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Risk perception for Hepatitis B Virus (HBV) infection among health care workers in Accra,Ghana

Open AccessPublished:November 26, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101189

      Abstract

      Background

      Hepatitis B Virus (HBV) infection is recognized as one of the most important occupational hazards to Health Care Workers (HCWs) globally. HCWs having good risk perception, is critical in adopting and adhering to preventive measures against occupational exposures and subsequent infection with the virus. This study assessed the level of risk perception for HBV infection among healthcare workers in five healthcare settings in Accra, Ghana, and identified how risk perception for HBV varies across the various professional categories.

      Method

      A cross-sectional study was conducted among six cadres of healthcare workers from five facilities in 2019. A structured questionnaire and susceptibility sub-scale was adapted and used to collect data. Data were analyzed using SPSS Software version 25.

      Results

      There were 313 HCWs who participated in the study. Mean age, 35 years (±7.6). The overall mean risk perception score was 92.3. There was a significant difference in risk perception scores between the six cadres of staff (F = 3.26, df 312, p = 0.007). A Post Hoc analysis showed a significant difference between the risk perception scores of Doctors and Orderlies, mean difference of 6.723, (p = 0.017; 95% CI = 0.83–12.60). Post-tertiary level education and training in infection prevention and control were significantly associated with high-risk perception for HBV.

      Conclusion

      HCWs have a high-risk perception for HBV infection and the risk perception varies across the various professional categories. The high level of risk perception observed in this study could be utilized to design preventive interventions for healthcare workers to prevent occupational exposures and subsequent infections.

      Keywords

      1. Introduction

      Hepatitis B Virus (HBV) which causes Hepatitis B virus infection is one of the leading blood-borne pathogens afflicting humans. And it is also known to be the most common chronic viral infection in the world.
      • Trepo C.
      • Chan H.
      • Lok A.
      Hepatitis B virus infection.
      This infection is one of the major global health problems and the 10th leading cause of death at the global level. WHO estimates that 296 million people were living with the chronic form of hepatitis B infection in 2019, with 1.5 million new infections occurring each year.
      • World Health Organization
      Hepatitis B [Internet]. Fact Sheet.
      The mechanism of transmission of HBV is diverse. In areas of high endemicity, HBV is transmitted mostly vertically from infected mothers to new-borns. In low-endemic areas, however, sexual transmission is predominant. The third major source of infection is unsafe injections, blood transfusions, or dialysis. Others include nosocomial transmission which is acquired through contaminated medical, surgical, or dental instruments, needle-stick injuries, and many more.
      • Trepo C.
      • Chan H.
      • Lok A.
      Hepatitis B virus infection.
      All over the world, Health Care Workers (HCWs) are constantly in contact with patients and their blood and body fluids and therefore are at constant risk of nosocomial transmission of HBV.
      • Sagoe C.
      • Pearson R.
      Risks to health care workers in developing countries.
      HBV infection is therefore recognized as one of the most important occupational hazards to HCWs globally.
      • Prüss-üstün A.
      • Rapiti E.
      • Hutin Y.
      • Campbell-lendrum D.
      • Corvalán C.
      • Woodward A.
      Sharps injuries Global burden of disease from sharps injuries to health-care workers.
      Studies have shown that, out of 36 million HCWs worldwide, 3 million (12%) sustain exposures each year of which close to 2 million HCWs are directly exposed to HBV annually.
      • World Health Organization
      Hepatitis B [Internet]. Geneva - Switzerland.
      The rates of HBsAg and antianti-HBc positivity which denote HBV infection and lifetime exposure to HBV in healthcare workers reported in several studies published in the last three decades range from 0.1% to 8.1% and from 6.2% to 73.4%, respectively.
      • Coppola N.
      • De Pascalis S.
      • Onorato L.
      • Calò F.
      • Sagnelli C.
      • Sagnelli E.
      Hepatitis B virus and hepatitis C virus infection in healthcare workers.
      In Ghana, however, the prevalence of HBV among HCWs was estimated to be 5.9%.
      • Senoo-Dogbey
      Distribution of serological markers of hepatitis B virus infection among health care workers in Ghana.
      HBV infection is preventable. Among HCWs, vaccination is considered the most cost-effective preventive measure in addition to adhering to universal precautions, proper sterilization of medical equipment, and appropriate hospital waste management.
      • Rachiotis G.
      • Goritsas C.
      • Alikakou V.
      • Ferti A.
      • Roumeliotou A.
      Vaccination against hepatitis B virus in workers of a gene hospital in Athens.
      These preventive practices are important for the realization of the global vision of elimination of viral hepatitis as an important public health threat by 2030.
      HCWs having good risk perception, that is the feeling of being susceptible to HBV infection is critical in adopting and adhering to preventive measures against occupational exposures and subsequent infection with the virus.
      In Ghana, the prevalence of HBV infection otherwise known as HBsAg positivity is high among the Ghanaian general population. A recent systematic review and meta-analysis estimated a pooled prevalence of 12.3%.
      • Ofori-Asenso R.
      • Agyeman A.A.
      Hepatitis B in Ghana: a systematic review & meta-analysis of prevalence studies (1995-2015).
      Among HCWs who are at high risk of HBV infection, a prevalence of 5.9% has been estimated.
      • Senoo-Dogbey
      Distribution of serological markers of hepatitis B virus infection among health care workers in Ghana.
      HBV vaccination coverage among HCWs is suboptimal as only 53.5% had received at least one dose of the vaccine in a recent study.
      • Ansa G.A.
      • Ofori K.
      • Houphouet E.E.
      • et al.
      Hepatitis B vaccine uptake among healthcare workers in a referral hospital.
      HCWs in Ghana have varied knowledge levels regarding HBV, its transmission, and prevention with most studies reporting fair to suboptimal knowledge in these areas.
      • Afihene M.
      • Duduyemi B.
      • A-Tetteh H.-L.
      • Khatib M.
      Knowledge, attitude and practices concerning Hepatitis B infection, among healthcare workers in Bantama, Ghana: a cross sectional study.
      ,
      • Aniaku J.K.
      • Amedonu E.K.
      • Fusheini A.
      Assessment of knowledge, attitude and vaccination status of hepatitis B among nursing training students in ho, Ghana.
      Information on the level of risk perception for HBV among HCWs in Ghana is unavailable therefore this current study aims to determine the level of risk perception for HBV infection among healthcare workers in five different healthcare settings in Accra, Ghana, and also identify how risk perception for HBV varies across the various professional categories.

      2. Methods

      2.1 Study design, study settings, and participants

      This study was a hospital-based cross-sectional analytical study that recruited healthcare workers from six different professional groupings. The participants were recruited from five public health institutions in the Greater Accra Region. The study was done in the 2nd half of the year 2021. A pre-tested questionnaire with closed-ended questions as well as questions with a 5-point Likert scale was used to collect data.
      This present study was undertaken in the Greater Accra Region located in the southeastern part of Ghana. The region has the smallest land size compared to the other 15 administrative regions of the country, occupying 1.4% of the total land area. The region is the second most populous region and harbors 17.7% of the total population. The Greater Accra Region has the highest number of healthcare workers. There are 29 health administrative districts and 1297 health institutions consisting of one regional hospital, 10 district hospitals, 118 general hospitals, 21 polyclinics, 292 clinics, 35 health centers, 707 CHPS compounds, and 106 maternity homes. The rest are, three university hospitals, two teaching hospitals, and two psychiatric hospitals.
      The choice of the Greater Accra region as a study region was purposeful given that this region has the highest number of HCWs compared to other regions in the country.

      2.2 Study population

      The study was opened to Nurses, Doctors, Laboratory staff, Anaesthetists, Orderlies, and Physician Assistants who were recruited from five levels of care namely, Regional Hospital, District Hospital, Policlinic, Health center, and Community–based Health Planning Services (CHPs). Each facility was selected randomly from the five levels except for the regional hospital which was selected purposively since it is the only regional hospital in the Greater Accra Region. The random selection of health facilities was to allow for the representation and inclusion of HCWs from all levels in the healthcare system in the study and to assess the impact of the facility level on risk perception for HBV.
      Inclusion Criteria Healthcare workers with an employment history of two years and above,18 years and above, and belonging to the six professional categories (Nurses, Doctors, Laboratory staff, Anaesthetists, Orderlies, and Physician Assistants) were those who were included in the study.

      2.3 Sample size estimation and sampling procedure

      The traditional formula used mainly in cross-sectional studies proposed by Cochran was used to estimate the sample size No=Z2pqd2
      • Cochran W.G.
      Sampling Techniques [Internet].
      given that, N0 = sample size, Z = the z-score that corresponds with 95% confidence interval (1.96), p = proportion of HCWs who have a high-risk perception for HBV, (50.0%, = 0.5) q = 1-P and d = margin of error set at 5% (0.05). Because sampling was done from a finite population and given the fact that HCWs were stratified into professional categories, a design effect and population correction factors were considered, therefore the minimum sample size of 313 was deemed adequate to detect any potential difference between HCWs with high and low-risk perceptions for HBV. The overall sample size was proportionally allocated to the five selected facilities based on size (their human resource strength or manpower). Within each of the selected health facilities or study sites, the required numbers from each cadre of health staff were chosen based on probability proportionate to size. Finally, within each professional category, a random sampling procedure was utilized using the HCW category-specific staff list as a sampling frame.

      2.4 Data collection instrument and procedure

      A pretested questionnaire which was self–administered was used to collect data from consenting HCWs. The questionnaire was in two parts. The first part had 13 items and elicited responses on socio-demographic and occupational variables (age, sex, occupational category, duration of employment, etc) whereas the second part had 6 items with 5 points Likert scale (Cronbach's alpha of >0.7.) The scale was adapted from the susceptibility subscale of the modified Champion's Health Belief Model Scale (CHBMS).
      • Champion V.L.
      • Reblin M.
      • Kasting M.L.
      • et al.
      Revised susceptibility , benefits and barriers scale for mammography screening.
      The questions in the scale were to test the participants feeling of susceptibility or vulnerability to HBV. This validated scale which has been used in assessing risk principally for breast cancer and very recently HBV infection was adapted and used in this study to measure HCWs' perceived susceptibility to HBV infection. The scale is an ordinal 5-point Likert's scale with responses ranging from ‘Strongly Agree’ ‘Agree’, ‘Neutral’, ‘Disagree’ and ‘strongly disagree’ which were awarded the marks of five, four, three, two, and one respectively giving a total obtainable score of 20. Even though this scale has not been validated in Ghana, it has been translated and validated in many countries (including Malaysia) with different cultural contexts and is trans-culturally adaptable.
      • Lee E.H.
      • Kim J.S.
      • Song M.S.
      Translation and validation of Champion's health belief model scale with Korean women.
      • Noroozi A.
      • Jomand T.
      • Tahmasebi R.
      Determinants of breast self-examination performance among Iranian women: an application of the health belief model.
      • Dewi T.K.
      Validation of the Indonesian version of champion's health belief model scale for breast self-examination.
      • Parsa P.
      • Kandiah M.
      • Mohd Nasir M.T.
      • Hejar A.R.
      • Nor-Afiah M.Z.
      Reliability and validity of Champion ’ s Health Belief Model Scale for breast cancer screening among Malaysian women.
      • Cummings K.M.
      • Jette A.M.
      • Rosenstock I.M.
      Construct validation of the health belief model.
      A recent study seeking to assess the perception of susceptibility to HBV infection among immigrants from south Asia successfully applied the susceptibility sub-scale of the modified Champion's health believe model in measuring risk perception for HBV infection.
      • Kue J.
      • Thorburn S.
      • Szalacha L.A.
      Perceptions of risk for hepatitis B infection among the Hmong.
      The research instrument was self-administered in all cases. It took each participant about 20–30 min to complete the questionnaire. All eligible participants returned the questionnaire.

      2.5 Data management and analysis

      Data were analyzed using SPSS version 21. Descriptive statistics (frequencies, means, etc) were used to summarize data. The analysis of Variance (ANOVA) procedure was undertaken to compare the mean risk perception scores among the six cadres of staff. A Games Howell Post-Hoc analysis was undertaken to identify the source of differences in the mean risk perception scores. A generalized linear model analysis was done to identify the factors associated with good risk perception for HBV. Level of significance was set at <0.005.

      2.6 Ethical considerations

      Ethical clearance was obtained from the Ghana Health Service Ethics Review committee (GHS/GARHD/006/17). Permission was sought from the facility/institutional heads before the participant recruitment. The overall purpose of the study, its nature, and its procedures were clearly explained after which they provided written consent to participate in the study. Appointments were sought from the eligible participants before approaching them. All source documents including the questionnaires were de-identified to ensure anonymity.

      3. Results

      3.1 Baseline characteristics of study participants

      A total of 313 HCWs from six professional categories participated in the study. The mean age of the participants was 35 years with a Standard Deviation (SD) of ±7.6. Majority (62.0%) of the participants were below age 30. Most of the participants were females (73.8%) and were recruited from higher-level facilities (68.0%) (Regional and district hospitals as well as polyclinics). Most of the participants (54.3%) worked at departments and units with low to moderate exposure to blood and body fluids. In all, 12.0% of the study participants had attained post-tertiary level of education. Nurses and midwives dominated the sample (48.8%), followed by doctors (20.4%). Attendance of workshops or training on the prevention of blood-borne infections was widespread with 81.5% having attended at least one training. Most of the participants, (76.7%) had an employment history of fewer than 10 years (Table 1).
      Table 1Personal and occupational characteristics of study participants.
      VariableN (313)Percent (%)
      Age categories
      ≤3019462.0
      >3011938.0
      Facility Type
      Lower Level10032.0
      Higher level21368.0
      Education Level
      Tertiary and below27588.0
      Post Tertiary3812.0
      Work Unit
      Unit with low to moderate exposure17054.3
      Units with high risk of exposure14345.7
      Employment history
      <10 Years24076.7
      ≥10 Years7323.3
      Infection prevention Workshop Attendance
      No5918.5
      Yes25481.5
      Gender
      Female23173.8
      Male8226.2
      Professional Category
      Doctor6420.4
      Nurse/Midwife15348.8
      Anaesthetist144.5
      Laboratory staff3711.9
      Orderly278.6
      Physician Assistants185.8

      3.2 Risk perception for hepatitis B infection

      The mean risk perception scores obtained ranged from a minimum of 87.8 to a maximum of 95.3 with a SD of ±8.97 and an overall percentage mean score of 92.3%; an indication of a high level of risk perception for HBV among the HCWs surveyed. In all, the majority representing 300(95.8. %) obtained good risk perception scores of over 75.0%.
      Table 2 shows the distribution of risk perception scores by the various sociodemographic and occupational variables. An Analysis of Variance (ANOVA) procedure did not reveal any significant statistical difference between males and females with regards to risk perception score (F = 0.819; df = 312; P = 0.366). However, results presented in Table 3 Show that there is a statistically significant difference between risk perception scores obtained by the various cadre of staff or professional categories (F = 3.26; df 312; p = 0.007). Results from a post hoc analysis using the Games Howell method identified the source of the differences in risk perception scores to be between scores of Doctors and Orderlies with a mean difference of 6.723, (p = 0.017; 95% CI = 0.83–12.60.
      Table 2Distribution of Risk Perception Score by Personal and occupational factors.
      VariableRisk Perception Score
      N(313)Mean (%)Standard Deviation
      Age Categories
      ≤3019492.87.9
      >3011991.510.5
      Facility type
      Lower Level10091.010.0
      Higher level21392.98.4
      Educational Level
      Tertiary and below27591.89.3
      Post Tertiary3895.65.5
      Work unit
      Units with low to moderate exposure17091.59.2
      Units with high risk of exposure14293.28.6
      Employment History
      <10 Years24092.09.2
      ≥10 Years7393.48.0
      Infection prevention workshop attendance
      No5989.810.2
      Yes25492.98.6
      Gender
      Female23192.08.8
      Male8293.19.5
      Overall31392.308.96
      Table 3Risk perception scores by various professional categories or cadre of staff.
      Cadre of staffNMean Risk Perception ScoreStandard Deviation (SD)
      Doctor6494.556.94
      Nurse/Midwife15391.338.81
      Anaesthetist1495.319.28
      Laboratory staff3793.4411.13
      Orderly2787.839.16
      PA1894.458.57
      Total31392.298.97
      F = 3.26 P = 0.007.

      3.3 Factors associated with good risk perception for HBV among HCWs

      Table 4 shows that respondents with post-tertiary level education had 3.72% higher risk perception than respondents with tertiary level education. Also controlling for other factors, having a post-tertiary level of education increased the average risk perception index by 3.15%. The education effect on risk perception is significant with p-values of 0.045.
      Table 4Factors associated with high-risk perception for hepatitis B virus Infection among Health care workers.
      VariablesUnadjusted EffectsAdjusted Effects
      BStd. Err.Sig95% CI Lower95% CI UpperBStd. Err.Sig.95%CI Lower95% CI Upper
      Training3.0981.2870.0160.5765.6192.5891.3110.0480.0215.159
       Trained
       Not Trained*
      Education3.7541.5510.0160.7146.7953.1511.5720.0450.0716.231
       Postgraduate and above
       Below Postgraduate*
      Cadre−0.0371.1010.973−2.1952.1220.9051.1720.440−1.3913.200
       Doctors/Nurses
       Other categories*
      Sex−1.0441.1530.365−3.3041.216−0.5651.2030.638−2.9241.793
       Males
       Females*
      Unit Of Work3.2021.0010.0011.2415.1653.0181.0530.0041.0005.081
       Critical Units
       Non-Critical Units*
      Facility Type1.8621.0840.086−0.2623.9861.0961.1190.327−1.0953.288
       Higher Levels
       Lower Levels*
      Age−1.2441.0430.233−3.2890.801−1.1341.1150.309−3.3191.052
       <30 Years
       >30 Years*
      Length Of Service1.4211.1980.235−0.9273.7690.4321.2720.734−2.0612.924
       >10 years
       <10 Years*
      • Reference group*.
      Respondents who were trained on the prevention of blood-borne infections recorded a risk perception of 3.1% more than their untrained peers, whilst adjusting for effects of other factors on risk perception, HCWs who were trained had an average risk perception of 2.58% more than their counterparts who did not attend a training, p values of <0.0048.

      4. Discussion

      4.1 Risk perception for HBV infection

      This study recognized that a high degree of risk perception for HBV is fundamental for HCWs in adopting preventive behavior to protect themselves from occupational exposure and subsequently prevent HBV infection. This was conceptualized based on concepts by the theorists of the Health Belief Model and some other researchers
      • Ferrer R.
      • Klein W.M.
      Risk perceptions and health behavior.
      who strongly proposed that the formation of good risk perceptions has implications for health behaviors. A high-risk perception for HBV was observed in this study with an overall risk perception index mean score of 92.3. This finding is similar to a findings from a study conducted in Japan that suggested that HCWs had high-risk perceptions for hospital Acquired Infections (HAIs) such as Severe Acute Respiratory Syndrome (SARS) and that 92% of the study participants were afraid of contracting SARS.
      • Imai T.
      • Takahashi K.
      • Hoshuyama T.
      • Hasegawa N.
      • Lim M.-K.
      • Koh D.
      SARS risk perceptions in healthcare workers,Japan.
      This present study's findings corroborate evidence from another West African country where researchers found a high-risk perception for HIV among community health workers with 96.5% of the respondents admitting they were at moderate to high risk of contracting HIV from their work environments.
      • Akinboro A.A.
      • Adejumo O.P.
      • Onibokun C.A.
      • Olowokere E.A.
      Community health care workers' risk perception of occupational exposure to HIV in ibadan, south-west Nigeria.
      On the contrary, a study done in Jos, Nigeria specifically on HBV found a lower overall risk perception score of 76.8% among HCWs.
      • Chingle M.P.
      • Osagie I.A.
      • Adams H.
      • Gwomson D.
      • Emeribe N.
      • Zoakah A.I.
      Risk perception of hepatitis B infection and uptake of hepatitis B vaccine among students of tertiary institution in Jos.
      Though the Nigerian study bears similarities with the current study in terms of applying a five-point Likert scale to measure risk perception, the study populations differ in that the Nigerian study included administrative staff. This category of HCWs may have a low-risk perception since they have minimal exposure to blood and body fluids and for that matter feel less vulnerable or susceptible to HBV.
      There is enough evidence to support the fact that in situations where risk perception is good enough people would take up preventive behaviors such as vaccination.
      • Chaudhari C.N.
      • Bhagat M.R.
      • Ashturkar A.
      • Misra R.N.
      Hepatitis B Immunisation in Health Care Workers. Med Journal, Armed Forces India [Internet].
      Therefore, the overall high-risk perception for HBV observed in this study is an important factor to spiral on to ensure that HCWs take up preventive behavior including HBV vaccination.
      The study also revealed a statistically significant difference in risk perception for HBV among the six categories of HCWs surveyed. Anesthetists demonstrated the highest risk perception whereas hospital sanitation workers also referred to as ward orderlies had the least risk perception for HBV. Few studies similarly reported low-risk perception for blood-borne infections among hospital sanitary workers. For example, a study done in a teaching hospital in Nigeria revealed that doctors, nurses, and laboratory staff were more likely to perceive themselves to be at higher risk of blood-borne infections compared to orderlies.
      • Hassan M.
      • Awosan K.J.
      • Nasir S.
      • et al.
      Knowledge, risk perception and hepatitis B vaccination status of healthcare workers in usmanu danfodiyo university teaching hospital, sokoto, Nigeria.
      Similar observations were made among sanitation workers or orderlies in another lower-level facility in another West African Country.
      • Abiodun O.
      • Shobowale O.
      • Elikwu C.
      • et al.
      Risk Perception and Knowledge of Hepatitis B Infection Among Cleaners in a Tertiary Hospital in Nigeria: A Cross-Sectional Study. Clin Epidemiol Glob Heal [Internet].
      The lower risk perception for HBV among sanitation workers could negatively influence their willingness to take up preventive behaviors such as vaccination against HBV since research evidence is available to show that the main driver for vaccination uptake by an individual is high-risk perception for the disease.
      • Betsch C.
      • Wicker S.
      E-health use, vaccination knowledge and perception of own risk: drivers of vaccination uptake in medical students.
      The low-risk perception for HBV in this sub-group of HCWs could explain the higher prevalence of HBV infection compared to the other cadres or categories of staff as reported in a recent study among HCWs in the southern part of Ghana.
      • Senoo-Dogbey
      Distribution of serological markers of hepatitis B virus infection among health care workers in Ghana.
      Again, a statistically significant difference in risk perception was observed between HCWs with lower educational status, those who lacked training in the prevention of blood-borne infections, and their highly educated and trained counterparts. This finding is consistent with findings from previous studies suggesting that there are variations in risk perception across the various cadre of health staff and that variations in the level of education and quantity and quality of In-service training in blood-borne infections and their prevention could account for the differences in risk perception.
      • Abiodun O.
      • Shobowale O.
      • Elikwu C.
      • et al.
      Risk Perception and Knowledge of Hepatitis B Infection Among Cleaners in a Tertiary Hospital in Nigeria: A Cross-Sectional Study. Clin Epidemiol Glob Heal [Internet].
      This observation calls for the re-designing of preventive training programs to meet the needs of those with a lower level education. For such individuals, simulation exercises and job, training are the most cost-effective. The hospital sanitation workers or ward orderlies recorded the lowest risk perception score. There is a great need for this population subgroup to be re-evaluated to identify their needs and there is also the need for this sub-group to be targeted more frequently.

      5. Conclusion

      This study has revealed that, generally, healthcare workers have a high-risk perception for HBV infection and the risk perception varies across the various professional categories. The high level of risk perception observed in this present study could be utilized to design health promotion and preventive interventions for healthcare workers to prevent occupational exposures and subsequent infections. Sanitation workers need to be engaged much more frequently in such intervention programs.

      Limitations

      This study was done in five out of the 1296 facilities in the Greater Accra Region and may not provide a good basis for generalization, nevertheless, being a cross-sectional study, it has generated new ideas and hypotheses for further research considerations.

      Funding support

      The authors did not receive any external financial support.

      Author contribution

      Conceptualization; Senoo-Dogbey V.E. Wuaku A.D; Data curation; Senoo-Dogbey V.E; Formal analysis; Senoo-Dogbey V.E; Investigation; Senoo-Dogbey V.E; Methodology; Senoo-Dogbey V.E; Project administration; Senoo-Dogbey V.E, Wuaku A.D; Resources; Senoo-Dogbey V.E, Wuaku A.D; Software; Senoo-Dogbey V.E; Supervision; Senoo-Dogbey V.E, Wuaku A.D; Validation; Senoo-Dogbey V.E, Wuaku A.D; Visualization; Senoo-Dogbey V.E, Wuaku A.D; Roles/Writing – original draft; Writing – review & editing: Senoo-Dogbey V.E, Wuaku A.D.

      Availability of data and materials

      The data on which these observations and conclusions were made is available from the corresponding author upon reasonable request.

      Declaration of competing interest

      The authors declare that there are no known competing interests.

      Acknowledgment

      We are thankful to all health care workers who participated in this study.

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