vaccine, items were standardized to a yes (1) or no (0) scale.

Statistical Analysis
Data were analyzed in the SPSS-16 software by using bivariate correlation, t-test, ANOVA, and linear regression statistical tests. Cronbach's Alpha and split half was used to estimate the internal consistency of the various measures.

Results
The range of participant's age was from 20 to 58 years with the mean of 30.5 years [95% CI: 29.8, 31.3], ranged from 20 to 58 years. The mean job history of respondents was 79.91 months [95% CI: 72.29, 87.54], ranged from 2 to 360 month. More information towards the demographic characteristics and the association between demographic characteristics with prevention behaviors of HB are shown in Table 1. In addition, the prevention behaviors of HB score was 3.14±1.45, and the participants achieved 62.8% of the maximum obtainable score for the preventive behaviors of HB. Table 2 shows the mean (SD), range and correlations between TPB constructs and prevention behaviors of HB. Signi cance levels at the 0.01 and 0.05 were the criteria for the analysis. Table 3 shows 22% of the variation in the prevention behaviors of HB, F= 42.351, P< 0.001 was predicting by the TPB constructs. Moreover, among the TPB constructs: attitude and perceived behavior control were the most in uential predictors of doing prevention behaviors of HB. Table 4 has been shown the answer to the preventive behaviors of HB items among participants.

Discussion
The main aim of our research was to determine socio-cognitive determinants related to preventive behaviors of HB among nurses in the west of Iran based on TPB. Our ndings showed that positive attitude and perceived behavior control were the most in uential predictors of doing prevention behaviors of HB.
Based on our ndings among the background variables, positive history of HB in family, women gender and higher education level were signi cantly associated with performed prevention behaviors of HB. Moreover, our result indicated the 58.5% of nurses in this study had completed HB vaccination as the most important of the prevention behaviors of HB, which is similar to other studies in the eld investigating the HB vaccination status among healthcare workers (21,22).
The positive family history of HB was related to a performed higher score of preventive behaviors of HB. Consistent with the ndings of our study, the ndings of the studies by Adekanle et al carried out research on hospital workers in Ethiopia and indicated risk perception was the main determinant of HB preventive behaviors (23). In addition, Yousafzai et al in their study indicated perceived threat as the predictor of sharps injuries among health care workers (24). It seems participants who had a positive history of HB in the family, had a high level of perceived risk towards HB.
Another nding of our study indicated the score of preventive behaviors of HB among women was signi cantly much more than among men. These ndings suggested that men compared to women are more in need of getting information about the important role of preventive behaviors of HB.
Our study also showed that the preventive behaviors of HB were associated with higher education, which is in line with the ndings of earlier studies investigated the HB prevention behaviors among health care workers. For example, Karaivazoglou et al in their study among health care personnel in southwestern Greece indicated a positive association between HB vaccine acceptability and higher education level (25). In general, higher education level is the predictor of the probability of performing healthy behaviors (26). According to these ndings, it seems that particular attention must be paid to people with a lower education level while planning educational programs.
Several studies have shown that the TPB constructs can explain health behaviors such as preventive behaviors of HB (13)(14)(15)(16)(17)(18)(19)(20). In this regard, Askelson et al reported attitude was the best predictor of mothers' intentions to vaccinate their daughters of Papillomavirus (13). The signi cant role of attitudes has been cited in previous human HPV vaccine acceptability studies (18,20). Because of the importance of' healthcare workers attitudes on preventive behavior, further study should explore ways to in uence their attitudes.
As well as, our results showed that perceived behavioral control was a strong predictor for the prevention behaviors of HB. Several studies indicated perceived behavior control or self-e cacy as a strong predictor for explains healthy behaviors. For example, Kahn et al in their study reported the e cacy was the primary factor driving participants' decisions about recommending HPV vaccines (27). Moreover, Gerend et al carried out research among women ages 18-26 and reported self-e cacy as a key predictor of human HPV vaccine uptake (15). Also, Roberto et al indicated pediatricians have positive PBC toward encouraging parents to get their daughters vaccinated against HPV (17). These ndings provide a foundation for planning health promotion program targeting health care workers in doing the prevention behaviors of HB.
Finally, our ndings indicated TPB variables were statistically signi cant for predicting the prevention behaviors of HB which, they were accounted for 22% of the variation in the prevention behaviors of HB. In this regard, Juraskova et al indicated the TPB constructs predicted 54% of the variance in HPV vaccination intention (16). Moreover, Bennett et al carried out research in 143 women at a Midwestern university and indicated social-cognitive predictors including health belief model (HBM) and TPB constructs explained 60% of the human HPV vaccine in intentions (19).

Conclusion
This research provides a foundation for planning health promotion program to increase the prevention behaviors of HB. Further research should explore ways to in uence healthcare workers perceived behavior control and attitudes towards doing the prevention behaviors of HB.