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Knowledge and Risk Assessment of Hepatitis B Infection among Barbers and Beauty Salon Workers in Mwanza, Tanzania
*Corresponding author: Semvua Kilonzo, PhD, Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania. Tel: +255712830256 sekipcb@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Kilonzo S, Jaka H, Mapunda S. Knowledge and Risk Assessment of Hepatitis B Infection among Barbers and Beauty Salon Workers in Mwanza, Tanzania. Int J Transl Med Res Public Health. 2024;8:e002. doi: 10.25259/IJTMRPH_476
Abstract
Background and Objective
Community-acquired hepatitis B virus (HBV) infection is increasing in developing countries. In Tanzania, there is an exponential increase in barbershops and beauty salons, which are potential sites of transmission of HBV. Occupational exposure rates and HBV vaccination rates among salon workers are unknown; their level of knowledge about infection prevention and control (IPC) is also unknown. This study aimed to evaluate the risk of infection and the knowledge of barbers and beauty salon workers about HBV transmission and prevention.
Methods
A cross-sectional study was conducted using a convenience sample of 200 barbers and beauty salon workers from 13 barber shops and 13 beauty salons in the urban district of Mwanza, Tanzania. Data were collected using a self-administered questionnaire, entered into EpiData version 3.1, and analyzed with Stata version 13. Categorical variables were expressed as frequencies, and association levels were compared using Fisher’s exact test.
Results
Fifty-four percent of the study participants were female, and the mean age was 25 (21.0–29.5) years. A total of 126 (63%) participants were aware of the existence of HBV infection, of which only 22% had general good knowledge of HBV transmission and prevention. Both HBV awareness (P < 0.001) and good knowledge of its transmission and prevention (P = 0.03) were positively associated with higher levels of education. Seventy-three (36.5%) participants reported a history of occupational injuries. Merely 27.8% of participants were familiar with the correct methods of decontamination beauty tools, and only 14.3% understood the correct procedures for post-exposure wound care. Vaccination coverage was low with only (2%) of barbers and beauty salon workers having received vaccines.
Conclusion and Global Health Implications
The frequent occupational injuries and inadequate vaccination among barbers and beauty salon workers amplify their risk of HBV infection. They also lack basic knowledge about HBV transmission and prevention, placing the clients they serve at high risk for infection. We recommend that training on HBV Infection Prevention and Control (IPC) should focus on this specific group, and the implementation of these measures should be closely monitored in barbershops and beauty salons. Moreover, this vulnerable group should be considered for a global vaccination program.
Keywords
Knowledge
Occupational
Exposure
Hepatitis B
Salon
Barbers
Tanzania
INTRODUCTION
Hepatitis B virus (HBV) infection has become a major public health problem. Approximately 300 million people worldwide are chronically infected with HBV.[1] Africa has one of the highest HBV burdens in the world, and sub-Saharan Africa is currently classified as a high-prevalence area, accounting for one-quarter of HBV burdens worldwide.[1] The prevalence of HBV in the general population of Tanzania is estimated at 6.2%.[2] HBV transmission occurs through contact with contaminated blood and other body fluids in clinical and non-clinical settings. Recent studies have shown that the transmission rate of HBV infection in the healthcare setting is generally declining due to increased adherence to modified infection prevention and control (IPC) protocols.[3] On the contrary, HBV transmission outside the healthcare system is high, and approximately 50% of all people infected with HBV have no known risk factors in developing countries.[4-7]
The rising popularity of barbershops and beauty salons in developing countries has contributed significantly to the horizontal transmission of the HBV virus.[8,9] Infections can be spread from one customer to another through sharing contaminated beauty treatment tools. These include tools that are used for shaving, tattooing, body piercing, and manicure. Moreover, infections may also spread to the service providers through mechanical occupational injuries such as needle sticks and cuts.[8,10] Significant amounts of infectious HBV deoxyribonucleic acid have been detected in shaving clippers and nail scissors[11,12] and people who shave in barbershops were found to be more than twice as susceptible to acute HBV infection as to the general population.[13] A large surveillance study in Italy reported that beauty treatment in barbershops and salons was attributed to 15% of acute HBV cases.[14] Furthermore, mechanical occupational injuries have been identified as another important risk factor for HBV infection in these settings, especially among service providers.[10] These injuries often occur without proper treatment and follow-up care. Studies have shown that up to 50% of hairdressers have experienced needle sticks or cuts with inadequate post-exposure care.[5,7] These injuries have been attributed to HBV seropositivity in barbers, which is higher than in the general population.[15] This places a major responsibility on barbers and beauty care workers to break the vicious cycle of transmission of HBV infection. In Tanzania, the government has worked hard to make sure that the preventive and control measures against HBV infections among barbers, and beauty salon workers and other vulnerable populations like illicit intravenous drugs users are in place to ensure reduction in transmission of the infections. These are highlighted clearly in the national strategic plan for control of hepatitis B and C. They include but are not limited to vaccination, raising knowledge and awareness of prevention, diagnosis, and treatment of HBV. Other strategic objectives that have been put into action are to strengthen the health facility’s ability and patient’s accessibility to diagnostic and treatment services.[16] Despite all these efforts, knowledge of HBV among barbers and beauty salon workers is still limited, and this raises their vulnerability to acquiring HBV infections. Thus, it becomes critical for barbers and beauty salon workers to have a detailed understanding of HBV transmission and preventive methods to halt this transmission.[17–19] To the best of our knowledge, information about the risk of infection for beauty salon workers and barbers and their knowledge and prevalence is scarce in Tanzania. Hence, this study is designed to assess the knowledge and awareness of barbers and beauty salon workers regarding HBV transmission, prevention methods, and associated infection risk.
METHODS
Study Design
This was a descriptive cross-sectional study conducted between October, 2020 and February, 2021 among barbers and beauty salon workers in Mwanza city, northwestern Tanzania.
Study Setting
This study was conducted in the Mwanza Region. The region is located on the spectacular southern shores of Lake Victoria, north-west of Tanzania. It covers an area of 1337 square km. Of this, 71.55 km2 (28%) is covered by water, and the remaining 184.9 km2 (72%) is a dry land. Approximately 86.8 km2 is urbanized while the remaining areas consist of forested land, valleys, and cultivated plains, grassy, and undulating rocky hills.[20]
This region is made up of seven administrative districts. These districts include Ilemela, Nyamagana, Kwimba, Ukerewe, Magu, Sengerema, and Misungwi, with a total population of 3,696,872 people as of the 2022 national census.[20,21]
The study took place in Nyamagana district in 13 administrative wards, namely, Buhongwa, Butimba, Igogo, Igoma, Isamilo, Mahina, Mbugani, Mirongo, Mkolani, Mkuyuni, Nyamagana, Pamba, and Kishiri. The health sector of Mwanza is well-built, with a total of more than 6 hospitals, 35 health centers, and 231 dispensaries. These provide a wide range of HBV prevention and treatment services in the region and other neighboring regions of the lake zone.[20] The main economic activities carried out by the Mwanza region’s population are businesses including barbershops and beauty salons, agricultural production, livestock keeping, and, to a significant extent, fishing.[20] There has been a significant rise in the number of barbershops and beauty salons in Mwanza, but there is a lack of specific data indicating the precise quantity of these establishments.
Sample Size Estimation
The sample size was estimated using the equation:
Where, Z = 1.96 (95% confidence interval), P = 0.11 (11% prevalence in subjects with sufficient knowledge in previous studies)[22] Q = 1–P and d = margin of error, that is 0.05.
Therefore, the estimated minimum sample size was n = 150. However, the study team was able to approach 200 participants from 13 wards.
Sampling Procedure
A total of 26 barbershops and beauty salons were selected; one barbershop and one beauty salon were chosen from each region. We invited all barbers and beauty salon workers from the selected facilities to participate in the study . The purpose of the study was explained to them, and consent form was signed accordingly.
Data Collection Tool
Data were collected using a structured self-administered questionnaire that was designed by authors guided by the study objectives. The questionnaire was originally designed in English and later translated into Swahili by an experienced language interpreter, who was not part of the research team. It was later pretested in a similar population in a nearby Ilemela district to ensure clarity and a good flow of questions. Two trained research assistants helped with the questionnaire administration during data collection and ensured the clarity and correctness of the questionnaire. We asked participants to read through all the questions initially, ensuring comprehension. Subsequently, all misunderstandings pertaining to the questions were clarified by the research assistant. We verified that all participants could read and write in Swahili language. The questionnaire consisted of five sections; Section 1 consisted of four questions on demographic characteristics; Section 2 contained one awareness question; Section 3 consisted of ten knowledge questions; Section 4 had two questions about occupational risk; and Section 5 had two questions about vaccination history.
Knowledge of HBV transmission and prevention was evaluated only among those who reported awareness of HBV infection. We used Bloom’s Modified Cutoff Total Knowledge Score scale[23] to measure participant’s knowledge of HBV. Here, a score between 80% and 100% of correct answers is good knowledge, 50%–79% is moderate knowledge, and <50% is poor knowledge. This questionnaire was developed based on the research objective and the previous literature.[24] Awareness was measured by one question that required a participant to answer whether they had heard about HBV or not.
Statistical Analysis
Data were extracted from the questionnaire. Consequently, the data extracted from the questionnaire was entered using the Epi data version 3.1 and analyzed with Stata version 13 (Stata Corp LP, College station, TX). The continuous variables were summarized using mean with standard deviation or median with interquartile range depending on the distribution; whereas, the categorical variables were summarized using frequencies and proportions. For the identification of associated predictors, bivariate logistic regression was first done for each independent variable, variables with P-values lower than 0.05 were considered statistically significant. Fisher’s exact test set at P < 0.05 was used to test for the significance of association in categorical variables.
Ethical Review
Ethical approval to conduct and publish results of the study was obtained from the Joint Ethics Committee of the Catholic University of Health and Allied Sciences/Bugando Medical Center with ethical clearance number 1666/2020. Permission was granted by the medical officer in charge of the city of Mwanza. Written informed consent was obtained from each participant after requesting and explaining the purpose of the study. The client’s information was only processed by the investigator and identifiers such as names were not included in the final analysis to maintain confidentiality.
RESULTS
Demographic Characteristics
From October 04, 2020, to February 23, 2021, we recruited a total of 200 barbers and beauty salon workers from 13 barber shops and 13 beauty salons. Of these, 54.0% were female, and the median age was 25 (21.0–29.5) years. Most (63%) of the participants had completed secondary education [Table 1].
| Characteristics | Frequency (n) | Percentage (%) |
| Sex | ||
| Male | 92 | 46.0 |
| Female | 108 | 54.0 |
| Age (years) | ||
| <20 | 26 | 13.0 |
| 20–30 | 135 | 67.5 |
| 31–40 | 32 | 16.0 |
| >40 | 7 | 3.0 |
| Education | ||
| Primary or none | 39 | 19.5 |
| Secondary | 126 | 63.0 |
| College/University | 35 | 17.5 |
| Type of facility | ||
| Barbershop | 115 | 57.5 |
| Beauty salon | 85 | 42.5 |
n: number of participants
Occupational Exposure
Out of the participants, 73 (36.5%) reported experiencing at least one needle stick injury throughout their carrier. Of these, the majority (53.4%) had five or more such injuries, 4.7% had between two to five injuries, and 21.9% reported one injury.
HBV Vaccination Status
Only four (2.0%) participants reported receiving the HBV vaccine, and all of them had only one dose.
Awareness of HBV Infection
A total of 126 participants (63.0%) were aware of the existence of HBV infection,and 37.0% of them had never heard of HBV.
Knowledge of HBV Infection
Overall, 22.2% of the participants who were aware of HBV infection were classified as having good knowledge about HBV infection transmission and prevention . Alternatively, 35% had moderate knowledge, and 42.9% had poor knowledge.
Only 33.3% of the participants were aware that HBV could be transmitted by sharing beauty treatment tools, and only a minority (26.3%) knew that it could be transmitted through trauma caused by sharp, contaminated objects. Proper decontamination (disinfection/sterilization) methods and appropriate post-exposure wound care were known to 27.8% and 14.3%, respectively. The entire set of post-exposure measures was unfamiliar to all participants [Table 2].
| Knowledge item | Correctly responded | ||
| Frequency | Percentage | ||
| 1. | HBV | 73 | 57.9 |
| 2. | HBV can be transmitted through contact with body fluids. | 60 | 47.6 |
| 3. | HBV can be transmitted from a mother to her unborn child. | 37 | 29.4 |
| 4. | HBV can be transmitted by sharing instruments for shaving, tattooing, body piercing, or other cosmetics. | 42 | 33.3 |
| 5. | Injury with a contaminated sharp object is a risk factor for HBV infection | 33 | 26.2 |
| 6. | HBV can be transmitted through blood transfusions | 41 | 32.5 |
| 7. | HBV infection is a preventable disease | 70 | 55.6 |
| 8. | HBV vaccines are available for prevention | 61 | 48.4 |
| 9. | Decontamination methods of beauty treatment tools | 35* | 27.8 |
| 10. | Post-exposure wound care procedure | 18* | 14.3 |
Factors Associated with HBV Awareness and Knowledge
Participants with at least a secondary level of education (referred to as literate) were significantly more likely to be aware of (90.8% vs. 9.5%) and have good knowledge about HBV infection (100% vs. 0%, P = 0.03), compared to those without such education (referred to as illiterate) [Table 3].
| Characteristic | Aware of hepatitis B (n=200) | Good knowledge (n=126) | ||||
| Yes (n=126) | No (n=74) | P-value* | Yes (n=28) | No (n=98) | P-value* | |
| Sex | ||||||
| Male | 67 (53.2) | 33 (44.6) | 0.24 | 16 (57.1) | 51 (52.1) | 0.67 |
| Female | 59 (46.8) | 41 (55.4) | 12 (42.9) | 47 (47.9) | ||
| Age (years) | ||||||
| <20 | 12 (9.52) | 14 (18.9) | 0.56 | 3 (10.7) | 9 (9.2) | 0.72 |
| 20–30 | 89 (70.6) | 46 (62.2) | 0.22 | 19 (67.9) | 70 (71.4) | 0.81 |
| 31–40 | 20 (15.8) | 12 (16.2) | 0.95 | 5 (17.9) | 15 (15.3) | 0.77 |
| >40 | 5 (3.9) | 2 (2.7) | 0.64 | 1 (3.5) | 4 (4.1) | 1.00 |
| Education | ||||||
| Primary or below | 12 (9.5) | 27 (36.5) | <0.001 | 0 | 12 (12.2) | 0.03 |
| Secondary or above | 114 (90.8) | 47 (63.5) | 28 (100) | 86 (87.8) | ||
| Type of facility | ||||||
| Barbershop | 19 (61.3) | 96(56.8) | 0.43 | 19 (67.9) | 41 (41.8) | 0.53 |
| Beauty salon | 11 (36.7) | 74 (43.8) | 13 (46.2) | 48 (48.9) | ||
| Vaccinated for HBV | 4 (3.2) | 0 | 0.12 | 3 (10.7) | 1 (1.0) | 0.02 |
| History of prick | 45 (35.7) | 28 (37.8) | 0.76 | 17 (60.7) | 28 (28.6) | 0.003 |
| Prick>5 times | 22 (17.5) | 17 (22.9) | 0.36 | 6 (21.4) | 16 (16.3) | 0.57 |
DISCUSSION
This study was conducted to assess the knowledge and risks of barbers and beauty salon workers about HBV infection. Despite a moderate level of awareness, participants are poorly informed about HBV transmission and prevention and are at high risk of infection.
At 63%, the level of HBV infection awareness in our study is significantly higher than the previously reported 13% in Nigeria and 1% in Morocco.[5,25] An ongoing global strategy campaign to raise awareness of viral hepatitis, which was officially launched in 2010[26] and was fully adopted in Tanzania in 2018,[26] may have facilitated with this variation. As such, the previous studies reported pre-campaign awareness data, and the general awareness level appears to have improved over the years, according to the most recent data.[27]
The significant knowledge gaps we identified, especially among illiterate people, are similar to those reported in other studies from developing countries. In Ethiopia, only 11% of barbers were found to have good knowledge of HBV transmission and prevention.[22] An experimental study in Egypt revealed a low baseline level (22%) of knowledge of barbers about HBV infection, which increased to 80.7% after the implementation of health educational guidelines.[28] Low knowledge that we detected especially in critical parameters such as sharing and proper decontamination of beauty tools put clients receiving services at these facilities at increased risk of HBV infection.
Furthermore, barbers and beauty salon workers in our study face continuous exposure to HBV, primarily due to the frequent mechanical injuries they sustain, such as cuts, and needle sticks,which increase their risk of contracting the HBV infection. Similar to other studies, mechanical injuries are common among this group. Almost 50% of barbers and hairdressers reported having such incidents in Turkey[28] and more than 55% in Nigeria. Moreover these injuries were correlated with seropositivity of HBV.[15] Thirty-seven participants in this study reported a mechanical injury, of which more than 50% had multiple incidents, which increases the risk of HBV infection. A slight variation in our findings may be explained by reporting bias as the information is from self-reporting. Some of the individuals might either choose not to report some information or could not recall some past injuries. All in all, this risk could have been minimized by vaccination against HBV and following the appropriate post-exposure measures recommended to reduce the chance of HBV transmission. Additionally, cleaning the affected site with water and soap or antiseptic and then attending the medical facility for a thorough serological evaluation, vaccination, and HBV immunoglobulin could have mitigated the risk.[29] However, none of the study participants were familiar with this complete set of procedures and none of them reported having taken three doses of the HBV vaccine according to standard recommendations.[30] Furthermore, only 2.5% participants were partially vaccinated. The low vaccination status is the same as reported in Nigeria, where only one out of 199 barbers and hairdressers was found to have been vaccinated against HBV.[31]
As far as we understand, our study is the first to explore the risks of HBV infection and gaps in related knowledge among barbers and beauty salon workers in Tanzania. These findings complement locally generated evidence to support national HBV control efforts in the country.
CONCLUSION AND IMPLICATIONS FOR TRANSLATIONS
Our study unequivocally shows that due to frequent occupational injuries and inadequate vaccination, barbers and beauty salon workers face an elevated risk of HBV infection. Furthermore, most participants, particularly those without formal training, have a significant lack of knowledge about HBV transmission and prevention, putting clients they serve at high risk of infection.
We propose comprehensive training in HBV transmission and prevention for this group, and we recommend regular oversight of IPC guidelines adherence across all barbershops and beauty establishments to reduce their risk of HBV acquisition and transmission to other customers. Furthermore, the effectiveness of alternative education forums, such as social media in reaching illiterate populations should be investigated. Given their high susceptibility to HBV infection, we recommend prioritizing barbers and beauty care workers in the global HBV vaccination programs.
Key Messages
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Majority of barbers and salon workers did not have adequate knowledge of HBV infection transmission and prevention.
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Barbers, beauty salon workers, and the clients they serve are at increased risk of HBV infection.
Acknowledgments
The authors are grateful to all participants for their support. They would also like to thank the city Medical Officer of Mwanza city for her involvement and permission to conduct this study.
COMPLIANCE WITH ETHICAL STANDARDS
Conflicts of Interest
The authors declare no competing interests.
Financial Disclosure
Nothing to declare.
Funding/Support
There was no funding for this study.
Ethics Approval
Ethical approval to conduct and publish results of the study was obtained from the Joint Ethics Committee of the Catholic University of Health and Allied Sciences /Bugando Medical Center with ethical clearance number 1666/2020.
Declaration of Patient Consent
The authors certify that they have obtained all appropriate patient consent.
Use of Artificial Intelligence (AI)-Assisted Technology for Manuscript Preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Disclaimer
None.
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