Knowledge and Attitudes Towards Patients with Hepatitis C Infection Among Healthcare Professionals at Hospital Slim River

ABSTRACT

Introduction: In 2019, the Ministry of Health Malaysia (MOH) introduced decentralisation strategies to expand access to hepatitis C virus (HCV) screening and treatment. Hospital Slim River, as one of the designated secondary care facilities, subsequently initiated HCV treatment services. This study aimed to assess the knowledge and attitudes of healthcare professionals towards HCV, and to examine the correlation between knowledge, attitude, and willingness to treat patients living with HCV. Methods: A cross-sectional survey was conducted from April to May 2024 using a self-administered questionnaire. The knowledge section covered five subdomains: the nature of the disease, transmission, symptoms, complications, prevention, and treatment. Attitude was assessed as a single overall domain reflecting perceptions and general views towards caring for HCV patients. Bloom’s cut-off point was applied separately for each domain: knowledge scores were categorized as high (80% or above), moderate (60 to 79%), or low (below 60%), while attitude scores were categorized as positive (80% or above), neutral (60 to 79%), or negative (below 60%). Results: A total of 226 healthcare professionals participated. Of these, 142 (62.8%) demonstrated a moderate level of knowledge, and 184 (81.4%) showed a neutral attitude towards HCV and the delivery of related care. Knowledge scores were significantly associated with profession (p=0.002) and self-reported adequacy of HCV knowledge (p=0.001). Attitude scores were significantly associated with gender (p=0.002), profession (p<0.001), and years of working experience (p=0.014). Weak but significant positive correlations were observed between knowledge and attitude (r=0.339, p<0.001), and between willingness to treat and attitude (r=0.384, p<0.001), suggesting that better knowledge may foster more favourable attitudes and greater readiness to manage HCV patients. Conclusion: Findings from this study highlight the need for targeted educational interventions to strengthen healthcare professionals’ knowledge and attitudes, thereby supporting the effective expansion of decentralized HCV services within hospital settings.

INTRODUCTION

Hepatitis C virus (HCV) infection, a state of liver inflammation caused by the hepatitis C virus, is responsible for considerable morbidity and mortality from chronic liver disease [1][2]. It has been estimated that 50 million people have chronic HCV infection worldwide, with about 1 million new infections occurring each year [1]. A nationwide hepatitis C screening campaign conducted in Malaysia in 2019 found that 1.9% of individuals screened tested positive for hepatitis C antibody [3]. 

HCV is a bloodborne virus transmitted through exposure to blood from unsafe injection practices, unscreened blood transfusions, injection drug use, and sexual practices that lead to exposure to blood [1]. Although modes of transmission of HCV are well documented, stigmatization against people with hepatitis C occurs in various settings. It has been reported that stigmatization is most commonly encountered in healthcare settings and spans across all categories of healthcare professionals [4,5].

Stigmatization may manifest as refusal of services (including access to diagnostic services and treatment), breaches of confidentiality, poorly delivered services, and the use of inappropriate infection control strategies [4]. In the Malaysian context, qualitative findings have highlighted that limited disease awareness and disease-related stigma among both patients and care providers continue to affect treatment acceptability and uptake [6]. However, published local studies specifically examining stigma among Malaysian healthcare professionals remain limited. The Anti-Discrimination Board of New South Wales [4] reported that many people with hepatitis C stated they had given up seeking treatment. Factors thought to impact healthcare professionals’ attitudes towards persons with hepatitis C include lack of knowledge regarding hepatitis C, lack of contact with individuals with hepatitis C, and a link between stigmatized intravenous drug use and hepatitis C infection [4]. Negative attitudes could, in turn, interfere with the willingness of healthcare professionals to treat hepatitis C patients due to their fear of contracting the infection [7]. A study by Pham et al. [8] showed a low positive correlation between knowledge and attitude scores.

Patients with chronic HCV infection may develop long-term complications, including cirrhosis, end-stage liver disease, and hepatocellular carcinoma (HCC) [9,10]. The WHO estimated that about 242,000 individuals died from hepatitis C in 2022, primarily due to cirrhosis and HCC (primary liver cancer) [1]. In Malaysia, many of the estimated 380,000 people living with hepatitis C remain undiagnosed [11]. In line with the World Health Organization (WHO)’s strategy towards the elimination of hepatitis C as a public health threat by 2030 (defined as a

90% reduction in new chronic infections and a 65% reduction in hepatitis C-related mortality, compared with the 2015 baseline), screening and treatment of hepatitis C in Malaysia have expanded tremendously.

Curative treatment stops hepatitis C transmission, prevents end-stage liver disease and liver cancer, and saves lives. It is likely to be cost-saving in the long term by avoiding expensive medical treatments for end-stage liver disease and liver cancer. This has been made feasible with the development of oral direct-acting antivirals (DAAs) that can cure hepatitis C in more than 95% of infected individuals [12]. The STORM-C-1 trial reported that 97% of participants achieved a sustained virological response at 12 weeks after treatment (SVR12). These findings supported the use of ravidasvir plus sofosbuvir as a 12-week or 24-week treatment option for patients with genotype 1a, 1b, or 3 HCV infection, with or without compensated cirrhosis [13]. In Malaysia, a combination of DAAs has been the gold standard for HCV treatment since 2019, facilitating the delivery of hepatitis C treatment in healthcare facilities without gastroenterologists or hepatologists, as well as in primary care settings. This necessitates that healthcare professionals working in healthcare facilities without a gastroenterologist or hepatologist become more competent in providing care to patients with hepatitis C.

The Ministry of Health (MOH) Malaysia has introduced several initiatives to expand access to HCV care. Under the National Strategic Plan for Hepatitis B and C 2019–2023 [14], HCV services are being decentralized from specialist centres to district hospitals and primary healthcare facilities. Key components include wider use of point-of-care testing, expanded access to affordable direct-acting antivirals, and enhanced training to equip non-specialist healthcare workers to deliver HCV care safely and effectively.

Hospital Slim River has started to provide hepatitis C treatment in conjunction with initiatives by the Ministry of Health (MOH) Malaysia. As a secondary care hospital in the southern zone of Perak that serves a largely semi-urban and rural population, and without on-site gastroenterology or hepatology specialists, HCV treatment here is delivered through a decentralized care model by general physicians, medical officers, pharmacists, and trained nurses. Thus, it is meaningful to investigate the level of knowledge and attitudes of healthcare professionals towards patients with hepatitis C infection, how attitudes are influenced by education, and how this can affect their willingness to treat these patients. This context is important because the success of decentralized HCV services depends heavily on the readiness and confidence of frontline healthcare professionals. This study allows evaluation of factors affecting healthcare professionals’ HCV knowledge and attitudes towards patients with hepatitis C infection.

METHOD  

A cross-sectional survey (with ethical approval from the Medical Research and Ethics Committee, Ref. No.: 23-02034-HBR (2)) using a self-administered questionnaire was conducted from April to May 2024 among healthcare professionals working at Hospital Slim River (Table Ⅰ). The questionnaire was adapted from a similar study conducted by Korkmaz et al. [15]; the original instrument was developed in English, later translated into Turkish for that study, and we adapted the English version for use in our setting. It comprises five parts: (i) demographic characteristics, (ii) knowledge about HCV infection (25 statements with ‘true’, ‘false’ or ‘uncertain’ answer options), (iii) attitudes and self-reported behaviour towards patients with HCV infection, (iv) attitudes and willingness to treat patients with HCV infection, and (v) fear of contracting hepatitis C. Parts (iii) to (v) used the same five-point Likert scale (‘strongly agree’ to ‘strongly disagree’). Although the article by Korkmaz et al. was open access, written permission to use the questionnaire was obtained via email from the author.  

Prior to data collection, the questionnaire was pilot tested with 30 healthcare professionals from various backgrounds (Table Ⅰ). This was conducted due to the absence of a reported reliability score in the original study by Korkmaz et al. [15]. The acceptable threshold for Cronbach’s alpha coefficient in a study conducted by Van de Mortel [16] was 0.7. However, several methodological papers indicate that Cronbach’s alpha values between 0.60 and 0.70 can still be considered acceptable for exploratory studies or adapted instruments [17,18]. The reliability of the questionnaire was considered acceptable, with a Cronbach’s alpha value of 0.68, as this was the closest value obtained to the standard threshold. No modifications were made to the questionnaire following the pilot test, as the instrument was deemed sufficiently reliable and appropriate for use in our local setting. The questionnaire was subsequently used for data collection.

Respondents were recruited using a simple random sampling method. A complete list of healthcare professionals was obtained from the human resource unit to identify eligible staff. Respondents of each staff position were then randomly selected by using a random numbers generator. Researchers then approached available staff (except nurses and medical assistants) directly during working hours in their respective units to invite them to participate in the study. Nurses and medical assistants were recruited through their respective heads of unit, who were first briefed on the study procedures and relevant information. A list of randomly selected participants, generated using a random number generator, together with the questionnaire forms, was then provided to the heads of unit to facilitate the recruitment process. Each participant was provided with an information sheet and a consent form, and those who agreed to participate completed the questionnaire on the spot or returned it later within the same day.  

Statistical analysis

The respondents’ summated score for each knowledge and attitude domain were categorized into three categories based on Bloom’s cut-off point. Respondents who scored 80% and above were categorized as having a high knowledge level or positive attitude. Respondents who scored 60% to 79% had a moderate knowledge level or neutral attitude, whereas respondents with scores less than 60% had a low knowledge level or negative attitude. All returned questionnaires were checked for completeness before data entry, and missing data were handled using a complete case approach with no imputation performed. Questionnaires with missing items within a specific domain were excluded only from that domain’s analysis, resulting in 226 complete cases for all domains.  The Statistical Package for the Social Sciences (SPSS) for Windows version 25.0 (IBM, New York) was used to analyse the data.

The respondents’ demographic characteristics, along with their knowledge and attitudes towards patients with HCV infection, were descriptively reported (in terms of frequency with percentage). Median (interquartile range, IQR) was reported for continuous data since normality checks using the Shapiro–Wilk test and visual inspection indicated that the data were not normally distributed. The Mann-Whitney U test and Kruskal-Wallis H test were used to assess the subgroup differences in knowledge and attitude scores across demographic characteristics. Correlations between knowledge scores and attitude scores, knowledge scores and willingness to treat hepatitis C patients, and attitude scores and willingness to treat hepatitis C patients, were analysed using Spearman’s Rank Correlation Coefficient. Statistical significance was set at an overall p< 0.05.

RESULT

A total of 226 healthcare professionals participated in this study. This corresponds to a response rate of 96.2% (226 out of 235 invited participants). Response rates were 98.5% among nurses (131/133), 85.4% among doctors (41/48), and 100% among dentists (5/5), medical assistants (22/22), dentist assistants (5/5), pharmacists (18/18), and therapists (4/4). The demographic characteristics of the healthcare professionals who participated in this study are shown in Table I. The majority of the respondents were female (74.8%), over 30 years old (84.5%), nurses (58.0%), and had working experiences of 11 years and above (54.4%). Additionally, 35.8% of the respondents unsure about their knowledge sufficiency regarding hepatitis C infection.

Overall, the knowledge of Hospital Slim River’s healthcare professionals regarding hepatitis C infection was categorized as moderate. The median knowledge score was 18 (IQR 4.0), with a minimum score of 10 and a maximum score of 23. The majority of the respondents (n= 142, 62.8%) had a moderate knowledge level about hepatitis C infection, while 30.5% (n= 69) had a high knowledge, and 6.7% (n= 15)  had low knowledge level. Item-level findings are presented in Table II. Nearly all healthcare professionals (n= 224, 99.1%) knew that hepatitis C can be spread through sharing injecting equipment. Furthermore, 98.7% (n= 223) of healthcare professionals were aware that sharp object injuries pose the highest risk for

Table I. Demographic characteristics of healthcare professionals.

Demographic characteristics		Results
		Frequency (n)	Percentage (%)
Age (years)	≤ 30	35	15.5
	31-40	136	60.2
	≥ 41	55	24.3
Gender	Male	57	25.2
	Female	169	74.8
Profession	Nurse	131	58.0
	Doctor	41	18.1
	Dentist	5	2.2
	Medical assistant	22	9.7
	Dentist assistant	5	2.2
	Pharmacist	18	8.0
	Therapists (speech therapists, physiotherapists, occupational therapists)	4	1.8
Working Year	≤ 5	43	19.0
	6-10	60	26.6
	≥ 11	123	54.4
Sharp Object Injury	Yes	36	15.9
	No	190	84.1
Education/ Training on Hepatitis C	Yes	143	63.3
	No	56	24.8
	Do not remember	27	11.9
Educational Resources (n= 396)	Lecture notes	147	37.1
	Conference and lecture notes	74	18.7
	Internet and newspaper	152	38.4
	Conference	18	4.5
	Others	5	1.3
Sufficient Knowledge on Hepatitis C	Yes	79	35.0
	No	66	29.2
	Not sure	81	35.8

 
transmission of hepatitis C for healthcare workers. However, 77.4% (n= 175) of respondents believed that sexual

transmission is a common route for hepatitis C transmission

and that there is an efficient prophylactic treatment for the injuries caused by a syringe from a patient with hepatitis C. Interestingly, 76.1% (n= 172) of respondents believed that medical and/or dental procedures increase a person’s chances of contracting hepatitis C. There was a significant difference found between profession (p-value = 0.002) and self-reported knowledge sufficiency (p-value = 0.001) with knowledge scores on hepatitis C (Table III). Further analysis using the Mann-Whitney U test showed significant differences among the nurse-doctor, nurse-medical assistant, yes-no, and no-not sure subgroups, with p-values of 0.001, 0.001, <0.001, and 0.016, respectively (Table IV).

Generally, Hospital Slim River’s healthcare professionals had a neutral attitude towards patients with hepatitis C infection. The median attitude score was 34.5 (IQR 6.0), with a minimum score of 28 and a maximum score of 49. Most respondents (n= 184, 81.4%) showed a neutral attitude, 14.2% (n= 32) exhibited a positive attitude, and 4.4% (n= 10) exhibited a negative attitude towards patients with hepatitis C infection. Item-level attitude responses are summarized in Table V.

Almost all healthcare professionals (n= 225, 99.6%) agreed that following infection control guidelines will protect them from being infected with hepatitis C at the workplace. However, a significant number disagreed with the statement that the possibility of being infected with hepatitis C is low while working at a hospital (n= 159, 70.4%). Furthermore, 81

% (n= 183) agreed that all patients should be tested for HCV before receiving healthcare. Significant differences were observed based on gender (p-value = 0.002), profession (p-value < 0.001), and working years (p-value = 0.014) regarding the attitude scores of healthcare professionals towards patients with hepatitis C infection (Table VI).

Table Ⅲ. Factors associated with knowledge scores of healthcare professionals on hepatitis C infection.

Demographic characteristics	Median (IQR)	Za	X2 (df)b	p-value
Age
≤ 30	19.0 (2.0)	–	3.669 (2)	0.160
31-40	18.0 (4.0)
≥ 41	18.0 (4.0)
Gender
Male	18.0 (5.0)	-1.472	–	0.141
Female	18.0 (4.0)
Profession
Nurse	18.0 (3.0)	–	21.450 (6)	0.002
Doctor	19.0 (3.0)
Dentist	19.0 (6.0)
Medical assistant	20.5 (5.0)
Dentist assistant	16.0 (6.0)
Pharmacist	18.0 (3.0)
Therapists (speech therapists, physiotherapists, occupational therapists)	17.0 (2.0)
Working Year
≤ 5	18.0 (4.0)	–	3.417 (2)	0.181
6-10	18.0 (4.0)
≥ 11	18.0 (4.0)
Sharp Object Injury
Yes	18.0 (4.0)	-0.725	–	0.468
No	18.0 (3.0)
Education/ Training on Hepatitis C
Yes	18.0 (4.0)	–	5.530 (2)	0.063
No	18.0 (3.0)
Do not remember	16.0 (6.0)
Self-reported Sufficient Knowledge on Hepatitis C
Yes	17.0 (3.0)	–	14.076 (2)	0.001
No	18.5 (3.0)
Not sure	18.0 (4.0)

a Mann-Whitney U test

b Kruskal-Wallis H tes

Table Ⅱ. Knowledge on hepatitis C infection.

No	Questions	Areas	Correct Response
			Frequency (n)	Percentage (%)
1.	Hepatitis C is caused by a virus.	Nature of disease	211	93.4
2.	Hepatitis C is a mutation of hepatitis B virus.		149	65.9
3.	Hepatitis C can be spread through close personal contact (e.g., handshaking, kissing).	Transmission	210	92.9
4.	Hepatitis C can be spread by mosquitoes.		214	94.7
5.	Hepatitis C can be spread through sharing injecting equipment, such as surgery materials.		224	99.1
6.	Hepatitis C can be spread from mother to baby during delivery.		184	81.4
7.	Some people are infected with hepatitis C after blood transfusions.		217	96.0
8.	Sexual transmission is a common route for hepatitis C transmission.		51	22.6
9.	A medical and/or dental procedure increases a person’s chances of contracting hepatitis C.		54	23.9
10.	Sharp object injuries, such as those from syringes or suture materials, pose the highest risk for transmission of hepatitis C among healthcare workers.		223	98.7
11.	The risk of transmission of hepatitis C through needle stick injury is 30-50%.		88	38.9
12.	Some people are infected with hepatitis C through unsterile tattooing.		218	96.5
13.	Hepatitis C virus can be transmitted through endoscopy and colonoscopy equipment.		120	53.1
14.	Transmission may occur from a hepatitis C positive individual to the other family members.		117	51.8
15.	Hepatitis C can be spread through sharing dishes of the patients with hepatitis C.		196	86.7
16.	Hepatitis C can lead to cirrhosis.	Complication	218	96.5
17.	Hepatitis C is associated with an increased risk of liver cancer.		201	88.9
18.	A person infected with hepatitis C may not have any symptoms of the disease.	Symptoms	151	66.8
19.	Symptoms of the disease are observed immediately after the entrance of hepatitis C virus into the body.		165	73.0
20.	People with hepatitis C should be restricted from working in the food industry.	Prevention	121	53.5
21.	There is a vaccine for hepatitis C.		189	83.6
22.	Hepatitis C is screened in the tests performed before marriage.		110	48.7
23.	There is an effective prophylactic treatment for the injuries caused by a syringe from a patient with hepatitis C.		51	22.6
24.	There is a pharmaceutical treatment available for hepatitis C.	Treatment	192	85.0
25.	People with hepatitis C should restrict their alcohol intake.		207	91.6

Table Ⅳ. Mann-Whitney U test on knowledge scores of specific groups based on profession and self-reported sufficient knowledge on hepatitis C.

Demographic characteristics	Z	p-value a
Profession
Nurse-Doctor	-3.417	0.001
Nurse-Dentist	-0.281	0.779
Nurse-Medical assistant	-3.323	0.001
Nurse-Dentist assistant	-0.433	0.665
Nurse-Pharmacist	-1.561	0.118
Nurse-Therapists	-0.697	0.486
Doctor-Dentist	-0.661	0.537
Doctor-Medical assistant	-1.669	0.095
Doctor-Dentist assistant	-1.123	0.283
Doctor-Pharmacist	-0.726	0.468
Doctor-Therapists	-1.858	0.069
Dentist-Medical assistant	-1.382	0.186
Dentist-Dentist assistant	-0.105	1.000
Dentist-Pharmacist	-0.302	0.801
Dentist-Therapists	-0.494	0.730
Medical assistant-Dentist assistant	-1.360	0.208
Medical assistant-Pharmacist	-1.462	0.155
Medical assistant-Therapists	-1.759	0.096
Dentist assistant-Pharmacist	-0.867	0.403
Dentist assistant-Therapists	0.000	1.000
Pharmacist-Therapists	-1.312	0.227
Self-reported Sufficient Knowledge on Hepatitis C
Yes-No	-3.699	0.000
Yes-Not sure	-1.460	0.144
No-Not sure	-2.412	0.016

^a significance level of 0.0024 (profession subgroups) & 0.0167 (self-reported sufficient knowledge on hepatitis C subgroups) after Bonferroni correction.

The Mann-Whitney U test conducted on attitude scores of specific groups based on profession and working years revealed significant differences among nurse-doctor (p-value < 0.001), nurse-medical assistant (p-value = 0.001), doctor-dentist assistant (p-value = 0.001), medical assistant-dentist assistant (p-value= 0.001), and working years (6-10 vs. ≥ 11) (p-value= 0.003) (Table VII).

A total of 93.4% of the respondents were willing to treat patients with hepatitis C infection. However, 77.9% reported a fear of contracting hepatitis C infection, and 73% expressed concern about becoming infected themselves. Knowledge had a weak positive correlation with attitudes towards hepatitis C patients, which was statistically significant (r= 0.339, p <0.001). Additionally, a statistically significant, weak positive correlation was found between willingness to treat hepatitis C patients and attitude scores (r= 0.384, p <0.001).

DISCUSSION

Principal findings

This study demonstrated that healthcare professionals generally possessed a moderate level of knowledge about hepatitis C infection, accompanied by largely neutral attitudes and a high willingness to treat patients. Significant differences
in knowledge and attitude scores were observed across professional groups, gender, and years of experience, indicating that certain cadres may require more focused educational support. Although knowledge and attitude were positively correlated, the relationship was weak, suggesting that improved knowledge alone may not be sufficient to meaningfully shift attitudes. Fear of occupational exposure remained evident despite strong agreement on the importance of infection control measures.

Table Ⅴ. Attitudes towards patients with hepatitis C infection.

No	Questions	Correct Response
		Frequency (n)	Percentage (%)
1.	All patients should be tested for HCV before they receive healthcare.	43	19.0
2.	Patients with HCV should be given the last appointment for the day.	125	55.3
3.	Healthcare professionals who are HCV positive should be discouraged from having contact with patients.	94	41.6
4.	I deliver the same standard of care to patients with HCV as I do for other patients.	170	75.2
5.	I pay attention not to spend time during care for the patients with hepatitis C.	139	61.5
6.	I feel that I do not have the skills needed to effectively and safely treat patients with HCV.	157	69.5
7.	I would prefer to wear two pairs of gloves when treating a bleeding hepatitis C-positive patient.	199	88.1
8.	I often use additional infection control precautions when treating patients with HCV.	210	92.9
9.	Following infection control guidelines will protect me from being infected with hepatitis C at work.	225	99.6
10.	My likelihood of being infected with hepatitis C is low while working at hospital.	67	29.6

Table Ⅵ. Factors associated with attitude scores of healthcare professionals towards patients with hepatitis C infection.

Demographic characteristics	Median (IQR)	Za	X2 (df)b	p-value
Age
≤ 30	35.0 (6.0)	–	2.610 (2)	0.271
31-40	35.0 (7.0)
≥ 41	34.0 (5.0)
Gender
Male	37.0 (7.0)	-3.171	–	0.002
Female	34.0 (6.0)
Profession
Nurse	34.0 (5.0)	–	43.023 (6)	0.000
Doctor	39.0 (5.0)
Dentist	33.0 (3.0)
Medical assistant	35.5 (6.0)
Dentist assistant	32.0 (5.0)
Pharmacist	35.5 (7.0)
Therapists (speech therapists, physiotherapists, occupational therapists)	40.0 (10.0)
Working Year
≤ 5	35.0 (6.0)	–	8.561 (2)	0.014
6-10	36.0 (6.0)
≥ 11	34.0 (6.0)
Sharp Object Injury
Yes	36.0 (6.0)	-1.534	–	0.125
No	34.0 (6.0)
Education/ Training on Hepatitis C
Yes	34.0 (6.0)	–	2.651 (2)	0.266
No	36.0 (6.0)
Do not remember	34.0 (6.0)
Self-reported Sufficient Knowledge on Hepatitis C
Yes	34.0 (5.0)	–	1.647 (2)	0.439
No	35.5 (7.0)
Not sure	34.0 (6.0)

a Mann-Whitney U test

b Kruskal-Wallis H test

Collectively, these findings highlight the complex interplay between factual understanding, perceived risk, and professional role, providing important insights for strengthening hepatitis C care in decentralized healthcare settings.

General knowledge level

Overall, healthcare professionals exhibited a moderate knowledge level regarding hepatitis C infection. Although this might be acceptable, there is significant room for improvement in hepatitis C knowledge for better care. In this study, it was found that doctor had significantly higher median scores than nurses and that medical assistants scored higher than nurses. This may be attributed to differences in training curricula, as medical assistants and doctors typically receive more extensive instruction in infectious diseases, clinical management, and exposure-related risk assessment compared

Table Ⅶ. Mann-Whitney U test on attitude scores of specific groups based on profession and working years.

Demographic characteristics	Z	p-value a
Profession
Nurse-Doctor	-5.503	0.000
Nurse-Dentist	-0.553	0.580
Nurse-Medical assistant	-3.312	0.001
Nurse-Dentist assistant	-1.904	0.057
Nurse-Pharmacist	-0.683	0.495
Nurse-Therapists	-1.685	0.092
Doctor-Dentist	-2.429	0.013
Doctor-Medical assistant	-1.657	0.098
Doctor-Dentist assistant	-2.976	0.001
Doctor-Pharmacist	-2.664	0.008
Doctor-Therapists	-0.240	0.832
Dentist-Medical assistant	-2.150	0.033
Dentist-Dentist assistant	-1.078	0.310
Dentist-Pharmacist	-0.638	0.538
Dentist-Therapists	-1.246	0.286
Medical assistant-Dentist assistant	-3.035	0.001
Medical assistant-Pharmacist	-1.367	0.180
Medical assistant-Therapists	-0.759	0.471
Dentist assistant-Pharmacist	-1.723	0.094
Dentist assistant-Therapists	-1.715	0.111
Pharmacist-Therapists	-1.456	0.166
Working Year
≤ 5 versus 6-10	-1.684	0.092
≤ 5 versus ≥ 11	-0.638	0.523
6-10 versus ≥ 11	-2.932	0.003

^a significance level of 0.0024 (profession subgroups) & 0.0167 (self-reported sufficient knowledge on hepatitis C subgroups) after Bonferroni correction.

to nursing programmes in Malaysia. Interestingly, 35% of respondents who self-reported sufficient knowledge scored lower than the 29.2% respondents who self-reported insufficient knowledge, indicating that more respondents in this study had a high level of confidence in their hepatitis C knowledge. Again, the 29.2% of respondents who reported insufficient knowledge scored higher than the 35.8% respondents who were unsure of their knowledge sufficiency. This discrepancy suggests that perceived knowledge is not always aligned with actual knowledge, reinforcing the need for objective competency assessments and continuous professional development.

Specific knowledge item

Almost all healthcare professionals answered questions related to sharing injecting equipment and sharp object injuries as modes of hepatitis C transmission correctly. However, 77.4 % of respondents believed that sexual transmission is a common route for hepatitis C transmission. This finding aligns with studies conducted by Korkmaz et al. [15], Joukar et al.[19], and Richmond et al. [20], where most respondents also believed that sexual transmission is a common mode of hepatitis C transmission. A large proportion of respondents (65.5 %) in a study conducted by Van de Mortel [16] believed there is an effective prophylactic treatment for injuries caused by a syringe from a patient with hepatitis C, which is similar to the findings of this study.

These recurring misconceptions may be explained by a combination of factors. First, hepatitis C is often discussed together with other bloodborne infections such as HIV, which may lead to the assumption that sexual transmission is similarly common. Second, the phrasing of some knowledge items in earlier studies and in the original questionnaire may not clearly differentiate between possible versus common modes of transmission, influencing how respondents interpret such statements. Third, these findings likely reflect underlying knowledge gaps among healthcare professionals regarding the relative efficiency of HCV transmission routes and the absence of effective post-exposure prophylaxis for hepatitis C. These recurring misconceptions across multiple countries suggest that certain areas of hepatitis C knowledge are globally misunderstood despite being well established in medical literature, indicating the need for more targeted educational emphasis in these domains.

Attitudes

In general, Hospital Slim River’s healthcare professionals had a neutral attitude towards patients with hepatitis C infection. In this study, it was found that male respondents exhibited a more positive attitude than female respondents. Subgroup comparisons revealed that doctors and medical assistants had a more positive attitude than nurses, and that doctors and medical assistants showed a more positive attitude than dentist assistants. These findings could be explained by the fact that doctors and medical assistants are primarily male. In addition, these cadres often receive more clinical exposure to infectious diseases and may therefore have greater confidence in infection control practices, which could translate into more positive attitudes. Interestingly, respondents with six to ten years of working experience had a more positive attitude than those who had worked for more than 11 years. One possible explanation is that more recent cohorts of healthcare professionals may have been trained with updated curricula that emphasize infection prevention, stigma reduction and patient-centred care.

It was thought that respondents in this study follow infection control guidelines strictly, given that almost all respondents believed that following infection control guidelines would protect them from being infected with hepatitis C at the workplace. However, some negative attitudes were observed in certain attitude statements. For instance, 70.4% of the respondents disagreed that the possibility of being infected with hepatitis C is low while working at a hospital. This finding resonates with studies by Korkmaz et al. [15] and Elneblawy et al.[21], which reported similar results, with 81.5% and 72.7% of the respondents stating that all patients should be tested for HCV before receiving healthcare. These findings indicate that fear of occupational exposure remains prevalent despite awareness of infection control guidelines.

Relationship between knowledge, attitude, and willingness to treat

A statistically significant but weak positive correlation between knowledge and attitude was noted in this study, suggesting that healthcare professionals with higher knowledge have better attitudes towards hepatitis C patients. This result is in line with findings from several articles (15,19–22). In contrast, a study conducted by Van de Mortel [16] in 2002 demonstrated no statistically significant relationship between knowledge and attitude. The majority (93.4%) of the respondents in this study expressed their willingness to treat hepatitis C patients, similar to findings in the studies by Van de Mortel [16] and Hu et al. [23] involving dental students. However, no significant correlation was found between willingness to treat hepatitis C patients and knowledge level. This reveals that willingness to treat hepatitis C patients would not necessarily increase even if healthcare professionals had a better knowledge level.

A similar finding was observed in studies conducted by Korkmaz et al. [15] and Van de Mortel [16]. Despite the lack of a significant correlation between willingness to treat hepatitis C patients and knowledge level, a statistically significant, weak positive correlation was found between willingness to treat hepatitis C patients and attitude scores. This suggests that willingness to treat hepatitis C patients is primarily influenced by attitude, indicating that attitude has a greater impact on healthcare professionals’ willingness to treat hepatitis C patients than knowledge scores. This highlights the importance of strengthening attitudes through stigma reduction, improved understanding of occupational risk, and enhanced confidence in infection control rather than focusing solely on knowledge-based interventions.

Limitations and future work

Questions assessing knowledge level may not be up to date with the current situation, as the questionnaire used in this study was adapted from an older study conducted by Korkmaz et al. [15] in 2016. An additional limitation is that self-reported behaviour was not validated against actual clinical behaviour; thus, self-reported responses may not reflect the actual attitudes of respondents [20]. Lastly, extrapolation of this study’s results is deemed infeasible, as this study was conducted at a single center.

Implications and recommendations

The findings of this study are expected to assist in the development of strategies for better provision of hepatitis C care and ultimately reducing the burden of hepatitis C infection in Malaysia. Given the moderate knowledge level, persistent misconceptions, and neutral attitudes observed in this study, targeted educational activities that focus on correcting misconceptions, reinforcing infection control practices, and addressing stigma may be beneficial. Differences in performance across professional groups suggest that role-specific training for nurses and dental assistants could help bridge identified gaps. Practical measures may include brief workshops on transmission and post-exposure management, online modules addressing common misconceptions, and scenario-based training to strengthen confidence in infection control. Evaluation of these interventions can be carried out through pre- and post-training assessments, complemented by objective measures such as adherence to exposure management protocols or other workplace safety indicators. These types of interventions align with the decentralized model of hepatitis C care and can support the effective implementation of services in district hospitals.

CONCLUSION

Overall, this study provided insights indicating that healthcare professionals at Hospital Slim River had a moderate knowledge level about hepatitis C infection and a neutral attitude towards patients with hepatitis C infection. A significant positive correlation was found between hepatitis C knowledge and attitudes towards hepatitis C patients, as well as between willingness to treat hepatitis C patients and attitude scores. The moderate knowledge level indicates that further improvement is needed to enhance knowledge level, which in turn could  improve attitudes and ultimately enhance the provision of hepatitis C care to patients. Findings from this research can be used to develop interventions to improve hepatitis C related knowledge and attitudes.

ACKNOWLEDGEMENT

We would like to thank the Director General of Health, Malaysia, for his permission to publish this article. We also extend our gratitude to Foong Sim Wong, Benita Vinoshini A/P Selvaraj, and Nur Asikin Mohd Pauzi for their assistance with data collection; Dr Ruben Skantha (gastroenterology trainee) for counterchecking questionnaire answers; and Dr Siti Nabilah Mohamad Zaini (Clinical Research Center, Hospital Raja Permaisuri Bainun) for her valuable insights throughout this study.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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