Ethical considerations
The Institutional Review Boards of both National Liver Institute Menoufia University and Ministry of Health and Population approved the study procedures. Approaches to ensure ethics were considered in the study regarding confidentiality and the verbal consent. The researcher introduced herself to the participants in the sample and explained the objectives of the study, to obtain their acceptance to be recruited in the study as well as to gain their cooperation.
The study tools establishment
Throughout the course of the present study, data were collected using a constructed questionnaire which was developed by the researcher based on literature review, revised by jury of professors, then tested for validity and reliability (Cronbach’s alpha 0.85). It included four parts:
Part I: Including socio-demographic characteristics of the study participants such as age, sex, educational level, job, marital status, and their medical history.
Part II: Including questions to address participants’ knowledge and attitude about hepatocellular carcinoma (HCC) and prevention of its risk factors especially viral hepatitis B and C, aflatoxins, and pesticides.
Part III: Including questions to address participants’ practice about hepatocellular carcinoma and prevention of its risk factors (HBV and HCV, aflatoxins, and pesticides).
Part IV: Including HCV status laboratory results of the study participants.
A pilot study was done on 15 participants using the constructed questionnaire to evaluate the questionnaire for clarity, time to fill the questionnaire, and applicability. These 15 participants were not included in the full-scale study. Based on the results of the pilot study, the questionnaire was modified and made ready for use.
The community-based intervention study was conducted from February 2017 till March 2019. The study was implemented in the family health unit (FHU), in a randomly selected village that was selected by a multistage random sampling technique with first stage of simple random selection of one district out of the ten districts of Menoufia governorate (Shebein El-Kom district). The second stage was simple random selection of one village out of all villages (N = 28 villages), and it was Kafr Tanbedy village. The third stage was a systematic random sampling of the family records, included within the (FHU), and located in Kafr Tanbedy. An equal geographical region distribution of the rural participants’ family records residing at the north, south, east, and west sites of the selected village was ensured. Out of the 200 study rural participants who were contacted for participation, only 188 subjects responded out of which 179 rural participants were evaluated pre- and post-health education intervention, with a response rate of 89.5%. The inclusion criteria were being a resident of Kafr Tanbedy for at least 10 years, adult with age ≥ 18 years old, and being able to participate in an educational intervention program.
Methods
This study was done by development and implementation of health education-based intervention about HCC and prevention of its risk factors by the researcher.
Development of a health education-based intervention
The health education-based intervention was adopted from the most recent international HCC prevention guidelines and educational programs to improve participant’s knowledge, attitude, and practice about HCC and its risk factors (HBV and HCV, aflatoxins, and pesticides), in which the researcher developed knowledge and practice modules regarding HCC, viral hepatitis B and C, and pesticide and aflatoxin prevention using two educational means—booklets and power point presentations.
Implementation of a health education-based intervention through three phases
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1.
Preparatory phase (pre-intervention family health unit visit) which included the following activities: participation agreement, discussing the objectives of the study, and collecting the selected participants’ data (using the questionnaire with its four parts).
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2.
The implementation phase: two parts which started after 2 weeks from the pre-intervention family health unit visit in which the participants were divided into groups; ten rural participants’ each group.
Part one: Health education intervention included three sessions/week. Each session is 2 h per day for 3 days per week for each group at the family health unit.
Part two: Serology; 3 ml of venous blood were withdrawn from each study participant and transferred slowly into a dry sterile centrifuge tube, and the whole blood was allowed to clot at 37° C, and then centrifuged for 10 min at 1500 rounds per minute; the clear supernatant serum was separated and stored in a freezer at −80°C till the time of testing. Each serum sample was tested for HCV antibodies by third-generation enzyme-linked immunosorbent assay (ELIZA) using kits of MUREX-Diasorin. This was done in the National Liver Institute research laboratory at the Clinical Pathology Department.
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The evaluation phase in which a follow-up visit was done for the study participants’ at family health unit 3 months after the health education program for reassessment of HCC knowledge, attitude, and practices of these participants.
Scoring system and data management
Scoring of knowledge
A score for each answer on questions of knowledge was given as follows: correct answer (2), wrong answer (1), and I do not know (0). HCC knowledge score ranged from 0 to 32, HBV and HCV knowledge score ranged from 0 to 18, pesticide knowledge score ranged from 0 to 18, aflatoxin knowledge score ranged from 0 to 26, and the total knowledge score ranged from 0 to 94 points. Good knowledge score was considered if the percentage was more than 50% and poor if the percentage was less than or equal 50%.
Scoring of attitude
A score for each answer on questions of attitude was given as follows: correct answer (2), wrong answer (1), and I do not feel that (0). Attitude scores ranged from 0 to 12 points. Positive attitude score was considered if the percentage was more than 50% and negative if the percentage was less than or equal 50%.
Scoring of practice
A score for each answer on questions of practice was given as follows: safe practice (2), sometimes safe practice (1), and risky practice (0). Practice score ranged from 0 to 38 and 0 to 36 points for males and females respectively. Good practice score was considered if the percentage was more than 50% and considered poor if less than or equal 50%.
Statistical analysis
Data was coded and transformed into specially designed form to be suitable for computer entry process. Data was entered and analyzed by using SPSS (Statistical Package for Social Science) statistical package version 20. Graphs were done using Excel program.
Quantitative data were presented by mean (X) and standard deviation (SD). Qualitative data were presented in the form of frequency distribution tables, number, and percentage. It was analyzed by chi-square (χ2) test. However, if an expected value of any cell in the table was less than 5, Fisher’s exact test was used (if the table was four cells) or likelihood ratio (LR) test (if the table was more than four cells). Mcnemar’s test was used to measure association between paired qualitative data. Significance levels were considered at 5% level