Abstract

Introduction: Viral hepatitis B and C remain major public health concerns globally, particularly in Africa. In the Democratic Republic of the Congo (DRC), limited access to screening and treatment contributes to high morbidity and mortality. Healthcare professionals play a critical role in prevention and control efforts, yet their knowledge, attitudes, and practices (KAP) are not well documented in certain regions. Materials and Methods: We conducted a descriptive, cross-sectional study among healthcare professionals in two general referral hospitals in Mbujimayi, DRC, from July 1 to July 31, 2025. Data were collected using a structured electronic questionnaire via KoboCollect. KAP scores were assessed using predefined thresholds and analyzed using descriptive statistics, bivariate tests, and multivariate logistic regression to identify associated sociodemographic factors. Results: Among 191 participants, 90.05% demonstrated adequate knowledge, 93.72% had favorable attitudes, and 86.91% reported good practices. However, only 9.42% believed hepatitis B and C could be cured, and vaccination coverage was low (24.08%). Younger age (<35 years), lower education level, and non-physician roles (especially midwives and nurses) were significantly associated with lower KAP scores (p < 0.05). Fear of death and perceived high treatment costs were common concerns. Conclusion: While overall KAP levels were satisfactory, critical gaps persist in curability awareness and preventive practices, particularly among younger and non-physician staff. Targeted training and improved access to vaccination and treatment are essential to strengthening hepatitis control efforts in the region.

Keywords

Hepatitis B, Hepatitis C, Knowledge, Attitudes and Practices (KAP), Healthcare Workers, Democratic Republic of the Congo, Sub-Saharan Africa

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1. Introduction

Viral hepatitis B and C are among the leading causes of chronic liver disease worldwide, contributing to significant morbidity and mortality. Globally, over 500 million individuals are estimated to be living with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. According to the World Health Organization (WHO), hepatitis B virus (HBV) and hepatitis C virus (HCV) together accounted for approximately 1.3 million deaths in 2022, primarily due to complications such as cirrhosis and hepatocellular carcinoma. Despite being preventable and treatable, these infections continue to pose a major public health challenge, particularly in low- and middle-income countries [1] [2].

Sub-Saharan Africa remains disproportionately affected by viral hepatitis. In 2022, the region reported over 64.7 million people living with chronic HBV infection (5.8% of the population) and nearly 8 million with HCV (0.7% of the population). The annual incidence of new infections and related deaths remains high, exacerbated by limited access to diagnostic services, antiviral therapies, and preventive interventions such as vaccination [2].

In the Democratic Republic of the Congo (DRC), HBV is considered to have intermediate endemicity (3.3%), while HCV prevalence is relatively low (0.9%). However, national data reveal alarmingly low diagnostic coverage (only 2.4% for HBV and 8% for HCV), with over 7800 deaths attributed to these infections, highlighting critical gaps in the health system’s response [3] [4].

HBV, recognized as the second most common human carcinogen after tobacco, is transmitted primarily through contaminated blood products, underscoring the importance of ensuring the safety of blood transfusions. This mode of transmission is particularly relevant in resource-limited settings, where blood screening protocols may be inconsistently applied, and where healthcare workers are frequently exposed to blood and bodily fluids [5] [6].

In recognition of this global challenge, the World Health Organization (WHO) launched the Global Health Sector Strategy on Viral Hepatitis 2021-2030, which aims to eliminate viral hepatitis as a public health threat by 2030. The strategy sets ambitious targets: diagnosing 90% of people living with hepatitis, treating 80% of eligible individuals, and reducing new infections by 90%. In the African region, the WHO Strategic Framework emphasizes early childhood HBV vaccination, improved blood safety, expanded access to diagnostics and treatment, and integration of hepatitis services into primary healthcare. Member States are encouraged to adopt multisectoral approaches and prioritize vulnerable populations, including healthcare workers [7] [8].

Healthcare professionals are central to the success of these efforts. Their knowledge, attitudes, and practices (KAP) directly influence the uptake of screening, vaccination, and treatment services. Inadequate knowledge or negative attitudes among health workers can perpetuate stigma, reduce patient engagement, and compromise the quality of care. Understanding the KAP profile of healthcare providers is therefore essential to inform training programs, policy development, and resource allocation [9] [10].

Mbujimayi, the capital of Kasai-Oriental Province in central DRC, represents a critical setting for such an assessment. Despite being a regional hub, the city faces significant health system challenges, including shortages of diagnostic tools, limited access to vaccines, and insufficient continuing education for health workers. Previous studies in urban centers such as Kinshasa and Lubumbashi have revealed gaps in hepatitis-related KAP among healthcare professionals, but data from more remote provinces remain scarce.

We hypothesized that certain sociodemographic characteristics—such as age, educational level, and professional category—are associated with significant differences in knowledge, attitudes, and practices (KAP) regarding hepatitis B and C.

This study aimed to assess the knowledge, attitudes, and practices of healthcare professionals in Mbujimayi regarding HBV and HCV, and to identify sociodemographic factors associated with suboptimal KAP. By aligning the findings with the WHO Strategic Framework, the study seeks to highlight opportunities for targeted interventions and contribute to national efforts toward hepatitis elimination in the DRC.

2. Materials and Methods

2.1. Study Design and Setting

We conducted a descriptive, analytical cross-sectional study between July 1 and July 31, 2025, in Mbujimayi, the capital of Kasai-Oriental Province in the Democratic Republic of the Congo (DRC). The study was carried out in two general referral hospitals located in distinct health zones: Saint Jean Baptiste General Referral Hospital in the Diulu Health Zone and Muya General Referral Hospital in the Muya Health Zone.

2.2. Study Population

The target population included healthcare professionals working in the selected hospitals. Participants were categorized into two main groups: medical professionals (general practitioners and specialists) and paramedical professionals (nurses, laboratory and imaging technicians, nutritionists, physiotherapists, anesthesiologists, and midwives). Inclusion criteria were being employed at one of the two hospitals and providing informed consent to participate in the study.

2.3. Sample Size and Sampling

We calculated the sample size using the formula for cross-sectional studies:

$n=\frac{Z^2\cdot p\left(1-p\right)}{d^2}$

The minimum required sample size was estimated at 151 participants, assuming an expected proportion of 50% for adequate knowledge, a precision of 8%, and a 95% confidence level. Our final sample (n = 191) exceeded this threshold.

A non-probabilistic, voluntary sampling approach was used. All eligible healthcare workers who agreed to participate during the study period were included. The final sample comprised 191 respondents.

2.4. Data Collection

Data were collected using a structured electronic questionnaire developed in KoboCollect and administered via Android smartphones. A pilot study was conducted from June 15 to 30, 2025, among 30 healthcare professionals from two hospitals in the city of Mbujimayi not included in the study, with the aim of pretesting the questionnaire to ensure the clarity and consistency of the items. The pre-tested questionnaire was administered by four trained third-year undergraduate students in Biomedical Sciences, under the supervision of a physician-academic assistant. Prior to fieldwork, all enumerators received one day of training covering: 1) research ethics and informed consent procedures; 2) administration of standardized questionnaires (avoiding leading questions); 3) neutral interview techniques; and 4) operation of the KoboCollect system. The survey covered all hospital departments, including Internal Medicine, Pediatrics, Gynecology-Obstetrics, Surgery, Laboratory, Imaging, Dentistry, Physiotherapy, and Pharmacy.

2.5. Variable

The questionnaire captured sociodemographic characteristics (age, gender, marital status, education level, profession, residence, and religion), as well as knowledge, attitudes, and practices (KAP) related to viral hepatitis B and C.

• Knowledge was assessed using 11 items covering general awareness, transmission routes, symptoms, complications, prevention, and vaccination. Scores ranged from 0 to 28. A score ≥ 14 was considered adequate, aligned with WHO standardized KAP surveys. This threshold reflects competence in identifying key hepatitis facts and transmission prevention strategies.

• Attitudes were measured using 4 items (maximum score: 6), including perceived risk, emotional response to diagnosis, and perceived cost of care. A score ≥3 was considered favorable.

• Practices were evaluated using 5 items (maximum score: 5), including screening history, vaccination status, and behavior toward infected individuals. A score ≥3 was considered good.

The cut-off points used to classify KAP scores (knowledge ≥ 14, attitudes ≥ 3, practices ≥ 3) were based on similar studies conducted in sub-Saharan Africa, ensuring comparability of findings across contexts.

2.6. Statistical Analysis

Data were exported to Stata version 16 for analysis. Descriptive statistics summarized participant characteristics and KAP levels. Bivariate analyses (Chi-square or Fisher’s exact test, as appropriate) were used to identify associations between sociodemographic variables and KAP outcomes. Variables with p ≤ 0.20 in bivariate analysis were included in multivariate logistic regression models to adjust for potential confounders. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were reported. Statistical significance was set at p < 0.05.

2.7. Ethical Considerations

Ethical approval was obtained from the Institutional Ethics Committee of the University of Mbujimayi (Approval No. 002/CEI/UM/2023). Written authorization was also secured from the Faculty of Medicine, Pharmacy and Public Health, and from the administrative authorities of both hospitals. All participants provided informed consent, and confidentiality and anonymity were strictly maintained throughout the study. All data collected via KoboCollect were anonymized and securely stored on password-protected servers, in compliance with ethical standards for electronic data management.

3. Results

3.1. Participant Characteristics

A total of 191 healthcare professionals participated in the study.

Table 1. Distribution of the study population by sociodemographic characteristics.

*Except for variables whose parameters are specified next to the variable name.

The mean age was 36 ± 7 years, with 63.35% aged 35 years or older. The majority were male (61.26%) and married (70.68%). Regarding education, 43.98% were medical doctors, 19.37% held a bachelor’s degree, 17.80% had an associate degree, and 17.28% had a secondary school certificate. Most participants resided in the communes of Kanshi (28.27%), Muya (25.65%), and Dibindi (20.94%). Professionally, doctors represented 45.55% of the sample, followed by nurses (36.13%), laboratory technicians (9.95%), and midwives/nutritionists (4.19% each). Nearly all participants identified as Christian (97.38%) (Table 1).

3.2. Knowledge, Attitudes, and Practices of Healthcare Workers on Viral Hepatitis

Figure 1 shows the frequency of adequate knowledge, favorable attitudes, and good practices among participants.

Figure 1. Assessment of healthcare providers’ knowledge, attitudes, and practices regarding HBV and HCV in the two hospitals in Mbujimayi.

3.2.1. Knowledge of Healthcare Workers on Viral Hepatitis

Overall, 90.05% of participants demonstrated adequate knowledge of hepatitis B and C (Figure 1). Table 2 presents participants’ knowledge of viral hepatitis.

Table 2. Distribution of the study population according to knowledge about HBV or C.

Most had heard of viral hepatitis (97.38%) and knew it affects the liver (95.28%). Commonly recognized types included HBV (24.60%), HCV (24.08%), and HAV (22.51%). Knowledge of transmission routes was high: contaminated blood (93.71%), unprotected sex (91.62%), sharp objects (89%), mother-to-child transmission (81.67%), and tattoos (60.73%). While 94.24% acknowledged the potential for complications, only 9.42% believed hepatitis B or C could be cured. Prevention methods were well known, with 94.24% citing vaccination and 78.53% mentioning pre-transfusion screening. However, only 89.53% knew that HBV vaccination is available for children (Table 2).

3.2.2. Attitudes toward Viral Hepatitis

A favorable attitude was observed in 93.72% of participants (Figure 1). Table 3 presents participants’ attitudes toward Viral Hepatitis.

Table 3. Distribution of the study population according to attitudes and perceptions toward viral hepatitis B and C.

Most believed they could contract hepatitis (81.67%) and would seek hospital care if diagnosed (31.93%). Fear was the most common emotional response (32.11%), followed by concern about death (51.83%) and transmission to family members (16.23%). The cost of diagnosis and treatment was perceived as high by 81.68% of respondents (Table 3).

3.2.3. Prevention and Care Practices

Good practices were reported by 86.91% of participants (Figure 1). Table 4 presents participants’ practices regarding prevention and care of viral hepatitis.

Table 4. Distribution of the study population according to practices regarding hepatitis B and C.

A large majority had undergone screening for hepatitis B or C (93.68%), primarily during blood donation (72.47%) or voluntary testing (67.41%). However, only 24.08% had been vaccinated against hepatitis B, and 3.14% had received treatment for hepatitis. Most participants (94.21%) expressed willingness to interact with infected individuals, and 81.68% considered the vaccine safe (Table 4).

3.3. Factors Associated with Knowledge, Attitudes, and Practices

Table 5. Factors associated with adequate knowledge of viral hepatitis B and C.

Among the 87 doctors, 3 were specialists (CS) and 84 were general practitioners.

In the analysis of factors associated with knowledge (Table 5), education level and professional category emerged as the strongest predictors. Physicians demonstrated the highest levels of knowledge, while midwives and laboratory technicians showed markedly lower scores. Although younger age (<35 years) was associated with poorer knowledge in unadjusted analysis, this effect was not sustained after adjustment.

Table 6. Factors associated with adequate attitude towards viral hepatitis B and C.

Among the 87 doctors, 3 were specialists (CS) and 84 were general practitioners.

Regarding attitudes (Table 6), most healthcare professionals exhibited favorable perceptions toward hepatitis B and C. However, professional category remained a significant determinant, with midwives showing notably less favorable attitudes. No other sociodemographic variable was significantly associated with attitude levels.

Table 7. Factors associated with adequate practice of viral hepatitis B and C.

Among the 87 doctors, 3 were specialists (CS) and 84 were general practitioners.

As for practices (Table 7), younger age, lower education, and non-physician roles were independently associated with suboptimal preventive behaviors. Midwives and nurses were less likely to report good practices, particularly in vaccination and care-seeking. These findings underscore the need for targeted interventions among younger and non-medical staff to improve hepatitis-related practices.

4. Discussion

4.1. Knowledge, Attitudes, and Practices of Healthcare Workers on Viral Hepatitis

This study conducted in Mbujimayi, Democratic Republic of the Congo, revealed that most healthcare professionals demonstrated satisfactory levels of knowledge, attitudes, and practices (KAP) regarding hepatitis B and C. However, significant disparities persist across age groups, education levels, and professional categories. These findings are consistent with those reported in other African settings and underscore the need for targeted interventions to address persistent gaps in hepatitis-related competencies among healthcare workers.

Knowledge levels were highest among physicians and those with advanced education, while midwives and laboratory technicians exhibited significantly lower scores. Similar trends have been documented in Ethiopia, where Hebo et al. found that although 73.9% of healthcare workers had good knowledge of HBV, only 42.6% demonstrated good preventive practices, and vaccination coverage remained low (25%) [11]. In Liberia, Freeman et al. reported that only 35.9% of healthcare workers had completed the HBV vaccination schedule, despite high awareness of transmission risks [12]. In South Africa, Mashilo et al. observed that while 83% of primary healthcare staff had good knowledge of HBV epidemiology, only 40% demonstrated adequate understanding of prevention and management strategies [13].

Attitudes toward hepatitis were generally favorable in our study, with most participants recognizing their vulnerability and expressing willingness to seek care if diagnosed. Nonetheless, midwives were significantly less likely to report favorable attitudes, even after adjustment. This finding aligns with studies from Ghana and Sudan, which highlighted similar attitudinal gaps among paramedical staff [14]. Fear of death and concerns about treatment costs were prevalent, echoing findings from Burkina Faso and Sierra Leone, where stigma and limited access to care were identified as major barriers to effective hepatitis management [14] [15].

Preventive and care practices were widely adopted, particularly screening, which was reported by over 93% of participants. However, vaccination coverage remained low (24.08%), and only a small fraction had ever received treatment. These findings mirror those from Ghana, where Kumah et al. found that although 100% of public health students were aware of HBV vaccination, only 58.8% had been vaccinated, and cost was a major barrier [16]. In a pan-African study involving 12 countries, Shah et al. reported that only 61% of healthcare workers were vaccinated against HBV, with significant disparities between East and West Africa, and cost cited as the most frequent reason for non-vaccination [14].

The finding that only 9.42% of participants believe hepatitis B or C can be cured may negatively affect patient counseling and adherence to treatment. Targeted educational interventions are needed to correct this misconception among healthcare workers.

The most commonly identified transmission routes—contaminated blood, unprotected sex, and sharp objects—are consistent with findings from studies in Dakar [17]. However, awareness of hepatitis virus types beyond B and C remains limited, as also reported in Morocco [18] and Ghana [16].

Our findings indicate descriptive associations between sociodemographic characteristics and KAP scores. Given the cross-sectional design, these results should not be interpreted as causal relationships.

4.2. Implications for Practice and Policy

Taken together, these findings highlight the need for structured continuing education programs, improved access to hepatitis vaccines, and enhanced communication strategies to address misconceptions and promote evidence-based practices. Aligning these efforts with the WHO Strategic Framework for Viral Hepatitis 2021-2030 will be essential to achieving national and regional elimination goals.

Future educational programs should emphasize the distinction between hepatitis B, which is preventable through vaccination, and hepatitis C, which is highly curable with modern antiviral therapies. This differentiation is critical for effective prevention and treatment strategies.

4.3. Limitations

This study has several limitations. First, its cross-sectional design precludes any inference of causality between sociodemographic factors and KAP outcomes. Second, data were collected through self-reported questionnaires, which may be subject to social desirability bias, particularly regarding attitudes and practices. Third, the study was conducted in only two hospitals in Mbujimayi, limiting the generalizability of findings to other regions of the Democratic Republic of the Congo or sub-Saharan Africa. Moreover, the use of non-probabilistic, voluntary sampling may introduce selection bias, limiting the representativeness of our findings. Therefore, results should be interpreted as specific to the two hospitals included in this study. Fourth, the absence of serological testing prevented correlation between reported practices and actual hepatitis B or C infection status. Finally, the low vaccination rate reported may reflect both limited access and recall bias, as many participants were unsure of their vaccination history.

Despite these limitations, the study provides valuable insights into hepatitis-related KAP among healthcare professionals in a resource-limited setting and highlights key areas for intervention aligned with WHO elimination targets.

5. Conclusion

This study highlights both strengths and gaps in the knowledge, attitudes, and practices of healthcare professionals in Mbujimayi regarding hepatitis B and C. While overall awareness and screening practices are encouraging, significant disparities persist among younger, less-educated, and non-physician staff, particularly midwives and nurses. Low vaccination coverage and limited understanding of curability reflect systemic barriers and missed opportunities for prevention. These findings underscore the urgent need for targeted training, improved access to vaccination, and integration of hepatitis services into routine care. Aligning local efforts with the WHO Strategic Framework for Viral Hepatitis 2021-2030 will be essential to advancing hepatitis elimination goals in the Democratic Republic of the Congo and across sub-Saharan Africa.

Contributions and Responsibilities of the Authors

André K.K. and Gloria K.L. wrote the study protocol. Darla N.C., Gloria K.L., Meseje K.M., Japhet T.N., and Daniel K.C. collected the data under the supervision of André K.K.; Stéphanie M.K. and André K.K. analyzed the data. Claude M.M. and André K.K. drafted the “Discussion”. Joris L.L. led the study from protocol development to conclusion.

Acknowledgements

The authors wish to express their sincere gratitude to the administrative and medical leadership of the Saint Jean Baptiste and Muya General Referral Hospitals in Mbujimayi for their support and collaboration throughout the study. We also acknowledge the contribution of the third-year Biomedical Sciences students from the University of Mbujimayi who assisted in data collection. Special thanks are extended to the Faculty of Medicine, Pharmacy, and Public Health for facilitating the ethical and logistical aspects of the research. Finally, we thank all the healthcare professionals who participated in the study for their time and valuable insights.

Conflicts of Interest

The authors declare that they have no competing interests.

References