Research:

Assessing the level of knowledge of hepatitis C among Pakistani students at University of Bedfordshire.

Submission due date: 8 April 2013

Student ID: 1127032

Words count: 15,553

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Table of Contents Chapters Contents Abstract Declaration Dedication Acknowledgements Chapter One 1.1 Introduction 1.2 Background 1.2.1 Hepatitis C Virus 1.2.2 Stages of Hepatitis C infection 1.2.3 Mode of Transmission of hepatitis C 1.2.4 Complication of HCV infection 1.2.5 HCV V/S other hepatitis viruses 1.2.6 HPA Report 2009 1.3 Rationale 1.4 Aims 1.5 Objectives Chapter Two 2.0 Review of the Literature 2.1 Methodology 2.2 Literature Review 2.2.1 Situation hepatitis C in Pakistan 2.2.2 Sources of transmission of hepatitis C in Pakistan 2.2.3 Responsibility of 19
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healthcare practitioners and community 2.2.4 Non-sterile syringes 2.2.5 Blood Transfusion 2.2.6 Barbers and HCV transmission 2.2.7 Transmission of HCV from mother to new-borns 2.2.8 Other routes of transmission 2.2.9 Pakistani immigrants in UK 2.2.10 Immigrants and hepatitis C 2.2.11 Ethnicity v/s health in the UK 2.2.12 Socioeconomic status v/s ethnicity and health 2.2.13 Current situation of hepatitis C in the UK 2.2.14 Pre-entry hepatitis C screening 2.2.15 Conclusion Chapter Three 3.0 Methodology 3.1 Ethical considerations 3.2 Research approach 3.3 Research design 3.4 Questionnaire 3.5 Piloting 28 29 30 31
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3.6 Method and Sampling 3.7 Data analysis 3.8 Cost 3.9 Time scale 3.10 Limitations Chapter Four Result and Discussions 4.1 Demographic characteristics of Pakistani students 35 4.2 Knowledge about hepatitis C 4.3 Symptoms of hepatitis C 4.4 Causes of spread of hepatitis C 4.5 Vaccination against hepatitis C 4.6 Prevalence of hepatitis C 4.7 Summary 4.8 Recommendations 4.9 Conclusion Chapter Five 5.1 Plans of dissemination 5.2 Reflection on Learning Reference list Bibliography Appendix

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I. Abstract Recent times have seen migration occurring on a large scale basis. This involves people from various parts of the globe emigrating for varying purposes. This migration has had a profound impact on public health and healthcare systems all over the world. Migration has become an essential determinant of public health. Currently Pakistan is ranked second highest, globally, for the prevalence of Hepatitis C within its population. Current values range from 4.5% to 8%. Due to the high prevalence of Hepatitis C in Pakistan and the fact that large numbers of Pakistani immigrants/students are travelling from Pakistan into the UK, there is a large potential of outbreak in the UK for the spread of hepatitis C. This serious and alarming correlation is taken as a base for this research paper.

Quantitative research method has been applied as it is the most suitable approach to carry out this study and to get the aims of this study. Cross sectional, selfadministered questionnaire survey has been followed as a research design to assess the level of knowledge about hepatitis C among Pakistani students at the University of Bedfordshire. The total number of Pakistani students who participated in this survey was 57 (29 males and 28 females). Sixteen students were from Peshawar, 15 from Lahore, 8 from Rawalpindi, 5 from Islamabad, 4 from Karachi 5 from Kotli and 1 each from Karak, Gujar Khan, Kohat and Mardan. The responses which determine the level of knowledge was analysed by software known as Statistical Package for the Social Sciences (SPSS). The software version was IBM SPSS Statistics 19. The statistical analysis which was performed at 95% Confidence Interval (C.I) and P values <0.5 were significantly considered. For statistical significance the Chi square test has been calculated.

Forty nine per cent of the participants had heard of hepatitis C whilst 29% of the participants had some knowledge about hepatitis C. Most of the participants who responded positively and had better knowledge about hepatitis C were from Peshawar, which is the capital city of Khyber Pukhtoon Khwa. The participants (90%) from Lahore and Rawalpindi were not aware of hepatitis C. The participants under 25 years of age had poor knowledge of hepatitis C. Fifty per cent of the participants from Peshawar had better knowledge about different modes of
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transmission of hepatitis C. More than 90% of the participants from Lahore and Rawalpindi did not know about different causes of spread of hepatitis C. Only 21% of the participants knew the fact that there is no vaccine against hepatitis C and Seventy three per cent did not know about the continent with highest prevalence of hepatitis C, only 14% correctly named Egypt with highest prevalence of hepatitis C.

Findings of this study suggest that Pakistani students have less knowledge regarding hepatitis C. University of Bedfordshire management should work closely with recommended departments to arrange campaigns regarding hepatitis C awareness.

Keywords: Students, Pakistani Students, Hepatitis C, Health awareness, Risky behaviours, Peshawar, Lahore, Karachi, Rawalpindi, Pakistani immigrants.

Declaration
I certify that the dissertation that I have submitted is my own unaided work and that I have read and compiled with the guidelines on plagiarism as set out in the student handbook. I understand that University may make use of plagiarism detection software and that my work may therefore be stored on a database which is accessible to other users of the same software. Students name: Muhammad Khurram Shahzad Students ID number: 1127032

Dedication
This project is dedicated to my wife Rose Khush Bakht. Her love, support and understanding has lightened up my spirit to finish this study.

ACKNOWLEDGEMENTS
It is with immense gratitude that I acknowledge the support and help of my Professor Gurch Randhawa. His support and flexibility greatly enhanced the learning experience. His everlasting curiosity and never ending optimism kept hope alive in this project. Dr Susan managed to show me how to attack the unknown without being crippled by a fear of failure. My appreciation for what she has given me will only increase with time. A special thanks to Dr Arshad Farooq for his valuable input, kind words of encouragements and over all guidance throughout this study and indeed, Masters programme

I gratefully acknowledge the financial support received from my dear wife Rose Khush Bakht. I would like to thank my siblings Naeem, Waseem, Faheem, Zakia and Bakhtawar, as well as my mother Shaheen Begum for supporting me in my quest for higher education. I would like to thank Opal Greyson and all my friends who have been here to support me and listen to me moan over the past five months.

Finally, to my late father, Muhammad Nizam, my hard work and efforts put forth in this project are merely an extension of all that you taught me over the years.

Chapter One 1.1 Introduction In recent times there has been migration occurring on a large scale basis. This involves people from various parts of the globe emigrating for varying purposes. Such purposes include educational, social and recruitment drive. In light of these changing migrating patterns there has been a need for legislative change in the policies of countries in order to deal with these emigration patterns. Worldwide migration has almost doubled in the past four decades. In 1960, seventy six million people migrated and by start of the millennium this figure had reached to 175 million (Lancet students, 2007). This migration has had a profound +impact on public health and healthcare systems all over the world. Migration has become an essential determinant of public health. In 1997 the European Commission asked the International Centre for Migration and Health (ICMH) to look into the health implications of migration into the European Union countries. This review highlighted the growing concerns over the increase of certain diseases within these European countries e.g. in conditions such as AIDS and tuberculosis there was increased concern over the growing number of cases recorded in line with the direct correlation of migrating numbers.

The UK is a country with rich ethnic diversity. This diversity first started with the initial migration of large populations of Indians and Pakistanis in the 1960s. In the early 1970s East African, Asian and Bangladeshi people migrated which was then followed by migration from the Chinese in various phases (Ali, 2006). Ethnicity has become a social division which is so difficult to be ignored (Ahmad and Bradby, 2008). The UK is facing a great scale of net migration. According to Migration Watch UK in 2010 the net migration was 250,000. The average net migration over the past 10 year has been 200,000 a year. The Office for National Statistics has predicted the UK population will increase up to 70 million in the next 15 years (Migration Watch, 2012). In 2003 Migration Watch UK raised the issue of importing infective diseases from different parts of the world without having a proper screening system for international students and workers. This could potentially result in a deadly outbreak. To date there has been no vaccination against Hepatitis C which gives full protection. The mainstay of treatment for hepatitis C is antiviral medicines which
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inhibit the virus from multiplying inside the body. Treatment is very costly and every year the NHS has to spend millions of pounds to provide hepatitis C virus (HCV) patients with these antiviral medications. The World Health Organisation in 2008 compared hepatitis C to a viral time bomb and estimates that about 180 million people (3% of the worlds population) are infected with hepatitis C. World Health Statistic 2008 lists cirrhosis of the liver as the 18th commonest cause of mortality in the world and by 2030 liver cancer would become the 13th commonest cause. Currently Pakistan is ranked second highest, globally, for the prevalence of Hepatitis C within its population. Current values range from 4.5% to 8%. Due to the high prevalence of Hepatitis C in Pakistan and the fact that large numbers of Pakistani immigrants/students are travelling from Pakistan into the UK, there is a large potential of outbreak in the UK for the spread of hepatitis C. This serious and alarming correlation is taken as a base for this research paper. Currently hepatitis C is considered as viral explosion in Pakistan yet it is still not considered as a serious issue by the health authorities in Pakistan. In one of the studies conducted in 2000 within Pakistan, researchers found that out of ten registered health care practitioners none had the knowledge of hepatitis C as a disease likely to be transmitted through non-sterile syringes. On the subject of nonsterile syringes, interestingly, only two mentioned hepatitis B and its risk of being contracted through non-sterile medium while half of them mentioned that using nonsterile medium could cause tuberculosis. Healthcare practitioners themselves do not have the basic, required knowledge regarding Hepatitis C therefore this knowledge is unlikely to be transferred to the general population. In the research ers views this is more likely to invite the potentially life threatening disease into the UK as currently, legislation only requires people passing through border controls to have a tuberculosis screen.

The author has also come from Pakistan for post-graduation studies and is gaining a valuable insight into the experience regarding the attitude, behaviours and beliefs towards various health concerns in the UK. The author, a doctor, has clinical experience and has worked in different teaching institutions in Pakistan where hepatitis C screening is included as a basic laboratory test before any surgical procedure(s) being carried out. The author has come to know that international
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students who are coming into the UK are from regions with high prevalence of Hepatitis C (in Pakistan) such as the Swat valley, Peshawar, Dir and many more cities of the Punjab and Sindh provinces. Many studies on small targeted groups including health professionals, blood donors, intravenous drug abusers and patients with chronic liver disease show that the prevalence of hepatitis C is at 40%. Seventy per-cent of the population of Pakistan live in rural areas and different studies show that prevalence of hepatitis C is higher there than urban areas. The reason for higher prevalence of hepatitis C in rural areas is due to lack of adequate health facilities and education. Poverty, un or ill-screened blood transfusions, malpractice, lack of community awareness programs and lack of implementations of government policies are all major contributors to this increased prevalence. Post September 11 th 2001 and the increase in terrorism has also been a major contributing factor (Nuareen et al, 2012).

Knowledge about certain diseases can help safeguard people and keep them protected as well as other community members. It was necessary to assess the level of knowledge about hepatitis C among Pakistani students and immigrants in the UK because this, inevitably, may be a reason for affecting other people. A cross sectional survey has been carried out to gain more knowledge about a small group of Pakistani Students who are studying in a UK university that have been selected because of well documented risky behaviour in the students which puts them at more risk of transmitting the disease.

1.2 Background
According to the World Health Organisation in 2008 about 130-170 million people of the world were infected with HCV. The prevalence, which is the burden of a disease, varies from country to country and in comparison there can be stark differences between the values from country to country. In Egypt it is over 10% and in the United States it is about 2%. In northern Europe it is as low as 1%. Pakistan, where the prevalence is second highest internationally, the rate of HCV ranges from 4.5% to 8%. Many studies on small targeted groups including health professionals, blood donors, intravenous drug abusers and patients with chronic liver disease show that the prevalence of hepatitis C in Pakistan is as high as 40%. Due to the fore-mentioned reasons it is described to have reached epidemic levels,

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Bearing in mind that due to a lack of screening facilities this figure may not include those people who are currently carrying the virus yet have not been officially diagnosed.

According to Armstrong et al (2006) Hepatitis C infection has become the leading cause of liver cirrhosis and the most common cause of liver transplantation in the United States of America. The study lasted three years (from 1999 to 2002) and included 15,079 participants. The outcome of this study was that 1.6% of the population had HCV infection and 1.3% of the population had chronic hepatitis C infection. According to the US Centres for Disease Control and Prevention (CDC 2011) an estimated 1.8% of the US population is positive for HCV antibodies. Because three out of four seropositive persons are also viremic (carriers), this corresponds to an estimated 2.7 million people with active HCV infection nationwide. Infection due to HCV accounts for 20% of all cases of acute hepatitis, an estimated 30,000 new acute infections, and ultimately eight to ten thousand deaths each year in the United States. HCV has rapidly surpassed HIV as a cause of death in the US (CDC, 2011). An examination of nearly 22 million death records over 9 years revealed a HCV mortality rate of 4.58 deaths per 100,000 people per year and a HIV mortality rate of 4.16 deaths per 100,000 people. Macias and his colleagues in 2008 discovered the high prevalence of hepatitis C in non-injecting patients. The above findings suggest that disease is present in population with having identifiable risk factors, the disease is not only associated with intravenous drug users, but research is needed to find other modes of transmission. It is important to assess the level of knowledge and awareness in high risk population other than intravenous drug users. 1.2.1 Hepatitis C Virus HCV is a blood-borne virus that mainly attacks hepatocytes, which are the liver cells and, as a result, produces an inflammatory response and slowly destroys the liver affecting its essential functions. Although it has always been regarded as a liver disease; hepatitis means inflammation of the liver (World Health Organisation, 2012). According to the NHS UK 2012 research has shown that HCV affects a number of other areas of the body as well as its primary site being the liver. In-turn the digestive system, lymphatic system, immune systems and the brain are all affected.

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1.2.2 Stages of Hepatitis C infection There are two main stages of Hepatitis C infection. Firstly acute infection, which is the initial six months of the infection and secondly chronic infection, in which infection goes beyond six months. The acute infection does not necessarily produce any noticeable symptoms. About 20% of patients will naturally clear the virus from their body within the first six months and the remaining 80% will go onto develop chronic infection. Some patients experience very few symptoms for long. Others may get signs and symptoms from the start of the infection. Some of the patients with chronic hepatitis will develop fibrosis and scarring (cirrhosis) of the liver; others will develop liver cancer or end stage liver disease, while others may experience very little liver damage for many years after infection. Hepatitis C remains undiagnosed for many years because its symptoms can be confused with other illnesses e.g. fatigue, depression, skin problems, pain, insomnia, and digestive disorders. This is why hepatitis C is often referred to as the Silent Epidemic (Hepatitis C Trust UK, 2012). 1.2.3 Mode of Transmission of Hepatitis C One can get infected with hepatitis C, if one comes into contact with blood or, less commonly, the body fluids of an infected person. Blood is the easiest way of transmission. Just a small trace of blood can initiate an infection. The virus can survive outside of the body in patches of dried blood on surfaces for up to sixteen hours but has been known to survive for up to four days at room temperature (NHS, 2012). Injecting drugs Blood transfusions Sharing toothbrushes, scissors and razors Body piercing Mother to child

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Needle stick and splash injury Unprotected sex

Currently, there is no vaccination available against HCV infection (Abrignani & Rosa, 1998). The treatment for HCV infection can minimise the liver damage but the treatment is costly and has to be taken for a long time with large numbers of side effects (British liver trust, 2008). Prognosis is better when it is diagnosed earlier. As they say prevention is better than cure and that can only be achieved with increasing awareness about the disease. 1.2.4 Complications of HCV infection HCV infection ultimately results in chronic hepatitis which may in turn develop into liver cirrhosis and/or liver cancer. 1.2.5 HCV versus other hepatitis viruses Hepatitis C (and B) spread in similar ways as discussed previously. Hepatitis A, in contrast, spreads through the oral-faecal route. Developing countries have been facing problems of hepatitis A infection for a long time; mainly due to poor or no sanitation. Hepatitis A virus infection resolves quickly and its complications are not life threatening. Hepatitis B infection is similar to HCV infection in many ways but there is medical treatment in the form of a vaccination available against hepatitis B. Hepatitis C, in stark contrast, is the most sinister of all of the fore mentioned as infection is longstanding and there is no medical management which gives a full resolution. 1.2.6 Health Protection Agency Annual Report 2009 It has been noted that there has been steady increase in the number of hepatitis C diagnoses in England, as shown in the following figure. The graph is also a good indicator in the prediction of subsequent diagnoses which may/will present in the future as well as by looking at the current pattern cases are constantly rising. The Health Protection Agency views this data in a positive light as more people are being diagnosed and therefore subsequent initiation of treatment is far quicker. But the
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researcher thinks in a different way and wants the health authorities to have a close look at the factors which are responsible for a constant increase in the prevalence of hepatitis in England itself.

Figure 1.1: Cumulative laboratory reports of hepatitis C infection from England: 1992 -2008

1.3 Rationale Bob Robert, the deputy political editor of the Mirror News (2007) had stated in his article Immigration: the true cost to Britain that the NHS is struggling to cope with the wave of new migrants and the foreign workers are being blamed for the rise in the cases of TB and HIV. This article depicts the true scene and every year thousands of Pakistanis visit the UK for different purposes and allowed to enter UK
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without being screened for HCV virus, raising a question in mind that we are heading towards inviting a problem in to the UK which could become mainstay here and the NHS may have to suffer the future burden. If we are ignoring this problem of Hepatitis C risings in the early stages then we will have to consider future expenditure burden on the NHS.

According to BBC news (2011), one consultant hepatologist estimated that about two third of the population of Bradford who were born in South Asia do not know they have hepatitis C and same is the case about other South Asians who live in different parts of the UK. This study is conducted to determine the level of knowledge and awareness for self-protection and safety for others. The study is important from the view of the NHS because people coming from Pakistan with so much risk factors of getting HCV infection in Pakistan; intend to stay for a longer period in the UK by getting involved in various employment or do further studies inside UK, and may become a potent risk factor for the spread of Hepatitis C in the UK. Although the UK has an efficient blood screening system and sufficient sterilization of surgical instruments but still these students with such a strong risk factor of second highest prevalence of Hepatitis C back home in Pakistan, will act as walking carriers of this deadly disease in different parts of UK and will potentially be putting British population at greater risk.

This research is important for assessing the knowledge about hepatitis C for personal protection and for others as well. The results of this study could potentially guide the health authorities about the prevalence of hepatitis C among the Pakistani community and this can be of useful interest for UK Border Agency for protecting its borders from hepatitis C infection. Findings of this study can also benefit international offices of different universities, primary care trusts (PCT), and NHS to have an idea about developing future campaigns about hepatitis C as it can give a true picture of level of knowledge of hepatitis C among international Pakistani students. This study will provide a platform for the health authorities to make arrangements for HCV screening tests for Pakistani students at their arrival in the UK.

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1.4 Aims The main aim of this study are as follow;; 1. Assess the level of knowledge regarding Hepatitis C among Pakistani students at University of Bedfordshire (UoB). 1.5 Objectives The main objectives are as follow; 1. To improve the level of knowledge of hepatitis C among Pakistani Students at University of Bedfordshire. 2. To identify if hepatitis C education is needed for Pakistani students in the UoB.

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Chapter Two 2.0 Review of the Literature 2.1 Methodology The time-scale of the research articles ranges from 1980 to 2012. Literature review was selected from;

Public Health Books Government documents and data bases On-line search engines Articles in Journals and Magazines British Nursing Index (BNI) The British Library PubMed iPhone software The Royal college of Nursing Library Previous research papers

The participants inclusion criteria to be used included; Age group between 18-65 years Either male or female International Pakistani Students of University of Bedfordshire

The participants exclusion criteria to be used excluded people with; Those who refuse to take part in the survey

The search work will be done with different combinations of keywords for following themes.

Hepatitis C and students awareness Hepatitis C in Pakistan Hepatitis C in Pakistani students. Hepatitis C awareness of Pakistani students. Health awareness of South Asian people in UK Hepatitis awareness among students.

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2.2 Literature Review The literature regarding various aspects of hepatitis C has been reviewed to get an insight into the transmission and prevalence of hepatitis C in Pakistan and then to look into the efficiency of the health authorities for the control of hepatitis C transmission.

2.2.1 Situation of Hepatitis C in Pakistan According to World Health Organisation (2009) Pakistan has got the second highest prevalence rate of hepatitis C (HCV) ranging from 4.5% to 8%. Many studies on small targeted groups including health professionals, blood donors, IV drug abusers and patients with chronic liver disease show that the prevalence of hepatitis C is 40%. The reason for higher prevalence of hepatitis C is due to lack of proper health facilities, lack of education, poverty, unscreened blood transfusion, misperceptions, malpractices, lack of community awareness programs and lack of implementations of government policies. WHO (2008) has compared hepatitis C to viral time bomb. World Health Statistic (2011) lists cirrhosis of liver as the 18th commonest cause of mortality in the world and by 2030 liver cancer would become the 13th commonest cause. About 70% of the population of Pakistan is living in the rural areas of Pakistan, and the prevalence of Hepatitis C is higher there. A five year program was initiated in 2005 by the Ministry of Health, which was named as National Program for Control and Prevention of Hepatitis but this program has not achieved what was aimed at, and now this federal program has been devolved to the provincial government without solid being achieved at federal level. According to the Economic Survey of Pakistan (2009), the government spends 2.5 % of GDP on Health sector. With such a low allocation of funds, political instability, terrorism throughout the country worsen the situation of health sector in Pakistan.

2.2.2 Sources of transmission of hepatitis C in Pakistan: Non-sterile equipment in hospitals and blood transfusions have been identified as a responsible source of HCV transmission but other important routes of transmission like unsafe injections, sharing razors, tattooing were ignored in the past. Tibbs, CJ in
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1997 reviewed the understanding hepatitis C infection in tropical countries, and ever since hepatitis C was considered an important disease in tropical countries but the routes of transmission were poorly defined except blood transfusion.

2.2.3 Responsibility of healthcare practitioners and community In one of the study in Pakistan, the researchers found that out of ten registered health care practitioners, none of them had the knowledge of hepatitis C as a disease, likely to be transmitted through non-sterile syringes, only two mentioned hepatitis B virus while half of them mentioned tuberculosis (Khan et al, 2000). The other contributing factors include lack of proper monitoring system and accountability in the hospitals. In rural areas of Pakistan the day care centres like basic health units (B.H.U.) and primary health centres (P.H.C.) are useless structure without any facilities and policies.

2.2.4 Non-sterile syringes Bari et al (2001) found that in Pakistan, HCV patients had a history of more therapeutic injections in the last ten years as compared to HCV negative participants. In one study it was reported that 44% of patients prefer injectable modes of treatment even though the oral treatment would have been as effective as a parenteral one (Khan et al, 2000). A further study was also conducted in which participants were included from all of Pakistans provinces and it was concluded (as is now known) that one of the main risk factors for HCV infection is the reuse of contaminated needles for major or minor surgical procedures. More than 70% of people in this research presented with this relevant history (Idrees & Riazuddin, 2008).

In 2008, a survey conducted in collaboration with the Ministry of Health, Statistic Division, Federal Bureau of Statistics (FBS) and Pakistan Medical Research Council (PMRC), showed that about 30% of the screened population was taking more than 5 injections per person per year. With the increasing numbers of injections per person per year the exposure rate also increased. The positivity of HCV was twice more in those where a syringe was reused. This literature shows that use of contaminated needles is playing a leading role in the spread of HCV infection. Khokar et al (2003) reviewed twelve month admission data to see the causes of deaths in 283 cases out
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of 8529 admissions. There were 160 deaths related to medical causes, including 33 (20.6%) deaths from chronic liver disease. Hepatitis C has been involved in going in to chronic hepatitis and hepatocellular carcinoma as its symptom reveal later in the life cycle.

HCV transmission has been a major Public Health problem in Pakistan. Fifteen years ago HCV transmission was attributed to the practice of reusing medical instruments in the hospitals and other healthcare facilities. Hoeve and his colleagues in 2012 conducted a study in Karachi, Pakistan, to examine the current situation of HCV transmission through hospitals. Three hundred laboratory confirmed HCV positive participants and 300 laboratory confirmed HCV negative participants were enrolled from clinics at Indus Hospital. The significant risk factors for both women and men were blood transfusion, delivery within the hospital or those who had some kind of dental treatment performed. The results of this study highlighted that those who bought their own needles for injection had a protective effect (59%). The widespread reuse of needles in the hospitals is one of the main drivers of hepatitis C epidemics. In Pakistan, a person uses about 8 to 14 injections a year, which is the highest number among developing countries. Out of which 94% of the injections are used unnecessarily (Qaiser, 2012).

2.2.5 Blood Transfusion In 2004 the US National Institute of Health attributed blood transfusion as a main factor for the high prevalence of hepatitis C. In 2009 Waheed and his colleagues conducted a study in which 91 different studies were reviewed dating between 1994 and 2009. This study concluded that prevalence of HCV was at 4.5% in the general population of which 48.67% were developing hepatitis C due to multiple blood transfusions. In 2012 Dawn News in Pakistan published a report by the Pakistan Society of Family Physicians saying that there were more than 400 hospital blood banks and laboratories in the major cities of Pakistan e.g. Karachi, Lahore and Peshawar. In about 80% of these, the specific blood donors remained unscreened with blood then subsequently going on to be transfused to those who need it. In less structured communities within rural areas of Pakistan the probability of a thorough blood screen is even more dramatically reduced. Despite recent development in the

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medical equipment and modern techniques for blood screening, blood transfusion is still the main route for HCV transmission in Pakistan (Raja Janjua, 2008).

2.2.6 Barbers and HCV transmission Like in any country of the world most people go to barbers for hair grooming and facial shaving. Rural area barbers have low literacy rates and have little or no knowledge about transmission of different diseases. A study conducted by Nizamy and Junjua which suggested that barbers had very little knowledge about hepatitis C. Many of them had no clue about hepatitis C. Some of them even associated it with jaundice. In 46% of cases shaving blades were reused. In one study conducted by Bari and his colleagues in 2001, in District Gujrat, Pakistan the situation was critical. About 93% of the barbers were unaware of the potential hazards of used blades on several customers and 48% of them were reusing unsterile equipment among several clients. Additionally they were also performing circumcisions and minor abscess drainage (Wazir et al, 2008). According to United Nations Children's Fund (UNICEF 2012) literacy rate of Pakistan is 61% and majority of population is unaware of general knowledge of the spread of hepatitis C. The medium of knowledge by means of banners, pamphlets, newspapers and television are not utilized effectively, either due to limitation of language differences throughout the country, affordability or illiteracy among general public.

2.2.7 Transmission of HCV from mothers to new-borns Levels of virus in the blood of the mother determine transmission of HCV from mother to baby, but can be transmitted by other factors like timing of the rupture of membranes (Ferrero et al, 2003), keeping in mind that about 70% of the population live in rural areas of Pakistan where there is no such quality care and should be also considered as a route of transmission of Hepatitis C.

2.2.8 Other routes of transmissions In haemodialysis, patients need repeated treatment. Prevalence of hepatitis C among these patients ranges from 23% to as high as 68% (Khokar et al, 2005).There is also an association between immigrants and Hepatitis C. In Pakistan many unqualified people start running their clinics after working at different posts in the hospitals such as nurses, laboratory technicians, medical and surgical
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technicians and dental technicians. Most of the population in rural areas go to these unqualified doctors for their treatment. They in turn then treat patients with no knowledge that they are in fact transferring viral doses of blood. In 2003, a study by Butt and co-researchers found unqualified dentists to be responsible for spreading hepatitis C as they use non-sterilised dental instruments.

2.2.9 Pakistani Immigrants in UK UK net migration has increased four-fold from 1997 to 2009. There has been a net migration of 200,000 a year, which topped 252,000 in 2010. More than 3 million immigrants have crossed into UK borders since 1997. In the next 16 years the UK population is expected to grow from 7 million to 70 million (Migration Watch UK, 2012).

In 1960s mainly Indians and Pakistanis started migration in to the UK followed by the migrations of other ethnic minorities in the UK like Bangladeshi, Afro-Caribbean, East African Asian and Chinese in various phases, (Ali, 2006). In 2001 Census, there were about 321,000 people who declared that they were born in Pakistan which represent nearly 0.56% of the British population. In 1991 the figure was 234,000. Pakistani population is heavily populated in the West Midlands and Yorkshire. The Pakistani population in Bradford accounts for 20% of the local

population, (BBC, 2012). These immigrants have been playing an important role in the economy of the UK. Whoever comes to UK and wants to work he has to pay the tax. The revenue collection has been a major part in the economy of the UK and immigrants have become a backbone in this regard. UK Immigration published a report in 2008 that immigrants have boosted the tax revenue by 35 billion dollars.

2.2.10 Immigrants and Hepatitis C Different studies in the past suggested that there is a strong historical association between immigrants and hepatitis C in different countries. In 1984, about 200 patients were admitted to a hospital in Qatar, showing symptoms of acute viral hepatitis. 91 patients were positive with HCV infection (Glynn et al, 1985). In United States, Celona and colleagues (2004) carried a survey from 1993 to 2000 on ethnic minorities including Asian, African American, Caucasian and Latino patients reported 1271 patients were positive with HCV antibodies in their blood. One of major
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complication of hepatitis C infection is hepatocellular carcinoma; the prevalence of hepatocellular carcinoma is increasing as result of the immigration to Europe and North America. The immigrants bring with them the chronic hepatitis which had happened to them as a result of HCV infection in their home countries (Sherman, 2010).

In Australia a similar study was conducted on immigrants and refugees, as they had high prevalence of hepatitis C in their home countries. The study found that prevalence of hepatitis C was 3% in Laotian and 8% in Cambodians (Caruana et al, 2005). In another study conducted by Department of Health and Ageing, 2006 showed that 10.9% cases are amongst immigrant population. Prevalence of hepatitis C among immigrants of Pakistani origin in the UK is about 2.7% and is the highest amongst all South Asian immigrants in UK (Uddin et al, 2009). A study at University of Bedfordshire suggests that level of knowledge of hepatitis C among International Students from South Asian countries is alarmingly low and is high risk for the spread of hepatitis C (Waqar, 2008). According to above evidence, it can be concluded that the prevalence of infectious disease varies in immigrants according to the country of origin (Ramos et al, 2003).

According to an immigrant service agency, Radio Canada International, in British Columbia (2011), Lorn Curry reports that, it is estimated that there are about 60,000 patients in British Columbia with hepatitis B and C, who are Asian immigrants and the province is trying to launch a campaign to raise awareness of danger of hepatitis B and C among Asian immigrants in British Columbia. In 1999 a survey was conducted among an immigrant community in southern Amazon in Brazil, and it was found out that the prevalence of hepatitis C virus infection was about 2-4% (Soutu FJ et al, 1999). The prevalence of hepatitis C is continuously evolving in Europe during the last 15 years. Four main factors for these epidemiological changes are: increased blood transfusion safety, condition of the healthcare settings has improved a lot and a lot of immigration to European countries from endemic countries (Esteban et al, 2007).

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2.2.11 Ethnicity v/s Health in the UK Health and different diseases have often been shown in relationship to the notion of identity and rates of mortality. Different conditions have been presented a stigma to certain ethnic minority groups, for example, cancers, tuberculosis, mental illness, ischemic heart diseases, depression and genetic diseases (Ahmad and Bradby, 2008). South Asian, Caribbean and people from the Afro-American race often present with genetic diseases such as thalassemia and sickle cell disease (Anionwu and Atkin, 2001). Overall cancer rates for ethnic minority groups are lower than the majority population there are certain cancers where incidence is higher among certain ethnic groups. South Asians have higher rates of liver and mouth cancer. Black men are more likely to be diagnosed with prostate cancer. Incidence of strokes is higher in Caribbean women, Bangladeshi men and women and lowest in the Chinese female population. Caribbean men are 50% more likely to die of stroke compared to the general population. Prevalence of diabetes is five times higher in African, Caribbean and Asian communities. Chinese people have the lowest rate of diabetes but still higher than the white majority population. There have been high, reported, rates of depression in Indian and Pakistani women but lower for Bangladeshi and Black Caribbean women (Ali, 2012).

2.2.12 socioeconomic status v/s ethnicity and health Health service provision and the social class of service users are closely related to each other, with the poor social class having the least access to good health services. This, obviously, can mean poorer health outcomes (Ahmad and Bradby, 2008). This was also explained by Tudor Hart and called it inverse care law (Tudor Hart, 1971). Socioeconomic status is an important predictor of individual health status of the group to which one belongs (Marmot, 1984). There are variations of health concepts and illness across cultures and time to time (Klienman, 1981). Accessibility to healthcare is strongly related to the seeking behaviour of the ethnic minority groups (Smaje, 1995).

National statistics in 2006 show that overall unemployment rate decreased. There are variations by ethnic group and the following table is showing those differences. Indian men have levels of unemployment similar to White men. Unemployment for Black Caribbean's, Black Africans, Bangladeshis and mixed race men approximately
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three times that of White British and White Irish men. Pakistani women have the highest rate of unemployment.

2.2.13 Current situation of hepatitis C in the UK Health Protection Agency (HPA) 2012 suggests that there around 216,000 individuals infected with hepatitis C in the UK. HCV related death and hospital admissions have increased in the UK. The hospital admissions were 612 in 1998, this figure has risen up to 1,979 in 2010. The numbers of HCV related deaths were 323 in 1996; this figure has risen to 1323 in 2010. It is predicated that about 15,840 individuals will be suffering from HCV related hepatocellular carcinoma or cirrhosis in England in 2020 if left untreated. HPA 2012 reveals that in 2011 about 13,000 South Asians were tested for HCV and about 3.4% tested positive

Uddin and his colleagues conducted research in 2010 to find out the prevalence of hepatitis C among different ethnic minority groups in England. Almost 5000 individuals were tested for HCV. Overall prevalence of hepatitis C for the South Asian community was 1.6%, with the highest being for the Pakistani community, which was 2.7%. This study suggested that Pakistani immigrants are having highest risk factor for HCV infection as compared to other different ethnic minority groups. There have been a few studies available regarding HCV prevalence among different ethnic minority groups, but there is evidence that these individuals are high risk groups for HCV transmission

Hepatitis C Trust is an important organisation, which is working in collaboration with National Health Service (NHS) and Health Protection Agency to fight against hepatitis C in the UK. According to this trust, about half a million people of the UK is having hepatitis C but nine out of ten people are unaware whether they have this disease or not in the first instance. This organisation was formed in 2004. This trust is playing a pivotal role in creating awareness about hepatitis C in the community. The trust provides information about hepatitis C in different languages. One has to register online to get monthly hepatitis C newsletters.

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2.2.14 Pre-entry hepatitis C screening In South East Asian countries and the UAE there is an adequate monitoring system for various infectious diseases including hepatitis C. If there is a monitoring system for hepatitis C, health authorities would be able to make a policy accordingly. Accurate data would be available for different countries and health authorities in response can make plans for visitors of differening countries. According to Migration Watch UK 2003, the countries with such monitoring systems, allow asymptomatic patients but an undertaken is obtained to bear the expenses in case of symptomatic condition arises. This reduces the burden on the local health system as well as the patient then being kept for monitoring of symptoms. There have been fewer studies on the prevalence of hepatitis C among students in the UK.

The following preventative measure can control the spread of hepatitis C infection in the UK by Pre-entry hepatitis C monitoring system Hepatitis C awareness programs for international students in the colleges and universities Hepatitis C screening programs in the universities each year

2.2.15 Conclusion It can be suggested by the review of the literature above, that Pakistan has high prevalence of hepatitis C and can serve as a potential risk factor for its spread within the UK. There have been fewer studies regarding knowledge of hepatitis C among international students in the UK. The current prevalence of hepatitis C makes Pakistan the second highest in the world. With such high prevalence of hepatitis C in Pakistan, low literacy rate and significant numbers of Pakistani immigrants in the UK, it is therefore required by the researcher to do more study regarding the role of international students in the spread of hepatitis C. The researcher suggests that this study would give an idea of knowledge of hepatitis C among Pakistani students and an action plan can be suggested to prevent the spread of hepatitis C in the UK by international Pakistani students.

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Chapter Three 3.0 Methodology 3.1Ethical Considerations Before undertaking any form of research, ethical approval must be obtained from the Local Research Ethics Committee (REC), Department of Health (DOH). It is important that the researcher be aware of the ethical issues which may/can arise and how the researcher might act upon responding to them, Bexter et al, (2010). The researcher obtained approval from the University Central REC. The university Central REC ensured and then observed the protection, safety and dignity of all actual and potential participants. The researcher submitted the proposal to the University Central REC; it was reviewed by the University Central REC and was approved considering no ethical issue was present. After approval had been given by the Ethical Committee and an indemnity letter was obtained from the university, actual research was followed then (can be seen attached in the appendix). There has been no introduction of any false claim or false entry into the research and the data has not been manipulated in view of getting predefined results. The desired help on the analysis of the data was obtained through the templates. The researcher considered factual data and was responsible in the processes of data collection, analysis and dissemination. According to the Royal College of Obstetricians and Gynaecologists (2006), all participants were clearly informed of their right to freely take part or withdraw from the study at any time. Parahoo (1997) is pointing out that the participants must be informed throughout the study about the voluntary nature of participation or withdrawal at any stage of the study. Adding to this, Polit and Beck (2006) state that prospective participants who are fully informed of the nature of the study being carried out, to include the risks and the benefits, are in a position to make rational decisions regarding participating in the study. They are informed of the power to
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freely consent enabling them to be a part of or refuse participation freely. The researcher has to provide full information that must be easy to understand. Confidentiality is an important ethical issue and researchers must ensure the anonymity of the participant, Nursing and Midwifery (NMC) (2009). The address of the participant is to be separated from the questionnaire and would only be used for results of the research study to be dispatched. Addresses were disposed of later. The researcher ensured that participants would not get harmed during the study as the participants were told about the nature of the study and they were told that study was not meant to look into their level of intelligence, rather it would help the researcher to assess their knowledge regarding hepatitis C and results of this study would give them some benefit, perhaps, in future. The questionnaire was explained to the participants as most of the participants were speaking different native languages so the researcher was able to explain those different medical terms in their native languages. Dimond (2006) states that a transparent atmosphere should be provided to the participants and each of the participants involved in the study should be aware of the proceedings. The researcher must ensure the wellbeing of the participants throughout the proceedings. Parahoo (1997) asks the researchers to follow ethical principles in a research study in order to ensure safety and rights of the participants. These principles are Beneficence (outcome of the study should benefit the participant). Maleficence (no harms to the participants). Fidelity (to create trust between the researcher and participants). Justice (treating participants fairly without favouritism). Veracity (to tell the truth to the participants even if that may cause them to withdraw from the research). Confidentiality.

3.2 Research Approach Researcher has selected the Quantitative research method as it is the most suitable approach to carry out this study and to get the aims of this study. The researcher is trying to look in to the descriptive data of a number of students
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having knowledge of hepatitis C within a sample group and to generalise the results of this study to parent population group that is international Pakistani students. As compared to quantitative approach, the literature suggested that qualitative approach is used to know beliefs, attitudes and perceptions in a certain group regarding some diseases (Creswell, 1994).

3.3 Research Design Cross sectional survey has been followed as a research design to assess the level of knowledge about hepatitis C. This design is appropriate as it meets the demands of the researcher to get information from the participants regarding the issue in hand. The researcher has found this design more appropriate because of less financial demand in order to conduct this research and also the researcher has to complete the study within a short period of time. A good proportion of participants can be expected when using this research design. In cross sectional survey there is no need for close observations and active interventions among the participants.

Polit and Hungler (1999), consider that a quantitative study develops understanding of the nature of relationships among differing phenomena. This method enables the researcher to look for the information that respondents have given regarding the issue under discussion. The advantages of selfadministered surveys are less costs, participants are told about the survey to clear any doubts in their minds and there would be a high response rate as compared to what is achieved with electronic surveys, mail surveys and oneon-one. In self-administered questionnaire researcher is sure about the person who is filling questionnaires and in mail questionnaires researcher is blind to who is filling the questionnaires for the participants (Bourque, 1995). The interviews could not be done because of the availability of fewer funds and also the researcher was unable to do the recordings. This needed a lot of time as well. There are also some disadvantages of this method like the data provide snapshots of points in time rather than a focus on the underlying processes and changes and also the survey relies on breadth rather than depth for its validity (Blaxter et al, 2010).
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The researcher collected data from international Pakistani students in the University of Bedfordshire, Luton campus during October-November 2012. The data was collected from the students in cafeteria and Learning Resource Centre, where students are mainly seen after their lectures. Pakistani students were asked to access more Pakistani students details and with their help the researcher had to visit their residential areas as well, outside the UoB. The students were informed about the nature of the study. The questionnaires were distributed amongst them, as most of the students were non-medical so the researcher had to explain them the medical terminology. The researcher also tried group administered survey to save some time. In the group administered survey, the questionnaires are distributed in a group setting, which ensures a high response rate (Sapsed, 2012). The participants were mostly from Septembers 2012 cohort intake. As they were quite new and they were mostly in different groups for different events e.g. induction, university orientation therefore the researcher tried to collect data during this time.

3.4 Questionnaire: The instrument (questionnaire) used in this research was designed very carefully. The questionnaire was then forwarded to the supervisor, who approved it after a few corrections. The researcher had to make a questionnaire in a way to make the participants understand easily about the questions they were asked. For designing the questionnaire the researcher followed the guidelines from the book by Bourque and Fiedler (1995, p.16). The guidelines in this book suggest that self-administered questionnaire are shorter as compared to the questionnaire used in other research designs, and the questions are closed. The questionnaire was made as short as possible with utmost care. A self-designed questionnaire was used as it is really difficult to find a comprehensive one. The response rate among the participants varies according to nature of the topic, number of questions, sponsorship, and language and wordings used in the questionnaire (Bowling, 2002). As the vast majority of the participants were non-medical and english was not their first language; the wording and language used in the
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questionnaire was kept easily understandable. The questionnaire had mostly close-ended questions with Yes or No options. Some of the questions were provided with an option others, where participants could add anything which came to mind. The participants could easily read the instructions to fill in the questionnaires. The questionnaire had 12 questions in total. Questions 1-10 had sub-categories. Questions 1-3 were about general knowledge regarding hepatitis C, questions 3-8 were about transmission, question 9 was about vaccine and questions 11-12 were about prevalence of hepatitis C. At the end of the questionnaire there were some personal questions to ask the participants.

3.5 Piloting: In the beginning 10 questionnaires were distributed among 10 participants to fill them up. They were asked about the wording and language used in the questionnaire. Everyone was satisfied about the clarity of the questions. The researcher was satisfied with the timing and costs required for the whole study. Everything was fine about the research and was started with high spirits.

3.6 Method and Sampling The sample which has to be used for this study must represent the population from which it is drawn. University of Bedfordshire is rich in students with different ethnic minority groups. Many students from South Asia come and study here. The University of Bedfordshire which was previously known as the Luton University is situated in the county of Bedfordshire. In Luton the majority of the population is of Pakistani origin. It has a number of Pakistani students because of its location and the environment, where one can easily adjust. University of Bedfordshire was a good place for the researcher to carry out this study because it was easier to find the desired population to study. It was easier for the researcher to get ethical permission for conducting the research. It was convenient for the researcher to undertake this study in this university within limited resources. International Pakistani students from 20122013 sessions were selected for the study from the Park Square campus of

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the university in Luton. The University of Bedfordshire has 24,000 students in total which include 363 students from Pakistan (BSU, 2012).

Snow ball method of sampling was performed. It started from a group of Pakistani students who represented Pakistani student society and were known to researcher as they lived in the same place close to the researchers accommodation. In this way researcher approached more students. This was the most appropriate way to approach these students in different groups, without having any list of students which inhibited the systematic sampling. Purposive sampling was one of the potential bias but in the researchers view, this was the most appropriate way of sampling in this situation. Systematic sampling would have been better but it was difficult to access to the students data in the university. The response rate would have been low in case of electronic or mail survey, but the researcher had to complete the project within a limited time. The total number of Pakistani students included in this study was 57 irrespective of gender and age. Exclusion criteria included those who were not willing to take part in the survey and students with learning disabilities. In this study, the confounding factors could have been the previous educational records and different duration of stay in the UK.

3.7 Data Analysis Many small-scale research studies which use questionnaires as a form of data collection would not need to go beyond the use of descriptive statistics and exploration of the inter-relationships between pairs of variables using frequency distribution and cross-tabulation (Blexter et al, 2010). The responses which determine the level of knowledge was analysed by software known as Statistical Package for the Social Sciences (SPSS). The software version was IBM SPSS Statistics 19. The complete analysis and discussions have been discussed and evaluated in the Appendix. The statistical analysis which was performed at 95% Confidence Interval (C.I) and P values <0.5 were significantly considered. Bar charts, tables, and texts have been used for the presentation of various data collected. For statistical significance the Chi square test has been calculated.

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3.8 Costs The estimated cost for the survey is around the 200 mark. The details of which are as follows: 1) Questionnaire printing costs: 40p per questionnaire (0.40 x 100 = 40) 2) Transport costs = approximately 100 3) Miscellaneous expenses = 60

3.9 Time scale

Month May 2012 June 2012

Activity submitted research proposal

Remarks Supervisors guidance

prepared own questionnaire and Keeping in touch with supervisor and doing literature review feedback on questionnaire Got Ethical approval, finalising the Supervisors guidance questionnaire, questionnaire. piloting of

July 2012

August 2012

Kept doing literature review going Supervisor guidance and involving with university to collect information about numbers of Pakistani students

November 2012

Questionnaire

was

distributed Supervisors guidance

among Pakistani students and started collecting data Kept doing literature review and Supervisors guidance data entry, writing Data entry and analysis, kept Supervisors help writing dissertation Completed writing of dissertation, Supervisors help feedback on draft 33

December 2012 January 2012

February 2012

April 2012

Submitted final work

Supervisors help

3.10

Limitations:

The results of this study may not be generalised to all Pakistani immigrants as only a small proportion of students have been studied within a small populace area, that being, within the University of Bedfordshire. At the start of the study the target was 100 students but it was time consuming to access all of them therefore the students included in this study were less than 100. There may be chances of recall bias among participants in some questions. Some of the students did not participate in the study due to lack of knowledge of hepatitis C itself. There were some participants who were mostly from non-medical faculties so there may be some difference of knowledge level regarding hepatitis C and also there may be difference between the level of knowledge of hepatitis C of undergraduate and postgraduate students.

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Chapter Four: Results and Discussions 4.1 Demographic characteristics of Pakistani students at UoB: The total number of students who participated in this survey was 57. Their demographic features were as follows: Total number of students: 57 Total number of male students: 29 (50.9%) Total number of female students: 28 (49.1%)

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Age: Total number of students under 25 years of age: 15 (26.3%) Total number of students from 25 to 30 years of age: 32 (56.2%) Total number of students above 30 years of age: 10 (14.3%)

Place of birth: The participants in this study were also asked about their city or village of birth in Pakistan. Most of the students were from Peshawar; the capital of Khyber Pukhtoon Khwa province. Followed by Lahore, Rawalpindi, Islamabad and Karachi; all major cities of Pakistan.
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Total number of students from Peshawar: 16 (28.1%). Total number of students from Lahore: 15 (26.3%) Total number of students from Rawalpindi: 8 (14%) Total number of students from Islamabad: 5 (8.8%) Total number of students from Karachi: 4 (7.8%) Total number of students from Kotli: 5 (8.8%) Total number of students from Karak: 1 (1.8%) Total number of students from Gujar Khan: 1 (1.8%) Total number of students from Kohat: 1 (1.8%) Total number of students from Mardan: 1 (1.8%) Peshawar, Mardan, Karak and Kohat represent Khyber Pukhtoonkhwa regionally as a province therefore 19 (33.5%) of students were from this province. Similarly Lahore, Rawalpindi and Gujar Khan are cities within the Punjab province and the number of students from this province was 24 (42.1%). Karachi is the only city from Sind province with 4 (7.8%) students. Islamabad which is the capital city of Pakistan has 5 (8.8%) students in this survey. Kotli represents Azad Kashmir with 5 (8.8%) students.

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Level of education: Students were asked about their level of education whether they are undergraduate or post-graduate students. There were 20 undergraduate students and 37 students represented post-graduate level of education.

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Familiarity with hepatitis C word: Students were asked if they had ever heard of hepatitis C. 49.1% of the participants answered Yes, 31.6% answered No while 19.3% were not sure about this question.

What is your gender? * Have you ever heard of hepC? Crosstabulation Count Have you ever heard of hepC? yes What is your gender? male female Total 13 15 28 no 13 5 18 not sure 3 8 11 Total 29 28 57

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In this part of the study females were in high percentage to have heard about hepatitis C. Students from Peshawar were highest in numbers to answer Yes to this question as compared to students who were born in Lahore, for example, as shown in the table given below.

What is your city or village of birth? * Have you ever heard of hepC? Crosstabulation Count Have you ever heard of hepC? yes What is your city or village of birth? Gujar Khan islamabad karachi karak kohat kotli lahore Mardan peshawar Rawalpindi Total 1 5 2 0 0 4 2 0 11 3 28 no 0 0 1 1 1 0 11 0 2 2 18 not sure 0 0 1 0 0 1 2 1 3 3 11 Total 1 5 4 1 1 5 15 1 16 8 57

Most of the post-graduate students were familiar with the word hepatitis C as compared to undergraduate students who were not much familiar with this deadly disease as evident from the following table (3 represent s undergraduate students, 4 represents post-graduate students).

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What is your level of education? * Have you ever heard of hepC? Crosstabulation Count Have you ever heard of hepC? yes What is your level of education? Total 3 4 8 20 28 no 6 12 18 not sure 6 5 11 Total 20 37 57

4.2 Knowledge about hepatitis C: The participants were asked about having knowledge of hepatitis C, 29% of the participants responded positively and 52.6% didnt know about hepatitis C. The remaining 17.5% were not sure of knowing about hepatitis C.

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Interestingly, female had better knowledge about hepatitis C when compared to males, only a few males know about hepatitis C. This comparison can be best seen in the table below followed by a bar chart

What is your gender? * Do you know what is hep C? Crosstabulation Count Do you know what is hep C? yes What is your gender? male female Total 7 10 17 no 18 12 30 not sure 4 6 10 Total 29 28 57

More than 95% of the participants from Lahore, Rawalpindi and Gujar Khan did not know about hepatitis C, however about 50% of the respondents from Peshawar mentioned Yes to this question as explained in the table given below.

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What is your city or village of birth? * Do you know what is hep C? Crosstabulation Count Do you know what is hep C? yes What is your city or village of birth? Gujar Khan islamabad karachi karak kohat kotli lahore Mardan peshawar Rawalpindi Total 0 3 2 0 0 2 1 0 8 1 17 no 0 2 2 1 1 0 12 1 4 7 30 not sure 1 0 0 0 0 3 2 0 4 0 10 Total 1 5 4 1 1 5 15 1 16 8 57

4.3 Symptoms of hepatitis C: Hepatitis C can remain undiagnosed for many years because its symptoms can be confused with other illnesses e.g. fatigue, depression, skin problems, pain, insomnia, and digestive disorders. This is why hepatitis C is often referred to as the Silent Epidemic (Hepatitis C Trust UK, 2012). Having knowledge about symptoms of hepatitis C can play a major role in the treatment of hepatitis C. The participants had less knowledge about symptoms of hepatitis C, 28% of the participants mentioned that they knew about its symptoms while the remaining participants did not know (28%) or were not sure (43%) about symptoms of hepatitis C. More than 90% of the students from Lahore, Rawalpindi and Gujar Khan did not know about symptoms of hepatitis C. The participants from Peshawar (90%) and Karachi (50%) had better knowledge about symptoms of hepatitis C. The participants who were post-graduate students (95%) had better knowledge about symptoms than did undergraduate participants. The participants in age group of 25-30 knew a lot about signs and symptoms of hepatitis C. No participant under 25 years of age knew about signs and symptoms of hepatitis C. Female participants had better knowledge about the signs and

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symptoms of hepatitis C than their male counterparts. This can be better explained in Bar Chart given below:

Seventy per cent of participants did not answer to this question regarding the signs and symptoms of hepatitis C. Most of the participants who answered Yes to this question were from Peshawar, Karachi and Islamabad. Participants who were at post-graduate level had the best knowledge of the for-mentioned. Most of female participants were aware of the signs and symptoms of hepatitis C and rightly answered the question. 4.4 Causes of spread of hepatitis C: The participants were asked to write at least one cause of spread of hepatitis C. 68% did not know at least one cause of spread of hepatitis C. Fifteen per-cent mentioned blood related causes for spread of hepatitis C, 12.3% suggested sex for its spread

44

and 3.5% of the participants wrote non-sterile syringes were a cause of spread of hepatitis C.

The participants were asked about the transmission of hepatitis C through kissing, using hepatitis C patient utensils and coughing. Hepatitis C does not spread through these sources, 10.5% answered Yes to this question and the rest of the participants (28.1%) answered No and 61.4% were not sure about these options. Seventy per cent of the participants were not sure about the spread of hepatitis C. Fifty per cent of the participants from Peshawar had better knowledge about different modes of transmission of hepatitis C. More than 90% of the participants from Lahore and Rawalpindi did not know about different causes of spread of hepatitis C mentioned in the given questionnaire. The vast majority (68.4%) of the participants did not know whether a mother could transmit hepatitis C virus to her unborn baby, while 31.6% mentioned Yes the mother could transmit hepatitis C virus to her newborns. Here, Peshawar was leading the way again and more than 50% of the participants were aware of the fact that hepatitis C could be transmitted by a mother
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to her baby, while participants from Lahore and Rawalpindi did not know about this possible mode of transmission of hepatitis C as shown in the following table:
What is your city or village of birth? * Can a mother transmit hep Cto her baby? Crosstabulation Count Can a mother transmit hep Cto her baby? yes What is your city or village of birth? Gujar Khan islamabad karachi karak kohat kotli lahore Mardan peshawar Rawalpindi Total 0 3 2 0 0 2 1 0 9 1 18 not sure 1 2 2 1 1 3 14 1 7 7 39 Total 1 5 4 1 1 5 15 1 16 8 57

4.5 Vaccination against hepatitis C: There is no vaccine available against hepatitis C virus. The participants were asked about availability of vaccine against hepatitis C virus, 79% were not sure about its availability. Only 21% seemed to be aware of the fact that there is no vaccine

46

available against hepatitis C virus.

4.6 Prevalence of hepatitis C: Currently Pakistan is ranked second highest, globally, for the prevalence of Hepatitis C within its population. Current values range from 4.5% to 8%. About 70% of the population of Pakistan is living in rural areas of Pakistan where the prevalence of Hepatitis C is higher. The participants were asked to name the continent of the world with the highest prevalence of hepatitis C. Seventy three per cent did not know about the continent with highest prevalence of hepatitis C, 21% named Asia and about 5% mentioned Africa with highest prevalence of hepatitis C. Africa (5.3%) has highest prevalence of hepatitis C, followed by South Asia (2.05%). In South Asia, Pakistan is ranked first with the highest prevalence of hepatitis C (4.5%-8%). Europe has the lowest prevalence of hepatitis C which currently stands at 1.03%. In the next question 75% of the participants did know about the country with highest prevalence of hepatitis C, 14% named Egypt and 7% mentioned Pakistan and 3.5% named
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Nigeria with highest prevalence of hepatitis C. The literature reveals Egypt (>8%) with highest prevalence of hepatitis C followed by Pakistan (4-8%).

Which country has highest prevalence of hep C? Frequen Valid Cumulative cy Percent Percent Percent Valid Nigeria 2 3.5 3.5 3.5 Egypt 8 14.0 14.0 17.5 Pakistan 4 7.0 7.0 24.6 Don't know Total 43 57 75.4 100.0 75.4 100.0 100.0

The participants who were aware of prevalence of hepatitis C were post-graduate students and were in age group of 25-30 and higher. 4.7 Summary: Forty nine per cent of the participants had heard of hepatitis C whilst 29% of the participants had some knowledge about hepatitis C. Most of the participants who responded positively and had better knowledge about hepatitis C were from Peshawar, which is the capital city of Khyber Pukhtoon Khwa. The participants (90%) from Lahore and Rawalpindi were not aware of hepatitis C. Those with better knowledge about hepatitis C were post-graduate students and were in the age group of 25-30. The participants under 25 years of age had poor knowledge of hepatitis C. Sixty eight per cent of the participants did not know at least one cause of transmission of hepatitis C. Fifty per cent of the participants from Peshawar had better knowledge about different modes of transmission of hepatitis C. More than 90% of the participants from Lahore and Rawalpindi did not know about different causes of spread of hepatitis C mentioned in the given questionnaire. There is no vaccine against hepatitis C, only 21% of the participants knew this fact. Seventy three per cent did not know about the continent with highest prevalence of hepatitis C, only 14% correctly named Egypt with highest prevalence of hepatitis C.

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4.8 Recommendation: The recommendations are as follow: The University of Bedfordshire Student Union: It is recommended for the University of Bedfordshire students union to organise hepatitis C awareness programs at least four times a year.

Pakistani student society: Pakistani student society works under the student union of the University of Bedfordshire. The Pakistani student society should arrange sports activities for students who come from Pakistan and name these activities in relation to hepatitis C awareness. There are many Pakistani doctors working in the NHS, Pakistani student should contact these doctors who can deliver lectures regarding hepatitis C awareness.

International office at University of Bedfordshire: International office in collaboration of Pakistani student society and University of Bedfordshire Student Union should arrange hepatitis C testing campaigns once a year especially for Pakistani students. International office should arrange hepatitis C awareness programs during induction sessions.

The Department of Public Health University of Bedfordshire: The department of Public Health should arrange activities where Public Health students and teachers are able to spread awareness regarding hepatitis C.

Mosques: There are places in the University of Bedfordshire where most Pakistani students offer prayers. Pakistani student society can use this place for hepatitis awareness.

UK Border Agency: UK Border Agency should ask/request international students for hepatitis C testing as part of their visa requirements before or upon entering UK borders.

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National Health Service (NHS): The NHS should direct their hospital to work in collaboration with different universities in the UK and send universities invitation letters to ask their students to participate in different health related campaigns including hepatitis C.

4.9 Conclusion: Findings of this study suggest that Pakistani students have less knowledge about hepatitis C infection. University of Bedfordshire management should work closely with recommended departments to arrange campaigns regarding hepatitis C awareness.

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Chapter 5

5.1 Plans for dissemination Research studies are conducted to gain findings what are aimed at the start, (Hickson, 2008) key findings should be given importance, and proposed actions should be taken. The study should indicate why the study gives the generalised results from findings therefore representing a wider population. The results and recommendations of this study will be posted to Participants along with brief introduction about hepatitis C to increase their awareness about hepatitis C. International office of University of Bedfordshire to make some policies regarding arranging activities to create awareness about hepatitis C among students. Pakistani student society and Student Union to work together in arranging activities to create awareness about hepatitis C. Luton Borough Council & Luton PCT to work in collaboration with Public Health department of University of Bedfordshire to discuss and help each other to arrange hepatitis C awareness campaigns. Health Protection Agency, UK Border Agency and Department of Health to make some necessary arrangements on broader scale. Luton and Dunstable local newspapers to create awareness among local community about hepatitis C disease. Pakistani doctors working in NHS to create awareness about hepatitis C among Pakistani community in the UK on a broader scale. Public Health teachers at University of Bedfordshire who helped me to complete this study. 5.2 Reflection on Learning This was the researchers first experience in carrying out actual research work, and has developed necessary experience for his future studies. In the beginning of this

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course, the author had no idea about conducting such study. The author kept learning new skills throughout this course and was able to apply them in this project. To decide about research topic was an important part of this survey. The researcher must have better understanding of the research topic. The author has worked in different hospital set ups in Pakistan and is aware of bad situation of hepatitis C in Pakistan. The research topic was decided and the next task was to construct a questionnaire. This was an uphill task and was completed after several meetings with research supervisor. In the researchers view, to construct a research question is the basis of any research because it has to be ethically approved and population under study must be able to respond this questionnaire. The next step was the field work and the experience of interacting with other students gave researcher more confidence. On the other hand, literature review was in progress. The literature review helped author improve his critical thinking skills and how to critically analyse the works of different authors. This also helped in understanding the research process. Data analysis was a challenging task but thanks to SPSS which made it possible. This whole module helped the author to become a better public health practitioner and has enabled author to analyse things in a critical manner. This course will serve as a basis for his success in years to come.

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53

Reference List 1. Abriqnani, S. & Rosa, D. (1998) Perspectives for a hepatitis C virus vaccine, Clin Diagn Virol, 10(2-3), pp.181-185 PubMed [Online]. Available at: http://www.ncbi.nlm.nih.gov/pubmed/9741644 (Accessed: 20 March 2012). 2. Radio Canada International (2011) Asian immigrants: Danger of high Hepatitis B rate among B.C. Asian immigrants. Available at:

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Appendix 1.1
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Title: Assessing the level of knowledge of hepatitis C among Pakistani students at University of Bedfordshire.
You are kindly invited to take a part in a research study and you are required to fill up a questionnaire regarding your knowledge about hepatitis C. Before making any decision whether or not to take a part, please read the following information. If you are not clear about anything in this participant information sheet please do not hesitate to contact the researcher. The contact details of the researcher are at the end of this participant information sheet. Please read this participant information sheet and then complete the consent form. Please read all the information in this participant information sheet carefully. Researcher: Muhammad Khurram Shahzad (Muhammad.Shahzad1@study.beds.ac.uk ) Research Supervisor: Gurch Randhawa (Gurch.Randhawa@beds.ac.uk ) What is the questionnaire about?

This questionnaire is a part of my MSc research project to assess the level of knowledge of hepatitis C among Pakistani students at University of Bedfordshire. The main aim of this study is to get an insight into the knowledge of Pakistani students and to find out if hepatitis C education is needed for Pakistani students at University of Bedfordshire. This questionnaire is prepared in order to find answers to general questions about hepatitis C. Who can be the participants?

If you are overseas Pakistani student studying at University of Bedfordshire and you are between 18-65 years of age, then you can be the participant

Why participate?

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Since the main aim of this study is to get an insight into the level of knowledge of hepatitis C among Pakistani students at University of Bedfordshire. If the researcher is able to get responses, this study will help to arrange hepatic C related educational activities in the university for the future students. How long will the questionnaire take?

The questionnaire has 12 questions in total. The questions 1-10 have subcategories. Questions 1-3 are about general knowledge regarding hepatitis C, questions 3-8 are about transmission, question 9 is about vaccine for hepatitis C and questions 11-12 are about prevalence of hepatitis C. At the end of the questionnaire there are some personal questions about the participants. This will take about 5-10 minutes to answer all questions. About privacy and confidentiality:

The researcher will keep your personal information confidential. Only the researcher and the research supervisor will have an access to your personal details. Your name and personal details will not appear on the research paper. About consent and change of mind to withdraw from participation.

If you fill this questionnaire up and hand it back to the researcher, this would be taken as your consent for participation. To participate in this study is of voluntary nature and everyone has a right to freely take part or withdraw from the study at any time and can inform me about withdrawal from this study by sending me an email at Muhammad.Shahzad1@study.beds.ac.uk. Any risk in participation?

This doesnt mean to judge your intelligence levels or knowledge about hepatitis C. if you feel yourself distressed at any point of filling questionnaire, the researcher recommends stopping filling in the questionnaire and handing it back to the researcher. Who developed the questionnaire?

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This questionnaire has been developed by Muhammad Khurram Shahzad, pursuing Master in Public Health at University of Bedfordshire. The questionnaire has been reviewed by Professor Gurch Randhawa (University of Bedfordshire).

Questionnaire

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Name: . Sex: Age: . City/Village of birth: Education level: . Please encircle appropriate option below each question. 1. Have you ever heard of hepatitis C? a) Yes 2. Do you know, what is hepatitis C? a) Yes b) No c) Not sure b) No c) Not sure

3. Do you know what symptoms appear when someone is exposed to hepatitis C? a) Yes If yes, then which of the followings: a) Skin and white part of eyes get yellowish coloured b) Flu c) Pains in the abdomen d) Loss of appetite e) Generalised body pains f) Bleeding from the gums Yes Yes Yes Yes Yes Yes No No No No No No b) No c) Not sure

Others

4. Please write at least one cause of spread of hepatitis C

65

a) ..

b) Dont know

5. Do you think one can get hepatitis C through close contact with HCV positive patients? a) Yes b) No c) Not sure

If yes, then what about following options? a) Kissing b) Sharing eating utensils c) Coughing Yes Yes Yes No No No

Others 6. Can hepatitis C spread through? a) Stagnant water b) Blood c) Mosquito Yes Yes Yes No No No Dont know Dont know Dont know

Others . 7. Can hepatitis C be transmitted by? a) Sharing tooth brushes b) Unprotected sex c) Surgical instruments d) Contaminated shaving blades e) Blood transfusion f) Contaminated needles Yes Yes Yes Yes Yes Yes No No No No No No Dont know Dont know Dont know Dont know Dont know Dont know
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Others 8. Can mother transmit hepatitis C virus to her baby? a) Yes 9. Is there any vaccine for hepatitis C? a) Yes b) No c) Not sure b) No c) Not sure

10. Which of the following is correct about hepatitis C patient? a) Has a long period of illness b) Has short period of illness c) Dies on the spot after exposure to HCV 11. Prevalence of hepatitis C infection is highest in a) Asia b) Africa c) Europe d) Dont know Yes Yes Yes No No No Dont know Dont know Dont know

12. Which country has highest prevalence of hepatitis C of the following? a) Nigeria b) Egypt c) Pakistan d) Kenya e) South Africa f) Dont know. I am really thankful to you for completing this questionnaire. If you wish to receive the results of this survey, then you are required to fill in the following spaces, the information provided here would be kept confidential.

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Name .. Age Sex House No Road .. Town . County . Post Code Email address ..

68