MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH

SOULIKONE PHAVONGXAY

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KNOWLEDGE OF AND ATTITUDES TOWARDS HEPATITIS B VIRUS
PREVENTION AMONG ARMED FORCES PERSONNEL (ARMY
HEADQUARTERS 605) IN VIENTIANE CAPITAL, LAO PDR IN 2019

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MASTER OF PUBLIC HEALTH

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CODE: 8720701

HANOI, 2020


MINISTRY OF HEALTH
UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH
AND
MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH
HANOI UNIVERSITY OF PUBLIC HEALTH

SOULIKONE PHAVONGXAY

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KNOWLEDGE OF AND ATTITUDES TOWARDS HEPATITIS B VIRUS
PREVENTION AMONG ARMED FORCES PERSONNEL (ARMY
HEADQUARTERS 605) IN VIENTIANE CAPITAL, LAO PDR IN 2019

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MASTERS OF PUBLIC HEALTH
CODE: 8720701

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SUPERVISORS:

KONGMANY CHALEUNVONG, PhD
VICE DIRECTOR INSTITUTE OF
RESEARCH AND EDUCATION
DEVELOPMENT, UNIVERSITY OF
HEALTH SCIENCES

DR. LE THI KIM ANH MD, PhD
DEPARTMENT OF BIOSTATISTICS
FACULTY OF FOUNDATIONAL
SCEINCES, HANOI UNIVERSITY OF
PUBLIC HEALTH


HANOI, 2020


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ACKNOWLEDGEMENTS
This independent study would not have been possible without the help and
support of many people.
I am very thankful to the Ministry of Health of the Lao PDR and the LEARN
project for funding my studies at the University of Health Sciences in Laos and the
Hanoi University of Public Health in Vietnam. The assistance of the Department of
Personal Health, Ministry of Health is also gratefully acknowledged for allowing
me to study at the University of Health Sciences in Laos and the Hanoi University
of Public Health in Vietnam.

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I would like to thank my thesis advisor Dr. Kongmany Chaleunvong, the
Vice Director of the Institute of Research and Education Development, University
of Health Sciences (UHS), Lao PDR and Dr. Le Thi Kim Anh, MD, PhD, from the
Department of Biostatistics, Health Data Science, Faculty of Foundational Sciences,
Hanoi University of Public Health (HUPH), Vietnam, who steered me in the right

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direction whenever needed.

I would like to acknowledge the valuable comments and encouragement

from the examination chair of my Independent Study Committee and I also wish to

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thank the external members of the Independent Study Committee.
I am most grateful to the leadership and personnel of the 605th Army
Headquarters, who kindly agreed to help and participate in this research. This study
could not have been completed without their generous assistance.
I am grateful as well to all the lecturers, teachers and staff of the UHS and
HUPH for their continuous assistance and helpful advice.
I would like to thank my classmates for their kindness during my studies at
UHS and HUPH.
Finally, I would like to thank my family for their love, understanding,
support, and encouragement during the time I was studying in Laos and Vietnam.
Soulikone Phavongxay


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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ..........................................................................................i
TABLE OF CONTENTS ............................................................................................ ii
ABBREVIATIONS .................................................................................................. iv
LIST OF FIGURES .................................................................................................... vi
SUMMARY.............................................................................................................. viii
INTRODUCTION ........................................................................................................1
CHAPTER 1 .................................................................................................................4

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LITERATURE REVIEW .............................................................................................4
1.1. Hepatitis B Virus (HBV) ................................................................................... 4
1.2 Definitions of knowledge of and attitudes towards HBV prevention ......... 7
1.4 Factors associated with knowledge of- and attitudes towards HBV prevention11

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1.5 Conceptual framework .................................................................................. 12
CHAPTER 2 ...............................................................................................................14

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RESEARCH METHODOLOGY ...............................................................................14
2.1 Study population ........................................................................................... 14
2.2 Study site and duration................................................................................. 14
2.3 Study design ................................................................................................... 15
2.4 Sample size ..................................................................................................... 15
2.5 Sampling method ........................................................................................... 16
2.6 Data collection method ................................................................................. 16
2.8. Ethical considerations ..................................................................................... 20
CHAPTER 3 ...............................................................................................................22
RESULTS ...................................................................................................................22


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3.1 Demographic information of participants ........................................................ 22
3.2 Knowledge of and attitudes towards HBV prevention .................................... 25
3.3 Factors related to knowledge of HBV prevention ........................................... 34

3.4 Multiple logistic regression analysis of dependent and independent variables44
CHAPTER 4 ...............................................................................................................51
DISCUSSION, CONCLUSION AND RECOMMENDATIONS ............................51
4.1 DISCUSSION .................................................................................................. 51
4.2 CONCLUSION ................................................................................................ 55

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N REFERENCES .......................................................................................................58
ANNEXES..................................................................................................................62
Annex 1: Questionnaire.......................................................................................... 62
Annex 2: Certificate of approval ............................................................................ 72
Annex 3: Consent form .......................................................................................... 74

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Annex 4: Thesis comments .................................................................................... 76
Annex 5: Minutes of explanation after thesis defence ......................................... 83

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ABBREVIATIONS
DNA

Deoxyribonucleic Acid


HBV

Hepatitis B Virus

KAP

Knowledge, Attitudes and Practices

Lao PDR

Lao People‟s Democratic Republic

UN

United Nations

WHO

World Health Organization

LSB

Lao Statistics Bureau

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LIST OF TABLES

Table 3.1 Demographic information ....................................................................... 22
Table 3.2 Distribution of sources of information on HBV prevention ................... 24
Table 3.3 Distribution of information on social factors relating to HBV prevention
................................................................................................................................. 25
Table 3.4 Knowledge of the nature of HBV ........................................................... 26
Table 3.5 Level of knowledge of nature of HBV .................................................... 27
Table 3.6 Knowledge of HBV transmission ........................................................... 28
Table 3.7 Level of knowledge of HBV transmission............................................... 29

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Table 3.8 Knowledge of HBV prevention .............................................................. 30
Table 3.9 Level of knowledge of HBV prevention ................................................. 31
Table 3.10 Knowledge of nature, transmission and prevention of HBV ................ 32
Table 3.11 Attitudes towards HBV prevention ....................................................... 32
Table 3.12 Level of attitudes towards HBV prevention ......................................... 34

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Table 3.13a Association of knowledge level of HBV prevention with individual
factors ...................................................................................................................... 35
Table 3.14 Association of knowledge of HBV prevention with social factors ....... 41


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Table 3.15 Association of knowledge of HBV prevention with sources of
information on HBV prevention ............................................................................ 42
Table 3.16 Association of knowledge of HBV prevention with individual
factors……………………………………………………………………………... 43
Table 3.17a Association of attitudes towards HBV prevention with individual
factors and family factors ....................................................................................... 45
Table 3.18 Association of attitudes towards HBV prevention and social factors ... 48
Table 3.19 Association of attitudes towards HBV prevention with sources of
information on HBV ............................................................................................. 49


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LIST OF FIGURES
Figure 1.1: Conceptual Framework: Knowledge of and attitudes towards HBV
prevention among armed forces personnel (Army Headquarters 605) in Vientiane
Capital, 2019...............................................................................................................13

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SUMMARY
Hepatitis B virus (HBV) infection is a global public health problem
especially in low to low-middle income countries, which account for 90% of the
total number of global HBV-infected patients. Military personnel in the Lao PDR
may often risk being infected because of their living in close quarters with others in
camp, sharing personal items and equipment and frequent participation in blood
donation drives. Also, they are often less educated; thus, their knowledge of HBV
infection is inadequate. Although several studies have reported the prevalence of
HBV infections among different risk groups, there has been no published data
among military camps in the country, hence this research on the knowledge of and

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attitudes towards HBV prevention among armed forces personnel in Vientiane
Capital, Lao PDR in 2019.

This analytic, cross-sectional study explores knowledge and attitudes in
relation to HBV prevention and identifies associated factors of armed forces
personnel. Some 422 members of Army Headquarters 605 in Xaithany District were

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selected through systematic random sampling and interviewed with a questionnaire.
The results indicate that the majority of the respondents show a very limited
knowledge of the nature of HBV and its transmission, with only a marginally higher

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proportion understanding HBV prevention. Most of the respondents, however, had

positive attitudes towards HBV prevention.

Overall, the knowledge of HBV nature, transmission and prevention of this
military group remains limited, possibly due to regimentation preventing easy
access to information.

The findings have added insights into how HBV infection is perceived and
how it is prevented by these army personnel.

Agencies concerned should be

prompted to increase this awareness among not just the armed forces but also the
general populace as well as their knowledge and understanding of the occurrence
and prevention not just of hepatitis B infection but of other diseases as well.


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INTRODUCTION
Hepatitis B virus (HBV) infection is considered to be a global public health
problem, especially in low to low-middle income countries because these countries
account for 90% of the total number of global HBV-infected patients. The virus is
transmitted through contact with blood or other bodily fluids such as vaginal fluids,
semen and mucous membranes of an infected person. For example, HBV can be
transmitted from mother to child at birth (perinatal transmission), by sexual contact
with an infected person, by using infected needles and by infected blood
transfusions, especially mother-to-infant transmission. (Public Health Authority of

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Sweden, 2015). Unlike other sexually transmitted diseases, HBV can be prevented by
vaccines (WHO, 2012).

Humans are the only known host of HBV, which is an important cause of
liver cancer or liver cirrhosis. More than a third of the world‟s population has been
infected with HBV at some stage during their lives. Half of the estimated 350
million chronic HBV carriers worldwide live in the Asia-Pacific region. Nearly

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40% of these individuals will die of liver-related complications or regression
hepatocellular carcinoma (Lavanchy, 2004).

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In Lao PDR, HBV infection is a public health problem. Approximately 50%
of adults are infected by the virus and the chronic infection rate is approximately
10%. (Jutavijittum et al, 2007; Black et al, 2014; Jutavijittum et al, 2014). In
addition, around 8% of blood donors are chronic carriers of HBV, which is a rather
substantial percentage of those who have donated blood. The government is trying
its best to encourage Lao citizens to acknowledge the disease and to address its
danger, but the prevalence and incidence of HBV infection remains high. This could
be caused by insufficient knowledge of HBV infection and the lack of a proactive
attitude on HBV prevention in communities. Since 2001, there has been a phased
introduction of HBV vaccination into the national immunization schedule.
Currently, infants are scheduled to receive the HBV birth dose within 24 hours of
birth, followed by multiple HBV vaccinations at the ages of 6, 10 and 14 weeks in



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combination with diphtheria, tetanus, pertussis and Hemophilic influenza B vaccines
(DTP- HepB-Hib) (WHO, 2011; LSB, 2012). The HBV vaccination at birth,
followed by a timely three-dose schedule, is assumed to be 70 to 95% effective in
preventing mother-to-child transmission of HBV (WHO, 2007; Centers for Disease
Control, 2012). It is believed that most infections occur during early childhood, e.g.,
during birth or early family life. If infected at birth, children have a 90% risk of
developing chronic infection. This rate decreases to 30% if infected between the
ages of 1 and 5, and to 5 to 10% if infected after the age of 5 (Angham, 2018).
Moreover, HBV infection remains highly contagious and transmitted through
parenteral, sexual and vertical (perinatal transmission) routes. An improved

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understanding of HBV infection routes among the population will enable the
reduction of the risk of HBV infection, which is especially true for young people
serving in the military. In most cases people living in military camps may be more
predisposed to HBV transmission through some common routes. In everyday life,
they are more likely to be infected by HBV, especially because they are not aware

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of its dangers. Sharing personal items and toiletries such as hair-brushes, combs,
razors and toothbrushes is common amongst people living in groups and it can
facilitate the virus transmission. (Alavian, 2013). In addition, people in the armed

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forces usually participate in blood donation drives in the Lao PDR, and sometimes
they are diagnosed with HBV infection through these campaigns. They are often less
educated; thus, their knowledge of HBV infection is inadequate. Although several
studies reported the prevalence of HBV infections among different risk groups, to
date there is no published data about HBV prevalence among military camps in the
country. Therefore, this research aims to focus on the knowledge of and attitudes
towards HBV prevention among armed forces personnel in Vientiane Capital, Lao
PDR in 2019.


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RESEARCH OBJECTIVES
1) To describe the knowledge of and attitudes towards HBV prevention among
personnel of the armed forces in Vientiane Capital in 2019.
2) To identify factors associated with the knowledge of and attitudes towards
HBV prevention among personnel of the armed forces in Vientiane Capital
in 2019.

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CHAPTER 1

LITERATURE REVIEW

1.1. Hepatitis B Virus (HBV)

1.1.1. Characteristics of HBV
Hepatitis B is a serious liver disease caused by HBV. The virus is transmitted
through human body fluids such as blood and serum. It is an alarming public health
problem worldwide. Its methods of transmission include mother to baby
transmission (perinatal), sexual contact, and the use of improper injection

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techniques. More than two billion people among the population alive today have
been infected at some point or other in their lives by the hepatitis B virus (HBV),
and approximately 350 million of them are carriers of this chronic disease. Out of
this population, 25-30% will die as a consequence of the infection. These carriers
run a severe risk of dying from liver cirrhosis and/or primary liver cancer. They also

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constitute a reservoir of infected individuals, who perpetuate the infection from
generation to generation (WHO, 2003).

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An estimated 70% of healthy adults with acute HBV infections are asymptomatic,
and the remainder have symptoms of liver diseases (e.g., abdominal pain, jaundice).
Less than 1.5% of acute HBV infections are fatal. The progression to chronic HBV
(infection beyond six months) varies dramatically depending on the age at the time

of the initial infection. Chronic infections develop in 80-90% of the infants (<1 year
of age) infected with HBV, and in approximately 25-30% of acute infections before
the age of 6, and in <1 to 12% of acutely infected older children or adults. The
remaining individuals generally resolve their HBV infection without consequences
and develop immunity. Chronic HBV can result in serious long-term health
complications such as chronic hepatitis, cirrhosis, and hepatocellular carcinoma.
Nearly 25% of those who become chronically infected in childhood and 15% of


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those infected in adulthood will die prematurely from cirrhosis or liver cancer
(Thomas et al 2011; Agbim et al. 2017).
Hepatitis B is a DNA virus of the Hepadnaviridae family. It replicates within
infected liver cells (hepatocytes). The hepatitis B virus particle, also known as the
Dane Particle, consists of an inner core and an outer surface coat.

1.1.2 Modes of HBV Transmission
The hepatitis B virus, as described in Kane et al., 1999; Simonsen et al., 1999; and

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Jodar et al., 2001, is carried in the blood and other body fluids. The virus is present
in the blood, semen, vaginal secretions, menstrual blood, and to a lesser extent,
perspiration, breast milk, tears and urine of infected individuals. The highly resilient
virus is easily transmitted through contact with infected body fluids. It is usually
spread by contact with blood in the following ways (Lee et al, 2006).

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1) Perinatal (mother to child) transmission:

Perinatal (mother to child) transmission is one of the most common and
serious modes of HBV transmission. Perinatal transmission occurs from

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mothers who are positive for hepatitis B surface antigens (HBsAg). More
than 90% of these women are chronic HBV carriers, although those acutely
infected with the virus may also transmit the virus to their children during
the pregnancy. Infected newborns rarely develop acute hepatitis, although
cases of fatal fulminant hepatitis have been reported. These carriers form a
pool of infectious individuals who will infect others in the community and
eventually their own offspring.
2) Transmission through an unsafe injection, needle-prick or reuse of unsterile
needles and use of contaminated needles and other medical and dental
equipment:
Surveys conducted in developed countries have revealed that approximately
30% of injections used for immunization are not sterilized (Eric et al,


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2005). Disposable syringes are reused, and reusable syringes are improperly
sterilized resulting in a significant risk of transmission of blood-borne
pathogens. Auto-destructive syringes and single use pre-filled devices can
reduce the transmission by averting inappropriate use. In some Western
countries needle-sharing by drug users is also a causative of HBV. If sterile
needles are not used it is possible to transmit hepatitis B through bodypiercing, tattooing, drug injection and acupuncture.

3) Through sexual intercourse:
Lastly, hepatitis B virus transmission is carried out during sexual
intercourse through contact with blood or other body fluids.

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1.1.3 Diagnosis of HB Viral Infection

A simple blood test could easily diagnose hepatitis B infection. The test looks for
antigens and antibodies in blood. If a person is recently infected, it will take 4 to 6

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weeks before the virus can be found in their blood. A blood test will show whether
the patient:

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Has been infected previously.

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Has an acute hepatitis B infection presently.

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Has recovered from a past infection and is now immune.


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Has a chronic hepatitis B infection and the virus is present in the blood.

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Is immune to hepatitis due to vaccination (Alavian et al, 2013).

1) Serology Test:
Eric E. Mast (2005) mentioned that Hepatitis B serologic testing involves
measurement of several hepatitis B virus (HBV)-specific antigens and
antibodies. Different serologic “markers” or combinations of markers are
used to identify different phases of HBV infection and to determine whether
a patient has acute or chronic HBV infection, is immune to HBV as a result


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of prior infection or vaccination or is susceptible to infection (Black et al,
2015).

2) Prevention:
The best way to prevent HBV infection is through vaccination. Hepatitis
vaccines are Alum-and highly purified preparations of the hepatitis B
surface antigen (HBsAg), the glycoprotein that forms the outer coat of the
hepatitis B virus (Sarah et al, 2017).

1.2 Definitions of knowledge of and attitudes towards HBV prevention


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1.2.1 Knowledge

Knowledge refers to the acquisition, retention and use of information or skills
(Badran, 1995). Cognition through which knowledge is acquired is a process of
understanding and is distinguished from the experience of feeling. Knowledge

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accrues from both education and experience. For example, knowledge possessed by
diabetics refers to their comprehension of the disease, its progression, and self-care
practice necessary for keeping diabetes under control (Fazal et al, 2016)

1.2.2 Attitudes

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Eagly and Chaiken (1993) in “The Psychology of Attitude” define attitude as “a
psychological tendency that is expressed by evaluating a particular entity with some
degree of favor or disfavor”. Attitude has three components: cognition, affect, and
behavior, as discussed by Katz & Stotland, 1959; Krech & Crutchfield, 1948; and
Rosenberg & Hovland, 1960 as cited in Eagly & Chaiken, 2007. Cognition
comprises true and false beliefs about the object of the attitude; health education
may change such beliefs. Thus, there may be overlap between knowledge and
attitude. For example, some hepatitis B patients may have beliefs that they may not
live healthy, long lives from hearing of older relatives dying at an early age from
such complications of hepatitis B as heart attack, stroke, or kidney failure; they



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assume that the same fate may befall them. The affective component of attitude is
the whole gamut of emotions toward every aspect of the attitude object. Some
hepatitis B patients may have a set of varying attitudes towards self-care
management of hepatitis B. They may love to exercise, as it makes them feel good
but hate self-monitoring their blood sugar because they are averse to pricking their
skin. The behavioral components of attitude are the proneness to act in particular
ways with reference to the attitude object. Thus, some hepatitis B patients may
follow through all recommendations by physicians, while other patients may not. In
summary, attitudes toward hepatitis B refers to any preconceived ideas about
hepatitis B and its management, patients‟ feelings or emotions towards aspects of

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hepatitis B and hepatitis B care, and the tendency to behave in particular ways
towards hepatitis B and its management (Eagly et al, 2007).

1.3 Overview and empirical studies on the knowledge of and attitudes
towards prevention of hepatitis B virus

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Krugman (1967) identified two types of hepatitis, which were termed MS-1 and
MS-2. MS-1 was typically acquired through the oral route after a short incubation

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period, whereas MS-2 was ostensibly transmitted parentally with a long incubation
period. MS-1 and MS-2 hepatitis were subsequently classified as hepatitis A and B,
respectively. Serial chimpanzee and human experiments confirmed that Australia
antigen was responsible for hepatitis B; hence, it was renamed as HBV. In 1970,
Dane and colleagues used electron microscopy to visualize diverse sub viral
particles (hepatitis B surface antigen existing in circular and filamentous forms in
addition to the complete enveloped virions, which were termed Dane particles)
(Dane, et al, 1970)

The study on the prevalence of hepatitis B and C virus infection among military
personnel at Bahir Dar Armed Forces General Hospital, Ethiopia was conducted
among a total of 403 military personnel from February to May 2015 by a cross-


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sectional study. It found that the sero-prevalence of HBV and HCV infection were
4.2 and 0.2 %, respectively. None of the study subjects were co-infected with HBV
and HCV. Higher prevalence of HBV infection (11.3%) was observed in the age
group of 40 and above. Being 40 years old and above (COR 7,6; 95% CI 2.0-29.0,
p=0,003), having a history of nose piercing (COR 5,9; 95% CI 1.2–29.9, p = 0.033)
and having had sexually transmitted infection (COR 4.3; 95% CI 1.1–16.4, p =
0.03) were significantly associated with these viral hepatitis infections. Intermediate
prevalence of HBV and low prevalence of HCV were observed among military
personnel. Strengthening HBV screening strategies among military personal may
further reduce these viral diseases (Tigist et al, 2015).

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A survey of knowledge about HBV among new military recruits in China found that
the majority of the respondents had poor knowledge, while only 119 (16.4%) had
adequate knowledge about HBV (Li, et al, 2017).

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The risk of HBV infection was reported to be higher in military personnel than the
general population in Saudi Arabia (SA); however, there is a lack of studies
assessing HBV awareness among the military personnel. A study of knowledge,

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attitude and practice (KAP) of HBV infection among Saudi national guard
personnel after educational intervention found that the overall improvement of
mean KAP score (204%) was also observed in all its component scores: disease
nature (272%), methods of transmission (206%), prevention and control (109%),
attitudes (155%), and practices (192%). The improvement was evident irrespective
of socio-demographic characteristics and history of HBV vaccine. KAP scores were
significantly associated with higher educational levels, higher monthly income,
administrative jobs, and higher job ranks (Majid et al, 2012).

The study on the knowledge and attitudes of patients towards Hepatitis B and C
in Nawabshan Medical College Hospital with 500 admitted patients found that
patients educated beyond the primary level had more knowledge than illiterate


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persons about the condition, especially regarding the cause, organ involved,
prevalence in society, presentation and vaccination for HBV. Apart from that,

there was a lack of knowledge on risk factors, especially among illiterate persons.
There was also a lack of responsibility and poor attitudes of even educated
persons towards the treatment of these diseases. Both literate and illiterate
persons were following customs of community and relying on homeopathic or
herbal medicine for their treatment (Altaf, et al 2007).

The study was carried out at Irrua Specialist Teaching Hospital in Edo state,
Nigeria, to determine health workers‟ knowledge, attitude and behavior towards

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hepatitis B infection by employing two hundred respondents from the different
cadres of health workers. More than three-quarters of the respondents (81%) had
ever heard about Hepatitis B infection prior to the study. Of those who were aware
of hepatitis B infection, 92% mentioned blood and blood products as routes of
transmission of Hepatitis B, 68.5% mentioned needles and sharp objects, while only

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37% said that the disease could be transmitted through sexual intercourse.
Incorrectly identified routes of transmission by the respondents included face-oral
transmission (14.2%) and transmission through drinking contaminated water

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(9.3%). On ways of preventing Hepatitis B infection, the majority correctly
identified preventive measures as including vaccination (77.2%), while more than
three quarters of the respondents (80.9%) said that Hepatitis B could be acquired as
a nosocomial infection from the hospital and 69.8% said that Hepatitis B infection

was widely transmitted like HIV/AIDS. A little more than three-quarters of the
respondents (75.5%) were aware of the existence of the Hepatitis B vaccine prior to
the study. Only 70.2% have actually ever received the Hepatitis B vaccine, out of
which only 59.4% completed the vaccination schedule. Poor compliance of health
workers to hepatitis B vaccination is an issue that deserves serious attention. There
is a need for health education campaigns for health workers so that they can
understand the risks that they are exposed to, based on the nature of their work
(Samuel et al, 2009).


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The assessment of Knowledge, Attitude and Practices in relation to HBV among
500 clinicians and medical students of Jhalawar Medical College, Rajasthan found
that clinicians and medical students had fairly moderate levels of KAP but with
important gaps of knowledge of HBV infection and vaccination. The majority of
those studied were medical students (60.2%) and the rest were clinicians. Mean
scores for knowledge, attitude and practice were 15.66 ± 1.9, 7.17 ± 1.15 and 6.8 ±
1.13 respectively. Significant and positive linear correlations between designation
vs. knowledge (r = 49.18, p < 0.00); vaccination status vs. knowledge (r = 28.88, p
< 0.001); duration of experience vs. knowledge (r = 23.51, p < 0.001) and attitude

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vs. vaccination status (r =3 0.14, p < 0.05) were observed (Baig et al, 2015).

1.4 Factors associated with knowledge of- and attitudes towards HBV
prevention


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1.4.1. Individual factors
1) Age

In Ethiopia soldiers aged ≥40 years (COR 7.6; 95 % CI 2.0–29.0, p = 0.003)

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were significantly associated with KAP of HBV prevention (Tigist, 2015).
In China among new military recruits, age (COR = 3.040, 95% CI 1.7245.359, P < 0.001) was also significantly associated with KAP of HBV
prevention (Li, 2017). In Australia, among people with chronic HBV, age
(P=0.02) was significantly associated with knowledge of HBV prevention
(Hajarizadeh, 2015).

2) Gender
In China, among new military recruits, gender (COR = 1.791, 95% CI
1.325-2.421, P < 0.001) was significantly associated with appropriate HBV
prevention behavior (Li, 2017). In South Nigeria, among health workers,


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sex or gender (X2 = 31.74; P = 0.00) was significantly associated with
HBV prevention (Samuel, 2009).

3) Education
In Saudi Arabia, military personnel with higher educational levels (pvalue <0.05) were significantly associated with HBV prevention (AlThaqafy, 2012). In Australia, among people with chronic HBV, education
level (P=0.02) was significantly associated with knowledge of HBV
prevention (Behzad, 2015).


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4) HBV history

In Ethiopia, soldiers who had a history of HBV (COR 4.3; 95 % CI 1.14–
16.4, p = 0.03) were significantly associated with HBV infections (Tigist,
2015); In Malaysia, among university students, it was found that family
history of HBV was significantly associated with HBV prevention

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(p=0.010) (Abdulrahman, 2016).

1.4.2. Social factors

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1) Vaccination Campaign of HBV

In Saudi Arabia, it was found that people who had a history of HBV were
significantly associated with KAP of HBV prevention (Al-Thaqafy, 2012).

1.5 Conceptual framework

After reviewing related empirical studies and based on the characteristics of the
study population, the conceptual framework was designed as the parameters for this
research. To summarize, there are two components which influence the knowledge
of and attitudes towards HBV prevention among personnel in the armed forces in

Vientiane Capital in 2019. These components are: the individual factors and social
factors (See Figure 1.1 below for the components and their sub-components).


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





Individual factors
Age
Gender
Ethnicity
Marital status
Religion
Education
Duty
Years in service
Rank in service

History of HBV
infection
HBV vaccination
status
History of blood
donation


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 Knowledge on HBV prevention
- Knowledge on HBV Nature
- Knowledge on Transmission
- Knowledge on Prevention

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 Social factors
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Source of information about
HBV prevention
HBV vaccination
campaigns HQ 605 camp
Health education and
communication on HBV in
HQ 605 camp

 Attitudes towards HBV prevention

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Figure 1.1: Conceptual Framework:

Knowledge of and attitudes towards HBV prevention among armed forces
personnel (Army Headquarters 605) in Vientiane Capital, 2019.



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CHAPTER 2
RESEARCH METHODOLOGY

2.1 Study population
The study population of this research consisted of military personnel from the 605th
Army Headquarters in Vientiane Capital, Lao PDR, with a total strength of 1,400.

2.1.1. Inclusion criteria
1) Male and female army personnel who were administrative-, technical- or

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combat duty personnel (new recruits and permanent soldiers) who were able
to answer the questions and sign an informed consent form.
2) Military officers who were present and agreed to participate.

2.1.2. Exclusion criteria:

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1) Army personnel who were absent during the data collection and/or unwilling
to answer the questionnaire.

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2.2 Study site and duration


Army Headquarters 605 is a battalion in the Lao People‟s Army in Xaythany
District, Vientiane Capital, Lao PDR. The number of personnel in this unit was
substantial enough to be representative of the military and Xaithany District, being
the same district as the researcher‟s, was convenient. Therefore, this camp was
selected as the study site. The research was conducted in a four-week period after
obtaining ethical approval from the Institutional Ethical Review Board (IRB) of the
Hanoi University of Public Health and the Ethical Review Committee of the
University of Health Sciences, Lao PDR.


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2.3 Study design
This study was an analytical, cross-sectional study that aimed to explore the
knowledge of- and attitudes towards HBV prevention and to identify determiners
related to that knowledge of- and those attitudes towards HBV prevention among
armed forces personnel (specifically at Army Headquarters 605) in Vientiane
Capital in 2019.

2.4 Sample size

H
P

The sample size of this study was estimated by using the following formula:

U

n=

where

= 384.16

e = the margin of error, in this study = 0.05;

H

p = the population proportion (%), the percentage of people having
knowledge of HBV prevention.

There had not been any research on the knowledge of and attitudes towards HBV
prevention in the Lao PDR; therefore, p=50% was used to achieve the best sample
size;
n = Minimum sample size needed for this study
α = Level of significance. With α=0.05, Z=1.96
n = 384 persons.

This sample size was added to by 10% in case of non-response participants or
invalid questionnaires. Thus, the final sample size was 422 persons.


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2.5 Sampling method
The sampling method used was systematic random sampling. The selection of the
respondents was firstly done by requesting for the name list of the personnel in the
unit from the camp‟s headquarters. Secondly, the systematic random sampling
interval was calculated by dividing the total number of soldiers with the sample size
(I=N/n) (N is all of the camp‟s soldiers, n is the sample size), so I=1400/422=3. So

the interval was 3, and thus the sampling from the name list started at 1 with
interval I (that is, 1, 4, 8, … until the end of the name list).

H
P

2.6 Data collection method

Data collection was conducted after the proposal was approved. Questionnaires
were employed as the tool for collecting data by using close-ended questions in

U

order to collect data and information from respondents that had been systematically
selected to take part in answering the questions.

The process:
-

H

The questionnaires were prepared in English, then translated into the Lao
language. The questionnaires were first pre-tested with 30 military personnel
from a nearby camp, and the questionnaires were improved after the testing.

-

A proposal was submitted for the data collection to the Headquarters of the
605 camp for approval.


-

A meeting was called with the selected survey participants.

-

Data

collection

was executed

through

self-administered

structured

questionnaires.
-

The researcher explained to the respondents the research objectives, read the
approval letter from the Headquarters, and explained how to answer the
questionnaires.