Improving Knowledge for Healthcare Workers

The rate of mothers who knew about the benefits of HBV vaccination was over 75.4%, but only 39.0% of them knew about the benefits of TCMR, only 27.65% of mothers thought that TCMR could prevent the disease [13]. In the study by author Pham Thi Thanh Hang on 380 pregnant women and postpartum mothers in Quang Ninh and Hoa Binh in 2017, it was shown that only 10.8% of mothers answered correctly to all questions related to HBV transmission routes and preventive measures. Although 86.1% of participants believed that HBV vaccination was necessary for newborns, only 66.1% answered that they were definitely willing to take their children for vaccination within 24 hours [11].

Thus, it is necessary to strengthen public health education to improve knowledge about HBV among women of reproductive age, especially issues surrounding mother-to-child transmission of HBV and vaccine safety, to improve postnatal HBV vaccination and eliminate mother-to-child transmission [16].

Dr. Kidong Park - WHO Representative in Viet Nam on World Hepatitis Day (July 28, 2019) called on “Everyone to join in the fight against hepatitis. Make sure your children and other children in your community are fully vaccinated. Educate yourself and others about the risks of viral hepatitis and how to get tested.”

1.5.7. Improving knowledge for medical staff

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Prevention of mother-to-child transmission of HBV is essential to control the global HBV epidemic [133], and it is necessary to understand gaps in knowledge, attitudes, and practices regarding HBV transmission among healthcare workers (HCWs). Several studies have been conducted to assess knowledge, attitudes, and practices regarding HBV among HCWs, but they have focused primarily on clinical prevention practices in adults. We identified three studies that assessed nurses and obstetricians and their knowledge and practices regarding vertical transmission of HBV [134], [135], [136]. Qualitative interviews were conducted with 16 obstetricians and 17 perinatal nurses in Santa Clara, California, to explore

understand the gaps in knowledge about HBV and the lack of provision of information about HBV to HBsAg-positive pregnant women [134]. According to Yang EJ et al., most HCWs perceived their own ineffectiveness due to lack of training and updating of knowledge about HBV. In addition, some felt that counseling and educating their patients was unnecessary because they did not have time and were not paid for it. In particular, patients' unwelcoming attitudes toward viral hepatitis also influenced their failure to provide counseling on this issue. This indicates that gaps still exist in public hospitals and that policies and practices are needed to prevent perinatal HBV transmission through assessment of maternal and newborn medical records [133], [137]. The research group of author Stephanie D Chao conducted a cross-sectional study to assess the current level of knowledge related to HBV and clinical practice of prevention among perinatal nurses [135]. The results of the study showed that about a quarter of the nurses interviewed answered most of the questions correctly on prevalence, risks; Clinical symptoms of HBV and recommendations for prevention of transmission were often ignored. To date, in China, there have been only two studies evaluating the general knowledge and attitudes of healthcare workers towards HBV and primary hepatocellular carcinoma [135], [138].

Research results by author Y Chen et al. in 2018 to determine knowledge about prevention of mother-to-child transmission of HBV in over 900 health workers in Guangdong province. The questionnaire consists of 27 questions divided into 3 parts: general knowledge; awareness of measures to prevent mother-to-child transmission of HBV and practices to prevent mother-to-child transmission of HBV. The results show that most health workers have inadequate knowledge about mother-to-child transmission of HBV, especially nurses, those working in non-communicable disease departments and young health workers. Therefore, this group needs to be trained in a comprehensive and systematic way about mother-to-child transmission of HBV in particular and hepatitis.

viral hepatitis in general [138].

1.6. Reasons for choosing the research location

Hai Phong Obstetrics and Gynecology Hospital is a grade I specialized hospital in obstetrics and gynecology in Hai Phong. After more than 40 years of development, with a scale of more than 450 beds, in fact at the peak there were about 570 beds, 609 staff members, the hospital has been doing well in gynecological examination and treatment, reproductive support... with guaranteed quality. The hospital's doctors and nurses are all highly qualified and experienced, serving the examination and treatment in the best way.

According to statistics, the 2020 capacity of the Obstetrics Hospital is estimated to serve over 171,000 people for examination; treat over 80,000 outpatients; the total number of patients giving birth is about 15,000 people, of which over 8,000 are obstetric surgeries... Pregnant women who register for pregnancy management at the hospital are examined and screened prenatally from pregnancy until the end of pregnancy with advanced, modern techniques in prenatal diagnosis.

Currently, Hai Phong Obstetrics and Gynecology Hospital in particular and Obstetrics and Gynecology Hospitals in general in Hai Phong do not have a specific procedure for early screening for hepatitis B virus infection in pregnant women to have measures to prevent hepatitis B transmission from mother to child. Therefore, we chose to conduct this study to assess the current situation of HBV transmission from mother to child in pregnant women with chronic HBsAg positive and to evaluate the results of measures to prevent mother-child transmission at this research site.

Chapter 2: RESEARCH OBJECTS AND METHODS

2.1. Research subjects, locations and time

2.1.1. Research subjects

- Pregnant women living in Hai Phong came to Hai Phong Obstetrics and Gynecology Hospital for examination and pregnancy management from October 2017 to March 2018.

 Selection criteria:

 First month of pregnancy and have a pregnancy management plan at Hai Phong Obstetrics and Gynecology Hospital

 Agree to participate in the study

 Have a specific address (within 30km radius of city center)

 Exclusion criteria:

 Pregnant women with a history of preeclampsia, eclampsia, diabetes, severe anemia, liver failure, kidney failure during pregnancy or in a previous pregnancy.

 Have been treated with antiviral drugs.

- Children born to chronically HBsAg-positive mothers who agreed to participate in longitudinal follow-up from March to October 2019.

 Exclusion criteria: Children born to HBsAg-positive pregnant women with malformations, severe acute illnesses requiring oxygen therapy and intensive postnatal treatment.

- Medical staff in departments that have direct contact with pregnant women: Prenatal Diagnosis Department, Obstetrics Department and Laboratory Department

 Selection criteria: agree to participate in the study; no plans to change jobs within the next 12 months.

2.1.2. Research location

Hai Phong Obstetrics and Gynecology Hospital.

2.1.3. Research time

The study was conducted from October 2017 to January 2020.

2.2. Research method

2.2.1. Research design

The study was conducted in two component studies:

 Longitudinal study to assess the rate of mother-to-child HBV transmission in pregnant women with chronic HBV and related factors.

 Non-controlled pre-post comparative intervention study to evaluate the results of preventive intervention using health education communication for pregnant women with chronic HBV and health workers at Hai Phong Obstetrics and Gynecology Hospital.

The interventions included health education for pregnant women with chronic HBV infection on measures to prevent mother-to-child transmission of HBV and education for health workers in direct contact with pregnant women at Hai Phong Obstetrics and Gynecology Hospital on screening and management of HBV in pregnant women.

After the intervention period: The pregnant women group will be assessed for changes in their knowledge, attitudes about hepatitis B virus and their practices on measures to prevent transmission from mother to child during pregnancy and after birth to assess the results of the intervention. The health workers group of the Obstetrics and Gynecology Hospital will be re-assessed for changes in knowledge, attitudes, and practices about VGB in pregnant women to assess the results of the communication intervention.

Pregnancy 7 months 3/2018 – 8/2018

First month pregnant women (n=1721)

10/2017 – 3/2018

Testing

Pregnant women with chronic HBV (n=183)

Follow the classification groups according to Decision 5448- BYT

Indicated for prophylaxis of mother-to-child transmission (n=24)

Indicated for treatment of hepatitis B (n=9)

No treatment indication (n=150)

Maternal communication intervention

Assessment of knowledge and attitudes of pregnant women (n=183)

Consultation on treatment and prevention of hepatitis B transmission (n=33)

Pregnancy management and postpartum care consultation (n=150)

Born 7/2018 – 1/2019

Assessment of intrauterine HBV transmission rate (n=183)

6 months after birth

Maternal intervention evaluation

Maternal KAP Assessment VGBSS + HBIG Injection Assessment

(n=176)

NYYT KAP assessment before intervention (n=131)

Transmission intervention

medical staff

12 months postpartum

Assessment of mother-to-child HBV transmission rate (n=176)

1/2019 – 1/2020

(End of series)

KAP assessment of health workers after intervention

(n=131)

Figure 2.1. Research design diagram

2.2.2. Sample size and sampling technique

2.2.2.1. Sample size for longitudinal studies

Apply the sample size formula to estimate the proportion for a research population:

n= Z 2 1-α/2 .p(1-p)/(pε) 2

In there:

- p is the prevalence rate of HBV in pregnant women in Hai Phong, referring to the rate of pregnant women with chronic HBV in Hai Phong in 1994 which was 12.5% [17].

- α is the statistical significance level, chosen as 0.05; Z 1-α/2 = 1.96;

- ε is the relative error value, chosen to be 0.1.

Substituting the values into the above formula, the minimum sample size is calculated as: 1682 (to account for screening refusal, the study needs to recruit at least 1700 pregnant women for longitudinal follow-up). In fact, 1735 pregnant women came for examination and pregnancy management during the study period and 1721 (99.0%) pregnant women agreed to participate, so the sample size used for the study to evaluate the HBV transmission rate in pregnant women with chronic HBV is 1721 pregnant women.

2.2.2.2. Sample size for intervention studies

Pregnant women with chronic HBV:

To have a statistically significant difference between the rates of correct knowledge about VGB before and after the intervention in this study, we calculated the sample size according to data from studies around the world and in the region [11], [137], [139]. The rate of correct knowledge of pregnant women before the intervention was estimated to be 50%. The rate of correct knowledge of postpartum mothers after the intervention was estimated to be 75%.



Z 2 P (1 

1  / 2

P )

ZP (1 

1  

P )

1 2



P (1 

P )



( P P ) 2

1 2

n 

Apply the formula for calculating sample size to compare two proportions before and after:

In there:

- n: Sample size of the mothers' group

- P1= 0.75 ; P2 = 0.5

-  : Statistical significance level, is the probability of committing a type I error

-  : Is the probability of committing a type II error

- Z 1-  /2 : The confidence limit value, corresponding to the confidence coefficient (1-  ), depends on the selected value of  . Take Z 1-  /2 = 1.96 (corresponding to  = 0.05).

- Z 1- : The critical value corresponding to the research strength (1-  ), depends on the chosen value of  . Take Z 1- = 0.842 (corresponding to  = 0.2).

- With significance level p = 5%, power (sample power): 80%, two-sided test. After calculating the minimum sample size needed for the intervention study on mothers is 116.

In fact, before the intervention, we assessed the knowledge of 183 pregnant women with chronic HBV. After the intervention, we re-assessed 176 postpartum mothers. Thus, we compared the KAP on VGB of 176 mothers before and after the intervention.

Healthcare staff:

To have a statistically significant difference between the rates of correct knowledge about VGB before and after the intervention in this study, we calculated the sample size according to data from studies around the world and in the region [12], [138], [140], [141]. The rate of correct knowledge of health workers before the intervention was estimated to be 70%. The rate of correct knowledge of health workers after the intervention was estimated to be 90%.



Z 2 P (1 

1  / 2

P )

ZP (1 

1  

P )

1 2



P (1 

P )

