Abstract
Objective
We aimed to describe the knowledge, attitude and practice (KAP) status of hepatitis B virus (HBV) among freshmen who were in the class of 2020 and from Jiangsu Province.
Methods
A random multistage sampling had been used to screen freshmen to conduct online questionnaire. The chi-square test was applied for pairwise comparison between sub-groups. Lasso regression and logistic regression were used to analyze the influencing factors of KAP about HBV. A structural equation model was established to explore the relationships among KAP of HBV.
Results
The total awareness rate of HBV among freshmen was 63.1%. More than 50% of freshmen reported that they were not willing to live with hepatitis B carriers. Only 51.0% of students had been immunized against HBV. The knowledge of HBV among students whose fathers had college/bachelor degree or above was 1.464 times higher than those whose fathers’ education level was junior high school or below (95% CI = 1.277~1.677). Both of positive attitude and behavior among female students were 1.424 times (95% CI = 1.329~1.525) and 1.468 times (95% CI = 1.291~1.669) than that within male students, respectively. The positive behaviors of students whose mothers had college education or above were 1.347 times higher than those whose mothers had the degree of junior high or below (95% CI = 1.147~1.582). Students who living with their parents were 1.167 times likely to have positive behaviors than those who living in other methods (95% CI = 1.020~1.334). The structural equation model had shown that the direct effect of knowledge on preventive motivation, attitude and behavior was 0.28, 0.53 and 0.10, respectively.
Conclusion
The population of freshmen still was far from a comprehensive understanding of HBV prevention and treatment. It is suggested that administrators of colleges and universities should pay more attentions to education of HBV knowledge as well as take multi-channel measures for prevention and management.
Introduction
As a kind of hepatotropic virus, Hepatitis B virus (HBV) can establish persistent and chronic infection among human race. In fact, it is a partially double-stranded hepatotropic DNA virusCitation1. Chronic HBV infection had become one of primary social public health problems that could develop into recessive condition. Among some of carriers, the virus would rise the risk of cirrhosis and cancer in the liver, which eventually lead to deathCitation2. The transmission route of HBV primarily are blood and bodily fluids, including perinatal transmission and mother-to-child transmission (MTCT) which as same as sexual and parenteral modes. Various types of molecular biological tools can be used to detect and quantify viral genomic components and analyze the sequences of HBV.Citation3,Citation4 At present, despite using vaccines as well as effective and well-tolerated viral suppressive medications, more than 250 million people are still infected with HBV worldwide.Citation5 There are about 1.5 million new infections each year, and HBV had caused an estimated 820,000 deaths in 2019.Citation6
Currently, the rights and interests of HBV infected patients in the way of further education, employment,Citation7 and marriage are still seriously affected.Citation8 It is still one of the most significant global public health issues which deserve far more attentions.Citation9 In fact, China has a high incidence of HBV.Citation10 Previous studies had reported the incidence rate of spontaneous HBsAg among chronic infections remained between 0.5% and 1.4% annually.Citation11 Regarding the transmission routes of HBV, students are an exposed population because of multiple risky behaviors.Citation12 One meta-analysis about HBV of college freshmen in China, mainland had shown that the total positive rate of surface antigen (HBsAg) was 7.0%,Citation13 and the anti-HBs positive rate of college freshmen was low.Citation14 Today, we are faced with a serious situation due to high population density and high mobility in these gathering places for students to study and live. Nevertheless, for most of students who just register in the university, their current knowledge mainly comes from middle and high school education which lack basic information of diseases, awareness of self-management and protection. These factors made them become a high-risk target population of hepatitis B without a hitch.
Although HBV can lead to a huge burden of disease, especially in endemic areas, it is preventable, and prevention is the only safe and cost-effective strategy against HBV. Sufficient knowledge and appropriate awareness of HBV infections is the key to preventing the spread of the virus.Citation15 The purpose of this study is to determine the level of KAP towards HBV among college and university freshmen in Jiangsu Province, China, so as to provide targeted suggestions and scientific references for future prevention and control of HBV among certain population.
Methods
Ethics Approval and Consent to Participate
This study had been reviewed and approved by the Human Research Ethics Committee of the Zhongda hospital affiliated Southeast University, China (approval ID: 2017ZDKYSB045). All participating subjects had received written detailed information on the study, and signed consent forms for the interview and the processing of sensitive personal data. For participants who were under 18 years old, parental informed consent was required to be obtained. The procedure of the study had been performed following the guidelines outlined in the Declaration of Helsinki.
Respondent
Freshmen who were in the class of 2020 are considered as research respondents. Totally, 12 of undergraduate universities/colleges in Jiangsu Province had been selected by stratified cluster random sampling, 11–14 classes had been randomly selected from each university/college, and 32–36 of students had been randomly selected from each class as well. A total of 5346 undergraduate students had been selected in the study. We had used a flow chart to describe the selection of respondents,Citation16 as it is shown in .
Figure 1 Flowchart of study participants.
Survey’s Content and Method
“Propagandist Education Points of Knowledge for Hepatitis B Prevention and Control” and “Guidelines for the Chronic Hepatitis B Prevention and Control 2019” had been used as reference for the design of this questionnaire. The contents of the questionnaire include (1) General demographic baseline data; (2) Hepatitis B prevention and treatment knowledge; (3) Hepatitis B prevention and treatment attitudes, motivations and behaviors. The survey had been carried out online via Jiangsu University Freshman Health Data Management System. School counselors and professionals from health department in each university had served as quality control officers, and they had organized students who were involved in the study to complete the questionnaire in the computer lab anonymously.
Statistical Methods
A total of 5346 students had been investigated, and 216 invalid questionnaires had been eliminated. The response rate of the survey was nearly 96%. Data processing and analysis had used IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL), measurement data of normal distribution were represented by mean ± standard deviation, and enumeration data had shown in frequency. The chi-square split test had been applied for comparing different groups when (α=0.05). The “dplyr”, “stringr”, and “tidyr” software packages of R 4.0.2 software had been applied for dividing multiple-choice questions. Due to the large sample size and a larger number of independent variables, by the principle of simplifying model and avoiding over-fitting, firstly, Lasso regression had been used to strictly screen independent variables, and then the Logistic regression model had been constructed for multi-factor analysis. SPSS AMOS 25.0 had been applied for building a structural equation model.
Results
General Demographic Data
Among a total of 5130 respondents, there are 2491 of males (48.6%) and the average age is 18±0.6 years old. More than 70% of students are 18 years old or under, 2719 of students (53.0%) are from urban regions, 1580 (30.8%) of them from towns, and 831 of students (16.2%) are from rural regions. Nearly 64.1% (3287/5130) of them are the only child in their families, and 2842 (55.4%) of students are currently living with their parents.
Knowledge Status of Hepatitis B Prevention and Treatment
Catalogue Selection
In single-choice questions, “Vaccination can effectively prevent hepatitis B” had the highest accuracy (95.0%); “Infect with hepatitis B is predisposed to cirrhosis or liver cancer” has shown 75.9% accurate, and “Will you still be infected with hepatitis B after vaccination?” has the lowest accuracy (39.5%). “The routes of transmission of hepatitis B” is a multiple-choice question that Cochran’s Q value is 9619.2, P < 0.001, which could point out the difference was statistically significant. Totally 8 options had different numbers: “Injected drug use” (20.3%) remaind the highest probability of being chosen, “Hugs and handshake” (2.1%) had the least selectivity. It is judged that this question had been answered correctly by choosing all 4 options, including unprotected sex, drug injection, tooth extraction, and tattooing/piercing at the same time.
Selection of Lasso Regression Variable and the Construction of Logistic Regression Model
Participants who had correctly answered 4 or more questions about hepatitis B prevention and treatment knowledge could be considered as aware respondents, and the number of aware participants is 3235 (63.1%). Knowledge awareness had been taken as dependent variable, and general demographic characteristics had been selected as independent variable to perform the Lasso regression analysis. To begin with, invoking the “glmnet” program package in the R software, and selecting the family = “binomial” model parameter. had shown that with λ increasing, the variable coefficients had continued to decrease. Secondly, the optimal harmonic parameter λ had been selected through cross-validation. In this case, lambda.min had been selected with a value of 0.005, as it had been shown in . Lastly, by plugging optimal parameter values into the model, a total of 6 optimal independent variables had been screened out in . The logistic regression model is further constructed with the 6 of selected independent variables. It is concluded that the awareness of hepatitis B knowledge among students whose fathers had achieved college/bachelor or higher was 1.464 times than these students whose fathers had the highest degree of junior high school or below (95% CI = 1.277~1.677). See .
Table 1 Results of Lasso Variable Screening
Table 2 Logistic Regression Results of Hepatitis B Knowledge
Figure 2 Dynamic process of Lasso screening knowledge variable.
Figure 3 The plug process of the optimal parameter λ.
Attitudes and Practice/Behaviors Related to HBV
Among the total of 5130 respondents, 38.46% of students had minded associating with hepatitis B carriers, and 58.7% of them did not want to live with hepatitis B carriers. Most of students (96.2%) think it is necessary to take detection of hepatitis B antibody before marriage, but only 51.0% and 28.5% of students had confirmed they had been vaccinated against hepatitis B and had completed hepatitis B blood test. Taking attitude (positive = 1, negative = 0) and behavior (positive = 1, negative = 0) as binary variables, single-factor analysis had shown there were statistical differences in attitudes between genders (χ2=18.94, P < 0.05). In addition, there were statistically significant differences in behaviors between genders, place of residence, parents’ education level, parents’ occupations and living styles as well (P < 0.05). See .
Table 3 Single-Factor Analysis of Positive Behaviors of Hepatitis B Among University and College Freshmen with Different Demographic Characteristics
After accurately screening the variables by Lasso regression, Logistic regression had been constructed by considering attitude and behavior as the dependent variables. According to the outcomes, the positive attitudes and positive behaviors of female students were 1.424 times (95% CI = 1.329~1.525) and 1.468 times (95% CI = 1.291~1.669) than that of male students’, the positive behaviors of students whose mothers had graduated from college/undergraduate or above are 1.347 times than that of whose mothers had only completed junior high school or below (95% CI = 1.147~1.582), and positive behaviors of students who were currently living with their parents were 1.167 times (95% CI = 1.020~1.334) comparing with other living styles. See .
Table 4 Logistic Regression Results of Hepatitis B-Related Attitudes and Behaviors
The Relationship Between Knowledge, Attitude and Practice/Behavior of Hepatitis B Prevention
During the exploratory analysis in this study, latent variable of prevention motivation has been included, and a structural equation model had been constructed together with all three latent variables of knowledge, attitude and behavior which are shown in . According to the value of correction index MI, one correction for the model had been proceeded, and the path: had been increased as well. In the case of large sample size, the revised model CMIN/DF=9.35 had required to combine with other indicators in order to investigate the model fitting effect. In addition to the above indicators, RMSEA=0.04 (<0.05), GFI, AGFI, IFI, CFI were 0.99, 0.98, 0.94, 0.94 (all >0.90) respectively, which had indicated that the constructed structural equation model might be better. Model path analysis had shown that the direct effects of knowledge on prevention motivation, attitude and behavior were 0.28, 0.53, and 0.10, respectively, which had provided reliable evidence that could prove knowledge was the main influencing factor of prevention motivation, attitude, and behavior. See and .
Table 5 Latent Variable and Observation Variable Assignment
Table 6 Model Results of Each Path
Figure 4 Schematic diagram of structural equation model.
Discussion
The results of our study had shown that freshmen who were from university and college in Jiangsu province had far less knowledge of HBV prevention and treatment. Although as the susceptible population to HBV,Citation17 they had not given rise to high attentions yet. The awareness rate of the questions “hepatitis B vaccination effect” (39.5%) and “whether HBV could be cured” (59.5%) had both remained in low-grade, and the percentage of students who had correctly answered all transmission routes of hepatitis B virus was only 4.7%. Our study had indicated that lack of awareness about HBV among students, which was in agreement with some other studies in this field,Citation18–20 This had reflected publicity may not be enough as well as incomplete promotions for HBV prevention and treatment among college and university freshmen. Due to the outcomes, it should bring more attentions among administrators of schools and directors of local health departments.
Over half of them would not like to live in the same dormitory with HBV carriers (58.7%). This is contrary to other research findings,Citation21 which had shown that students had negative attitudes towards people living with HBV. The discrimination is more serious than we ever imagined.Citation22 It also had reflected a lack of knowledge about transmission of HBV. By having sufficient knowledge and a positive attitude towards HBV infection, people may reduce stigma and discrimination against HBV.Citation23 It requires schools to promptly provide positive guidance, increase efforts to conduct peer education, and promotes relevant knowledge of HBV transmission pathways to create an equal and harmonious campus environment for HBV carriers.
As a vaccine-preventable disease, vaccinate is cost-effective in reducing the burden of HBV among high-risk and high-prevalence populations.Citation24 This study had revealed that the most of respondents had an appropriate knowledge on vaccination can effectively prevent hepatitis B, despite this awareness only 51.0% of respondents had confirmed that had been received a full-dose of the HBV vaccine, the vaccine coverage was higher than previous studies.Citation25,Citation26 However, the vaccination rate is much lower than the requirement of “China Viral Hepatitis Prevention and Control Program (2017–2020)”,Citation27 which makes them vulnerable to hepatitis B. Obviously, it warns the ministry of health to formulate and implement relevant policies as soon as possible to improve HBV vaccination progress for improving students’ knowledge of HBV vaccinations.Citation28 Moreover, it is necessary to streamline vaccination programs in colleges and universities in order to provide certifications of vaccination for students at the time of admission. Besides, to encourage non-vaccinated students to receive HBV vaccinationCitation29 and ensure availability and accessibility of the vaccine to studentsCitation30 are still important as well.
Compared with traditional chi-square analysis and other methods, Lasso regression would be easier to produce a sparse model by adjusting the value of penalty parameter within parameter estimation.Citation31 In addition, it also could simultaneously achieve dimension reduction process and optimal selection of variables. It is often used to deal with a large number of independent variables in general cases to avoid model over-fitting. Therefore, this study had adopted Lasso regression to strictly screen independent variables and then constructed the Logistic regression model. The results had shown that females, parents with high education and students who were living with their parents had produced better knowledge, attitudes and behaviors. This may be because females are more likely to be concerned about the accumulation of knowledge and their health than males, similar findings had been reported VietnamCitation32 and Saudi Arabia,Citation18 while this is contrary to other research findings.Citation33 Higher level of parents’ education lead to higher degree of children’s health literacy by playing as examples for their children.Citation34 This finding had supported that of Mora and Trapero in SpainCitation35 and Balegha et al in Ghana.Citation33 This finding had also been explainable that highly educated parents had greater access and understanding of hepatitis B infection prevention, and had been more willing to pay for hepatitis B infection preventive services, such as hepatitis B screening, vaccination.Citation33 During this period, living with parents had made students get parents’ cares and education fully and timely. In general, these factors had played a positive role together in HBV prevention and treatment.
Finally, the structural equation model had concluded that the awareness of hepatitis B knowledge had a significant positive effect on prevention motivation (0.28), attitude (0.53) and behavior (0.10), which means by popularizing and propagating hepatitis B knowledge. It could correct their discriminatory attitude towards hepatitis B virus carriers. It is significant for them to form early prevention awareness and produce positive behaviors such as voluntary vaccination and hepatitis B detection to reduce infection rate and morbidity of hepatitis B.Citation19 This is similar to the study conclusion of previous studies.Citation36,Citation37 This study had involved prevention motivation as latent variable in the process of building the model, unlike the traditional “knowledge, attitude and practice” model. With certain latent variables increased, it would optimize evaluative indicators of the model. This also reminds us that while paying attention to the relationship between “knowledge, attitude and practice” in future health education work, we should emphasize the formation of prevention motivation and its important role. On the other hand, for continuing to explore the relationship between attitudes and behaviors, it is necessary to involve more diseases attitude other than discrimination during questionnaire design stage in the future as well as comprehensively consider the process of behavior dynamic development so that we could be able to achieve in-depth information of attitudes and behaviors.
Conclusion
In summary, due to a lack of precise KAP about hepatitis B in freshmen who were from colleges and universities in Jiangsu, the work of health education of HBV requires to be further strengthened among this certain population. In addition, administrators of colleges and universities should focus on promotion and education of vulnerable knowledge spots and promptly publicize certain national policies and regulations toward HBV in order to carry out prevention and health education via multiple ways. Remarkably, it is also recommended that to take an initiative in hepatitis B screening for freshmen and provide gratis HBV vaccination to all the students who had incompletely vaccinated or non-vaccinated. This strategy would achieve great significance for increasing the inoculation rate of hepatitis B vaccine.
Limitations of the Study
There are several limitations in our study. Firstly, the information had been collected by using a self-administered questionnaire. Secondly, the honesty and seriousness of the respondents to the questions were difficult to access and validate. Thirdly, we had not investigated the education level of students in high schools. However, we believed that the region of students can reflect the education level within high schools, and the education level of high school in urban areas is usually higher than that in rural areas.
Data Sharing Statement
The datasets analyzed in this study are available from the corresponding author Pingmin Wei ([email protected]) after co-authors’ approval of the request.
Disclosure
The authors declare that they have no competing interests.
Acknowledgment
We thank the freshmen who participated in this research.
Additional information
Funding
References
- Yuen MF, Chen DS, Dusheiko GM, et al. Hepatitis B virus infection. Nat Rev Dis Primers. 2018;4(1):18035. doi:10.1038/nrdp.2018.35
- Shih C, Yang CC, Choijilsuren G, Chang CH, Liou AT. Hepatitis B virus. Trends Microbiol. 2018;26(4):386–387. doi:10.1016/j.tim.2018.01.009
- Behzadi P, Ranjbar R, Alavian SM. Nucleic acid-based approaches for detection of viral hepatitis. Jundishapur J Microbiol. 2015;8(1):e17449. doi:10.5812/jjm.17449
- Behzadi P, Behzadi E, Alavian SM. DNA microarray technology in HBV genotyping. Minerva Med. 2017;108(5):473–476. doi:10.23736/S0026-4806.17.05059-5
- Nguyen MH, Wong G, Gane E, Kao JH, Dusheiko G. Hepatitis B virus: advances in prevention, diagnosis, and therapy. Clin Microbiol Rev. 2020;33(2). doi:10.1128/CMR.00046-19
- World Health Organization. Hepatitis B; 2021. Available from: https://www.who.int/news-room/fact-sheets/detail/hepatitis-b. Accessed June 9, 2022.
- Oka T, Enoki H, Tokimoto Y, et al. Employment-related difficulties and distressed living condition in patients with hepatitis B virus: a qualitative and quantitative study. BMC Public Health. 2017;17(1):568. doi:10.1186/s12889-017-4416-3
- Smith-Palmer J, Cerri K, Sbarigia U, et al. Impact of stigma on people living with chronic hepatitis B. Patient Relat Outcome Meas. 2020;11:95–107. doi:10.2147/PROM.S226936
- Valizadeh L, Zamanzadeh V, Bayani M, Zabihi A. The social stigma experience in patients with hepatitis B infection: a qualitative study. Gastroenterol Nurs. 2017;40(2):143–150. doi:10.1097/SGA.0000000000000223
- Tao J, Zhang W, Yue H, et al. Prevalence of hepatitis B virus infection in Shenzhen, China, 2015–2018. Sci Rep. 2019;9(1):13948. doi:10.1038/s41598-019-50173-5
- Hu H, Shen Y, Hu M, Zheng Y, Xu K, Li L. Incidence and influencing factors of new hepatitis b infections and spontaneous clearance: a large-scale, community-based study in China. Front Med. 2021;8:717667. doi:10.3389/fmed.2021.717667
- Bentouhami MR, Chakib A, El Fane M. Hepatitis B knowledge, attitudes and practices among Moroccan college students. Rev Epidemiol Sante Publique. 2019;67(6):397–402. doi:10.1016/j.respe.2019.06.002
- Zhao R, Liu Q, Zhuang GH. A meta-analysis of the test results of five indicators for hepatitis B virus of college freshmen in current mainland China. Chin J Prev Med. 2018;52(8):849–854.
- Xu Y, Liu Y, Wang J, et al. Hepatitis B virus infection seromarkers among college freshmen and their immune responses to different vaccination policies of hepatitis B vaccine. Hum Vaccin Immunother. 2021;17:1–8.
- Dehghani B, Dehghani A, Sarvari J. Knowledge and awareness regarding hepatitis B, hepatitis C, and human immunodeficiency viruses among college students: a report from Iran. Int Q Community Health Educ. 2020;41(1):15–23. doi:10.1177/0272684X19896727
- Behzadi P, Gajdács M. Writing a strong scientific paper in medicine and the biomedical sciences: a checklist and recommendations for early career researchers. Biol Fut. 2021;72(4):395–407. doi:10.1007/s42977-021-00095-z
- Xu Y, Liu Y, Wang J, et al. Hepatitis B virus infection seromarkers among college freshmen and their immune responses to different vaccination policies of hepatitis B vaccine. Hum Vaccin Immunother. 2021;17(11):4587–4594. doi:10.1080/21645515.2021.1959829
- Al-Shamiri HM, AlShalawi FE, AlJumah TM, AlHarthi MM, AlAli EM, AlHarthi HM. Knowledge, attitude and practice of hepatitis B virus infection among dental students and interns in Saudi Arabia. J Clin Exp Dent. 2018;10(1):e54–e60. doi:10.4317/jced.54418
- Karimi-Sari H, Bayatpoor ME, Aftabi Khotbesara M, et al. Knowledge, attitude, and practice of Iranian health sciences students regarding hepatitis B and C virus infections: a national survey. Am J Infect Control. 2017;45(11):e135–e141. doi:10.1016/j.ajic.2017.07.012
- Mesfin YM, Kibret KT. Assessment of knowledge and practice towards hepatitis B among medical and health science students in Haramaya University, Ethiopia. PLoS One. 2013;8(11):e79642. doi:10.1371/journal.pone.0079642
- Brener L, Cama E, Broady T, Hopwood M, Treloar C. Comparing Australian health worker and student attitudes and concerns about providing care to people living with hepatitis B. Health Promot J Austr. 2022;33(1):282–288. doi:10.1002/hpja.475
- Qin YL, Li B, Zhou YS, et al. Prevalence and associated knowledge of hepatitis B infection among healthcare workers in Freetown, Sierra Leone. BMC Infect Dis. 2018;18(1):315. doi:10.1186/s12879-018-3235-1
- Le TV, Vu TTM, Mai HT, et al. Social determinants of stigma and discrimination in Vietnamese patients with chronic hepatitis B. Int J Environ Res Public Health. 2019;16(3):398. doi:10.3390/ijerph16030398
- Chahal HS, Peters MG, Harris AM, McCabe D, Volberding P, Kahn JG. Cost-effectiveness of hepatitis B virus infection screening and treatment or vaccination in 6 high-risk populations in the United States. Open Forum Infect Dis. 2019;6(1):ofy353. doi:10.1093/ofid/ofy353
- Aroke D, Kadia BM, Anutebeh EN, et al. Awareness and vaccine coverage of hepatitis B among Cameroonian medical students. Biomed Res Int. 2018;2018:3673289. doi:10.1155/2018/3673289
- Sannathimmappa MB, Nambiar V, Arvindakshan R. Hepatitis B: knowledge and awareness among preclinical year medical students. Avicenna J Med. 2019;9(2):43–47. doi:10.4103/AJM.AJM_164_18
- Commission. NHaFP, Commission. NDaR, Technology. MoEMoSa, et al. Action plan for the prevention and treatment of viral hepatitis in China (2017–2020). Chin J Viral Dis. 2018;8(01):1–5.
- Liao X, Liang Z. Strategy vaccination against Hepatitis B in China. Hum Vaccin Immunother. 2015;11(6):1534–1539. doi:10.4161/21645515.2014.980206
- Upadhyay DK, Manirajan Y, Iqbal MZ, Paliwal N, Pandey S. A survey on medical, dental, and pharmacy students’ knowledge, attitude, and practice about hepatitis B infection in a private medical university of Malaysia. J Res Pharm Pract. 2020;9(3):128–134. doi:10.4103/jrpp.JRPP_20_8
- Maina AN, Bii LC. Factors affecting HBV vaccination in a medical training college in Kenya: a mixed methods Study. BMC Public Health. 2020;20(1):48. doi:10.1186/s12889-020-8158-2
- Zeng C, Thomas DC, Lewinger JP. Incorporating prior knowledge into regularized regression. Bioinformatics. 2021;37(4):514–521. doi:10.1093/bioinformatics/btaa776
- Nguyen TTL, Pham TTH, So S, et al. Knowledge, attitudes and practices toward hepatitis B virus infection among students of medicine in Vietnam. Int J Environ Res Public Health. 2021;18(13):7081. doi:10.3390/ijerph18137081
- Balegha AN, Yidana A, Abiiro GA. Knowledge, attitude and practice of hepatitis B infection prevention among nursing students in the Upper West Region of Ghana: a cross-sectional study. PLoS One. 2021;16(10):e0258757. doi:10.1371/journal.pone.0258757
- Mao Y, Xie T, Zhang N. Chinese students’ health literacy level and its associated factors: a meta-analysis. Int J Environ Res Public Health. 2020;18(1):204. doi:10.3390/ijerph18010204
- Mora T, Trapero-Bertran M. The influence of education on the access to childhood immunization: the case of Spain. BMC Public Health. 2018;18(1):893. doi:10.1186/s12889-018-5810-1
- Zhang Y, Meng Y, Guo Z, Wang D, Dong Y, Li M. Survey of knowledge, attitude and behavior toward HBV among undergraduates in private colleges in Zhengzhou. Modern Prev Med. 2018;45(06):1072–1075.
- Xiang Y, Wang A, Cui X, et al. Investigation on knowledge, attitude and practice related to hepatitis B prevention and therapy among college students in Shaanxi province. Pract Prev Med. 2020;27(10):1233–1236.