Knowledge, Health Beliefs, and Self-efficacy Among Adult Patients with Hepatitis B

Wu. Knowledge, Health Beliefs, and Self-ef-ficacy Among Adult Patients with Hepati tis


Introduction
Hepatitis B is a major global public health problem. More than two billion people worldwide have been infected with hepatitis B virus, and more than 240 million have chronic hepatitis B [1]. In sub-Saharan Africa and East Asia, which have the highest prevalence of hepatitis B, an estimated 5%-10% of the adult population is chronically infected [1]. Hepatitis B contributes to approximately 30% of cirrhosis and 53% of hepatocellular carcinoma cases [2] as well as over 686,000 deaths every year [1]. Hepatitis B is endemic to Vietnam, where hepatitis B prevalence is 10% to 20% among the general population, higher than the prevalence in other countries [1,3]. Complications from hepatitis B, such as cirrhosis and liver cancer, were among the 10 leading causes of death in Vietnam in 2015 [4]. Moreover, the financial burden of treating chronic hepatitis B infection is relatively high in Vietnam. The cost of treating the chronic form of the disease was approximately US$450 per patient per year in 2008, which equals nearly 50% of the per capita gross domestic product of Vietnam [5].
Hepatitis B knowledge includes awareness of its ethology, signs and symptoms, transmission, treatment, and management [6].
Adequate knowledge regarding infection control and management among patients with hepatitis B can lead to positive attitudes and good practices in managing the disease and, in turn, help limit the spread of the infection to the community [6]. In one study, patients in pharmacies and emergency rooms with higher hepatitis B knowledge scores were more willing to accept hepatitis B testing [7]. Providing information onthe disease to patients with chronic hepatitis B contributes to improving self-efficacy and self-care performance [8]. Increased hepatitis B knowledge leads to more testing and vaccination as well as to improved practices in daily life and decreased hepatitis B infection rates. Moreover, higher levels of knowledge about the disease result in increased self-efficacy among patients to change their lifestyles in such a way that promotes their health [9,10].

ARTICLE INFO AbsTRACT
According to Wai et al. [11], health beliefs concerning hepatitis B among patients include patient perceptions of susceptibility to the disease, its severity, benefits of and barriers to taking action, and cues indicating when to take health action. Studies have reported that accurate health beliefs contribute to high rates of compliance with hepatitis B screening, vaccination, and preventive behaviours, thus decreasing the risk of infection and the overall incidence of the disease. In Iran, health care workers' perception of the risks related to hepatitis B and cues to take action motivated them to improve health care practices at work to reduce their own risk of infection [12]. Previous studies have suggested that enhancing knowledge and health beliefs regarding hepatitis B can convince more people to get vaccinated, promote preventive behaviours, and reduce the incidence of the disease, which in turns improve the health of individuals and society as a whole [13,14]. In Singapore, a study revealed that 44% of patients with chronic hepatitis B did not comply with hepatocellular carcinoma screening because of perceived barriers to action (waiting time for blood tests) and failed to remember the dates of follow-up visits [11].
Self-efficacy is a major determinant of health behaviour, as identified in the Health Belief Model created by Glanz, Rimer, and Viswanath (2008) [15]. Self-efficacyrefers to a person's confidence in their ability to successfully perform specific actions to achieve a goal [16]. The self-efficacy of patients with hepatitis B refers to their degree of confidence in adopting health behaviours related to medical instructions and medication adherence; managing symptoms and complications; exercising and resting; managing diet, health, and stress; and preventing disease transmission [8].
Previous studies in South Korea have reported that self-efficacy had a significant effect on the self-care performance and selfmanagement compliance of patients with chronic hepatitis B [8,17]. Similarly, a study conducted in the Netherlands observed that increasing self-efficacy contributed to reducing the level of depression and improving the health-related quality of life of patients with chronic liver disease [18]. Self-efficacy was associated with the willingness to modify personal lifestyle behaviours to protect one's health and prevent the further spread of the hepatitis B virus (Wang et al., 2009). In addition, numerous studies have reported that self-efficacy is significantly correlated with hepatitis B virus screening and vaccination [19,20]. Therefore, self-efficacy is considered a factor affecting self-care performance,

Study Design
The current study used a cross-sectional correlational design to measure three main variables, namely knowledge, health beliefs, and self-efficacy, among adult Vietnamese patients with hepatitis B and to explore the relationships among them.

Data Analysis
The researchers used SPSS version 20.0 for data entry and statistical analysis. The significance level of the statistical tests was set at α = .05. Descriptive statistics were used to analyse the demography, knowledge, health belief, and self-efficacy questionnaire responses, and the results were expressed by means, standard deviation (SD), frequency, and percentages. The relationship between demographic characteristics and self-efficacy, as well as the relationships among study variables, were examined using the independent-samples t test, ANOVA, and the Pearson product-moment correlation coefficient.    Note: *p < 0.05, **p < 0.05, ***p < 0.001, t = t-test, F = ANOVA, Post hoc (LSD).

Characteristics of the Study Sample
Participants diagnosed with hepatitis B 11-15 years before the study had better hepatitis B knowledge than did those diagnosed less than 1 year and 1-5 years ago. Similarly, participants who knew they had the disease for 6-10 years and those diagnosed more than 15 years ago had greater knowledge than did those diagnosed less than 1 year ago (Table 3).Participants who regularly exercise had better hepatitis B knowledge (t = 2.662, p = .009) and self-efficacy (t = 4.174, p < .001) than did those who do not exercise regularly.
Moreover, participants without any other personal habits included in the study exhibited higher self-efficacy (t = −2.354, p = .02) than did those with any other such habits. Regarding interactions between personal habit variables, participants who reported drinking, smoking, using illicit drugs, or sharing toothbrushes did not differ from participants who did not report such habits with respect to hepatitis B knowledge, health beliefs, and self-efficacy (Table 4). Note: *p < 0.05, **p < 0.01, ***p < 0.001, (2-tailed), t = t-test.

Relationship Among Hepatitis B Knowledge, Health Beliefs, and Self-Efficacy
Hepatitis B knowledge was positively correlated with health beliefs (r = .248, p < .01). However, no significant relationships were observed of hepatitis B knowledge and health beliefs with self-efficacy (Table 5). Note: **p <0.01.

State of Knowledge, Health Beliefs, and Self-Efficacy
The results of the present study revealed that, overall, participants possessed an adequate level of hepatitis B knowledge.

Vietnam differs Pakistan, where the Hepatitis B Knowledge
Questionnaire was first created and revealed that patients there had poor knowledge about their disease [6]. This difference may be explained by the fact that Vietnam is one of the countries with the highest prevalence of hepatitis B; therefore, knowledge about the disease is widespread. An explanation for the findings of this study might be that most participants in this study (87.7%) had been diagnosed as having hepatitis B more than 1 year before the study; participants with a longer duration since diagnosis have significantly higher knowledge scores.
In our Vietnamese study, the average health belief score was

Differences in Self-Efficacy in Relation to Demographic Characteristics
Inthe present study, self-efficacy differed significantly in modifying their lifestyles [26]. Similarly, a study conducted in Vancouver, Canada, on people living with HIV/AIDS who used illicit drugs demonstrated that older age was linked to greater selfefficacy regarding the ability to adhere to antiretroviral treatment [27].
The present study revealed that marital status was related to self-efficacy. Married participants scored significantly higher in self-efficacy than single participants. This finding is similar to the results of a study on people with scleroderma that demonstrated that overall self-efficacy was significantly correlated with marital status [28]. Moreover, a cross-sectional study that measured the self-efficacy in accessing hepatitis B screening and vaccination among Chinese immigrants in New York City indicated that when participants were advised to do these things by their spouses, they exhibited greater self-efficacy and were much more likely to undergo the screening [20].The present study revealed that participants with a habit of exercising had more self-efficacy. This finding was consistent with the aforementioned Nigerian study on patients with chronic diseases, in which exercise was positively and significantly correlated with self-efficacy [26]. Similarly, a cross-sectional study conducted on patients with chronic illnesses attending government health care centers in Iran demonstrated a significant relationship between self-efficacy and physical activity [29].  [32]. Similarly, a study conducted in Australia on adolescents with cystic fibrosis indicated no significant correlation between disease knowledge and general Self-Efficacy Scale scores [33].

Relationship among Knowledge, Health Beliefs, and Self-Efficacy
Our study did not detect the expected association between knowledge and self-efficacy, possibly because the average self-  [34].
The present study demonstrated no significant relationship between accurate health beliefs and participants' self-efficacy.
However, this finding differs from the research from other countries on hepatitis B, which has focused on the relationships between participants' self-efficacy and each component of the Health Belief Model. Raoofi et al. [13]indicated a significant and direct correlation between self-efficacy and perceived severity of hepatitis B infection, perceived benefit of hepatitis B vaccination, and perceived barriers to receiving hepatitis B vaccination in women in Iran [13]. Similarly, a study by Slonim et al. [35]in the United States reported a low selfefficacy among adolescents who exhibited low levels of perceived susceptibility, severity, and response efficacy related to hepatitis B and the hepatitis B vaccine [35].