.Introduction
Hepatitis B virus infection is of global concern, statistically, the world all over has recorded an estimated number of 325 million people who are affected with it. Surprisingly, about 1.34 million people died from it in 2015. (WHO,2017)
Narrowing it down, Africa has had its own share of it. A number of 75 million people across the African continent are affected by this chronic infection. Search has found out that in Nigeria, being the most populous country in Africa has an estimated prevalence rate of 13.6% of its population suffering from the infection. Moreover, in Senegal which is a neighbouring country to Nigeria also reported 11% of the infection in the ensuing year not forgetting 5.7% in Ethiopia. In the Gambia, hepatitis B associated liver cancer is the most common cancer among men and the third most common in women.(Olufumilayo, 2015)
Among the reasons why the prevalence of Hepatitis B Virus infection keep soaring high in Africa is due to these factors but not limited to includes the lack of information about the virus’ transmission. The mode of transmission of this infection is well established through contact with the blood or the body fluids of an infected person. Re-use of razors and similar sharp objects that are contaminated with infected blood through tattooing and body piercing. (Olufumilayo, 2015)
With this practices at stake, WHO estimated that 1.7 million people are infected through these unsafe practices.
Ghana which shares many characteristics with Nigeria in terms of culture and many ways of life also is burdened with this infection with a prevalence rate ranging from 4.8% – 21%. Unfortunately, this classifies Ghana among the endemic countries in Africa.(Walana, Hokey, & Ahiaba, 2014)
Notwithstanding, the high prevalence of Hepatitis B infection in most countries are high, Korea has seen a significant 3% decrease of Hepatitis among young adult and a corresponding 1% decreases in children meaning they are doing their possible best to clamp down this menace. However, Hepatitis infection among Caribbean children and adolescent aged 0-19 years lied between 4.3% and 5.4% which was held in a constant state over time.(Kwon & Lee, 2011)
Hepatitis B infection is a viral infection that affects the liver and can cause both acute and chronic disease such as cirrhosis and liver cancer. The virus is transmitted through contact with the blood, semen, and saliva, or other body fluids such as breastmilk, sweat, urine and tears of an infected person.(WHO,2016).
Perinatal transmission is believed to be the major route by which HBV infection is disseminated in endemic populations. Babies born to mothers who are positive for Hepatitis B surface antigen(HBsAg) who do not become “vertically” infected during the perinatal period are at risk of infection during early childhood. In adults, high-risk sexual activity is one of the most common routes of transmission for HBV. (Kim, 2009)..
Hepatitis B virus infection is vaccine preventable. To prevent HBV transmission in childhood, the HBV vaccine was introduced in the expanded program on immunization (EPI) in many sub Saharan African countries in the years 2000.(Ekouevi et al., 2017). It was introduced in Ghana on the 1st January 2002. Hepatitis B Virus infection still remains high in the country with varying prevalence rate.
1.2 Problem Statement
Hepatitis B Virus (HBV) infection is very fatal and therefore a public health issue globally. From 1990 to 2013, deaths resulting from hepatitis Virus infection has increased from 0.94% to 1.54% making it the seven leading cause of death globally. It has disability-adjusted life-years (DALY) ranging from 33.3% to 45.6% between 1990 to 2013.(Stanaway et al., 2016)
A research conducted in Nigeria by Aminu, Okachi, Abubakar, & Yahaya, ( 2013) shows the prevalence rate of 12.5% Hepatitis B infection among students. Also, Julius et al., (2012) published in their research conducted among blood donors at Tamale Teaching Hospital indicating a prevalence rate of Hepatitis B Virus infection of 10.79% among the youth of age category 20-29 years.
Although there is a limited data on the prevalence of (HBV) infection across the country in Ghana, studies conducted by Walana, Hokey, & Ahiaba, (2014) indicated the prevalence rate ranged from 4.8% to 21% in Ghana. However, in Ghana the regional variation estimated 4.8% to 12.3% in the general population, 10.8% to 12.7% in blood donors and about 10.6% in pregnant women. (Luuse et al., 2017). Another study conducted among blood donors in the Ho Municipal Hospital indicated a prevalence rate of 7.5%. (Osei, Lokpo, & Agboli, 2017)
This result shows that Volta region is of intermediate to high endemicity with HBV infection
The prevalence of HBV infection is much higher in rural communities than in urban areas and the youth stand a greater risk of being infected with HBV due to their sexual and other risky behaviours such as sharing of sharp objects among themselves (Zampino et al., 2015).
According to Ghana Statistical Survey,( 2014) Krachi Nchumuru has a rural population of 79.5% and 45.0% youthful population putting them at a higher risk of being infected with HBV. Couple with this, a data from Krachi Nchumuru District Disease Control Unit (DDCU) on a screening exercise conducted in the Senior High Schools (SHS) among students in 2016 shows an alarming HBV infection prevalence rate of 15.5%. As a result, a study is necessary to examine the causal factors influencing the prevalence of Hepatitis B Virus infection among Senior High School students in Krachi Nchumuru District.
1.3 Conceptual Framework
Associated factors Knowledge on HBV
Fig 1. Conceptual Frame Work
Narrative of the conceptual framework
The conceptual framework above illustrates the relationship between exposure and outcome variables of (HBV) infection using some of the associated factors that have been known to be linked with the spread of HBV infection. Using age as example, older SHS students who are sexually active are more likely to be expose to body fluids such as blood, saliva, sweat, semen and vaginal secretion of an infected person through sexual activities. Place of residence of a SHS student also have some relationship with HBV infection as it is prevalent in rural settings than urban. Some cultural practices are linked to some religions. For example, traditionalist using sharps for scarification (means of making tribal marks), ear piercing without sterilizing. This create a path for HBV infection among the youth. Socio-demographic characteristics such as educational attainment influences knowledge and perception on HBV infection. The knowledge and skill attained through education may influence one’s cognitive functioning making them respective to health educational messages eventually changing their health seeking behaviour. Lack or inadequate knowledge on HBV infection among SHS students may lead to high infection rate thereby making them more vulnerable.
1.4 Justification for the Study
Hepatitis B Virus infection (HBV) is associated with various clinical features which leads to Chronic carrier state in 5 to 10 % patient infected in adult life and 85 to 90% in childhood. HBV infection can progress to chronic liver diseases such as liver cirrhosis and hepatocellular carcinoma (HCC) and eventually leading to death(Zekri et al., 2007)
Hepatitis B Virus (HBV) infection is on intermediate or high level endemicity in low-income countries over a period of five decades. Though there is decrease in the prevalence rate of HBV infection in some countries due to universal vaccination programs, some countries however are still having high prevalence of HBV infection with hyperendemicity in the rural areas with the youth being most vulnerable. In several low-income countries where prevention, management and treatment of HBV infection is a huge burden on the governments and healthcare authorities, the distribution of the HBV infection is high.(Zampino et al., 2015).
Hepatitis B infection is vaccine preventable. Despite the introduction of the vaccine into the expanded program of immunization (EPI) in Ghana in 2002, a data of 15.5% HBV infection prevalence rate from the District Disease Control Unit proves that HBV infection is high among senior high school students in the District.
Identifying the factors leading to the high prevalence of HBV infection and it possible medium of transmission within the study population is very important in minimising the HBV infection transmission.
The information received would inform the District Health Management Team (DHMT) and other stake holders on interventions needed to reduce HBV infection in the District.
Research Questions
The study seeks to answer the following questions;
1. What is the proportion of Senior High School students who are infected with Hepatitis B Virus in Krachi Nchumuru District.
2. What are the associated factors influencing the prevalence of Hepatitis B infection among Senior High School Students in the District.
3. What is the Knowledge of students on HBV infection.
4. What are the practices among students that may lead to HBV infection
OBJECTIVES
General objective
To examine the factors influencing the prevalence of Hepatitis B infection among Senior High School Students in Krachi Nchumuru District.
Specific Objectives
1. To determine the proportion of Senior High School students who are infected with Hepatitis B Virus in Krachi Nchumuru District.
2. To identify the associated factors influencing the prevalence of Hepatitis B infection among Senior High School Students in the District.
3. To explore SHS student’s Knowledge on HBV infection.
4. To identify practices among senior high school students that may lead to HBV infection
Chapter two
Literature review
Prevalence of HBV infection
World Health Organization (WHO) reported in 2017 that, an estimated number of 325 million people globally are infected with Hepatitis B Virus (HBV).
The HBV infection endemicity is high in countries in African region and Western Pacific Region with the respective prevalence rate 8.83% and 5.26%. Other countries in WHO region recorded the prevalence rate of HBV infection ranging from 0.20% for Mexico to 13.55% for Haiti in the Americas, 0.49% for Seychelles to 22.38% for Sudan in the African region.(Schweitzer, Horn, Mikolajczyk, Krause, & Ott, 2015).
HBV infection affect between 5% to 10% of the population in Sub Saharan Africa causing an estimated number of 50% to 80% liver cancer.(Bigna et al., 2017)
High- Prevalence Populations
This refers to countries where chronic Hepatitis B Virus infection affects more than 8% of the population. Most of these infections occur at birth or in early childhood this may progress to chronicity. The high HBV infection is common in Asia Pacific and sub-Saharan African regions. It has been estimated globally that 45% of the world population lives in an area of high prevalence. There is evidence that vertical transmission is common in Asia than in African where majority of the women are highly infected. The impact of infant vaccination against HBV infection is great in high-prevalence populations. This is clearly seen in China where the prevalence rate of HBsAg fell from 9.7% to 1.0% in children under five the outcome prevented
an estimated 16 to 20 million cases of chronic hepatitis B. Meanwhile in Gambia, efficacy of infant vaccination is preventing 95% of chronic HBV infections. (Maclachlan & Cowie, 2015)
Intermediate-Prevalence Populations
North Africa, Middle East, part of Eastern and Southern Europe, Latin America and south Asia are part of regions of the world classify to have intermediate HBV prevalence of 2% to 7%. These shows a similar proportion of the world population to high prevalence areas which is slightly more than 40%. Transmission occurs vertically or horizontally in this regions. (Tre’po et al., 2014)
Low Prevalence Populations
Globally, people living in low HBV prevalence countries are few constituting 12 % of the world’s population among these countries are Australia, Asia, Northern and Western Europe, Japan, North America and some countries in south America. The mode of transmission in adolescents in this population is mostly through sexual contact, injecting drugs and other blood related exposure.1.2 million people who inject drugs are living with chronic Hepatitis B and 6.4 million have been exposed previously.(Maclachlan & Cowie, 2015). The burden of Chronic Hepatitis B virus infection among people who inject drugs varies with the following prevalence rates. Eastern Europe 22.8% of the global population and north America 22.2% of the global population. (Kowdley, Wang, Welch, Roberts, & Brosgart, 2012)
In Ghana, studies across all the regions among all the populations size were analysed. The national HBsAg was 12.3%. 10.8% prevalence rate was recorded among voluntary blood donors, replacement blood donors recorded a HBV infection prevalence rate of 12.7 and 13.1 was recorded among pregnant women. From 1995- 2015 the national prevalence rate kept on fluctuating. HBV infection prevalence of 17.3% was recorded from 1995-2002 followed by 14.7% from 2003- 2009 and the lowest was record from 2010 to 2016.Narrowing it down to the regional level, regional prevalence rate of 13.1% was recorded in the Ashanti region, Greater Accra recorded 10.6% prevalence rate, Northern and Central regions recorded 13.1% and 11.5% respectively. On the other hand, Eastern and Brong –Ahafo regions recorded
13.6 % and 13.7%.(Ofori-Asenso & Agyeman, 2016)
Associated factors influencing Hepatitis B infection
Age
There is a variation in age-specific HBV prevalence by geographical region with highest edemicity level in sub-Saharan African Region. A study conducted by Ott, Stevens, Groeger, & Wiersma, (2012) indicated that , Hepatitis B infection rate in Caribbean children and adolescent aged 0-19 years ranged from 4.4% to 5.4% which was kept constant over a period of time. Meanwhile a research conducted in China shows a higher HBV infection rate among the youth. The following HBV infection prevalence rate was recorded 10.6% among the age group 0-14 and 77.6% among age 15-49 as well as 11.8% among age group 50 years and above .(Chen et al., 2015).
The story was not different among European Union member state(EU). Member states recorded a prevalence rate of 33.8% among age group 25-34 years of both chronic acute HBV infection.(Centre et al., 2016). An estimated high HBV prevalence rate of 16.4% was recorded Togo among age group 15-24 years.(Gani KT & Layibo Y, 2015). In Ghana, a study conducted in Ho municipal hospital to determine the prevalence rate of Hepatitis B among pregnant women in the Volta region, recorded the highest HBV infection prevalence rate of 5.3% among age group 15-20 years with lowest 0.0% among age group 21-40 years.(Luuse et al., 2017)
Sex
A study conducted in Addis Ababa, Ethiopia among patient with chronic heart problem estimated high HBV infection among males than females with a prevalence rate of 38.2% and 31.8% respectively.(Ayele & Gebre-selassie, 2013).
Ekouevi et al., (2017) suggested from study conducted in Togo among university student that there is the need for prevention program to target the most vulnerable group majority of which are male with HBV prevalence rate of 5.8% as compared to their female counterpart with a prevalence rate of 3.1% most of whom ever had sexual relationship before. Another study conducted in Nigeria among university student reveal that, with a HBV prevalence rate of 14.4% among male student as compare to 9.8% in female, males are likely to be infected with HBV than female.(Aminu et al., 2013)
Marital Status
A study conducted in Nigeria confirm that the prevalence rate of HBV infection is high in married people than those who are single. The prevalence rate among married group is 50.7% and 32.4% was recorded in those who are single. Furthermore, 21.3% of the married group with HBsAg were confirm to be polygamist while 43.3% said they recently had contact with sex workers in their community.(E & Olabode, 2011).
Also another research conducted in Tanzania show similar revelation of HBV infection being prevalence in married groups than single people. Single or divorce group has a prevalence rate of 1.9% while married or cohabiting had a prevalence rate of 9.7%(Manyahi, Msigwa, Mhimbira, & Majigo, 2017)
Place of Residence
Globally, China is the country with the largest rural population and labour resources with the rural population lagging behind the urban health and education resources. A study conducted in China shows a HBV prevalence rate of 4.04% in rural Zhejiang which categorized the population among the intermediate epidemic area of Hepatitis B.(Yang et al., 2017).
An epidemiological serosurvey of HBV conducted in China reported that, the HBsAg prevalence among people living in urban area ranged from 0.4%-0.6% which was lower than persons living rural settings with a prevalence rate ranging from 1.0% to 1.2%. Furthermore, people born in smaller hospital or at homes in rural communities have a higher chance of been infected with the HBsAg. The result continue to indicate that, supposing a child is born in a family where a member is HBsAg positive (OR 4.26) and was not vaccinated (OR 2.06) and living in rural community, that child had a greater chance of being infected with HBsAgs than a child who has been vaccinated and lived in urban community.(Yonghao et al., 2015)
Knowledge about HBV infection
Outcome from a study conducted in Poland on the prevalence of HBV and knowledge of hepatitis B among patient attending primary care clinics shows that, some of the people were not aware on HBV infection and those who had a little Knowledge got it from the media and the medical staff. 76.7% of the respondent scored 50% and 45.6% were not aware of the potential causes of HBV infection. Also, patients low educational level was negatively linked to high knowledge HBV infection Level. (Ganczak, Dmytrzyk-Daniłów, Korzeń, Drozd-Dąbrowska, & Szych, 2015).
Another study conducted in Egypt among students reveals that the risk of HBV transmission through sharing personal belongings often goes unnoticed. An estimated number of 48% of students were aware that sharing items like nail cutters, scissors, toothbrushes and using unsterilized syringes are risk factors for Hepatitis B Virus infections transmission.(Sami, Salama, Elmosalami, Abdel-latif, & Abdel, 2015)
Causes
Hepatitis B is a dangerous liver infection caused by hepatitis B virus (HBV) which is transmitted by coming into contact with an infected body fluid such blood,
Saliva, breastmilk, tears, sweat, vaginal secretion and semen (WHO,2017). The normal incubation period of the HBV is 90 days from exposure to onset of symptoms which may differ from 6 weeks to 6 months.(Osei et al., 2017)
Mode of Transmission
There are three major ways one can infected with Hepatitis B Virus namely, perinatally thus from infected mother to child, through sexual transmissions which common among people with multiple sexual partners, men who have sex with men, and people with previous history of sexually transmitted diseases. The final major source of infection is unsafe injections, blood transfusion and tattooing, scarification, ear piecing. Though there are three main ways one can be infected with HBV, there are other possible means of being infected this include nosocomial infection which can occur through medical and surgical procedures such as needle-stick injuries and organs (Tre’po et al., 2014)
According to annual epidemiological report 2015, data on HBV transmission recorded this values, heterosexuals’ transmission which was most commonly recorded was 29.9% followed by nosocomial transmission 17.9%, transmission on non-occupational injuries was 12.0% whilst transmission among men who have sex with men recorded 11.8% prevalence rate of HBV infection. The prevalence rate of 9.3% was recorded among those who got infected through injecting drug use. The most common route of transmission was mother to child which recorded 59.5% (AER , 2015)
Signs and Symptoms
Usually, the signs and symptoms appears about one to four months after one is being infected with HBV, though it could be seen as early as two weeks after infection. The symptoms may not appear in young children, some of the symptoms include yellowish eyes and skin (jaundice), dark urine, extreme fatigue, nausea, vomiting not forgetting abdominal pains. (WHO, 2015)
Effects/ Complications
Though HBV is very infectious and deadly, it severity varies from mild illness with few symptoms or no symptoms to severe conditions which requires hospitalization. In some people particularly adult, the HBV is cleared in their system without treatment, this caliber of people become immune and protected against further HBV infection(CDC, 2016)
Meanwhile, HBV infection may lead to cirrhosis, liver cancer and even death if not diagnosed early. A research conducted in China indicated that, 43% of those infected with HBV developed liver cancer and 40% developed cirrhosis representing a substantial change over preceding two decades (Maclachlan & Cowie, 2015).
Also, the risk of chronic HBV infections differs inversely with age, in neonate, the risk of chronic HBV infection is 80% to 90% whiles 30 to 60% risk of chronic HBV infection was recorded in infants with the adult population recording 5% risk of chronic HBV infection. (Kwon & Lee, 2011)
Preventive Measures
. According to Tre’po et al.,( 2014), HBV infection can be avoided by not transmitting blood from infected person to uninfected person. Moreover, bloods should be screen for HBsAg before transfusion. Furthermore, the study conducted by Tre’po went on to state that, the best way to avoid being infected with HBV is screening and vaccination of the at risk adults as well as universal vaccination of neonate.
Among drug users and the youth, provision of needle exchange programmes for injecting drug users and the use of condoms to reduce the risk of sexual transmission is the best way to avoid being infected with HBV.(Aspinall, Hawkins, Fraser, Hutchinson, & Goldberg, 2011)
A study conducted in Nigeria among students reveal that the high prevalence rate of 12.5% HBsAg recorded shows that HBV infection is common among student and it may be due to it mode of transmission hence a health educational talk is necessary in the schools on the mode of transmission and how to prevent HBV infection. (Aminu et al., 2013)
Practices among students
Risky Behaviour among students.
Some risky behaviours noted for transmission of HBV infection among the youth includes, unsafe daily practices like sharing toiletries, and sharp objects like blades and shaving sticks. Not all but also some cultural practices like scarification, tattooing and ear piecing not forgetting sexual activities. These activities mostly increase the risk of HBV infection among the youth(Zampino et al., 2015)
Chapter three
METHODS
STUDY DESIGN
The study will be a cross-sectional and descriptive as well as sero-prevalence survey.
STUDY AREA
The study will be conducted in the selected Senior High Schools in Krachi Nchumuru District (KND) of the Volta Region. Krachi Nchumuru District was created out from Krachi West District following the passing of the legislative instrument (L.I. 2084) and was established and inaugurated on the 28th of June, 2012 at Chinderi the District capital. The District is located at the North Western Part of the Volta Region of Ghana and lies between Latitude 70 4” N and 80 25’ N Longitude 00 25’ W and 00 20’ E. It shares boundary with Krachi West District to South, Krachi East District to the east, Sene District to the South West and Kpandai District to the North. The total land area of the District is 1,194.90 sq km. Due to the closeness of Krachi Nchumuru District to Brong-Ahafo and Northern Region, the is socio-cultural exchanges between the Districts in these regions.
Educational Facilities
Krachi Nchumuru District can boast of three senior high schools and one vocational school. Two out of the three senior high schools are privately own. The schools run both hostel and boarding system with some students being day students.
Population Size
According to 2010 population and housing census, the population of Krachi Nchumuru is 72,688 representing 3.4% of the region’s total population. Males form 50.4% whiles females constitute 49.6%. The District has a rural population of 79.5% with a youthful population of 45.0%.
figure 2: map of Krachi Nchumuru District
VARIABLES
Dependent variables
Presence or absence of Hepatitis B surface antigen(HBsAg)
Independent variable
• Socio-demographic characteristics of student’s
1. Age,
2. Sex,
3. Marital Status
4. Place of Residence
• Knowledge on HBV infection among SHS student
1. Causes
2. Mode of Transmission
3. Health effect or complications
4. Preventive measures
• Practices Among Students
1. Risky Behaviours
STUDY POPULATION
The study population includes first year Senior High School students selected from various secondary schools in the District.
Sample Size
The sample size was obtained using the Cochrane formula stated below,
N= Z2 * P (1-P)
D2
Where N is the estimated sample size
Z is the constant for a 95% confidence interval given as 1.96
P is the prevalence rate of HBV infection among SHS students which is 15.5% = 0.155
This value is taken from the HBV screening conducted among SHS students in 2016 by the Krachi Nchumuru District Disease Control Unit.
D is the percent margin of error taken as 5%= 0.05
Substituting the values into the formula,
N= Z2 * P (1-P)
D2
N= 1.962×0.155× 0.845 = 201.24
0.052
Hence, the minimum sample size = 201.24 = 201 SHS Students
But considering 10% to cater for non-responsiveness and other unforeseen challenges like, the sample size is,
(10 ×201) =20.1
100
adding the answer to 201 we have 20.1+201=221
Therefore, the sample size is 221 participants
SAMPLING TECHNIQUE
The study will be conducted on first year senior high school students in two different senior high schools in Krachi Nchumuru District.
Two Senior High Schools will be selected at random using simple random sampling technique. Proportion to size calculation will be use to decide the number of participants to be interviewed in each senior high school.
Selection of Students
In selecting the students, the number of respondents expected from each stratum will equally be distributed among the participating senior high schools. For gender balance to be ensured, the number of qualify students in each school will be shared among the male and female students if possible. In enrolling the students, school registers will not be used. For each selected school, the total number of first year senior high school student present thus both boys and girls at the time of visit by the research team pick cards with inscriptions YES or NO. The cards will be selected from non-transparent bag. At any particular instant of selection, the number of YES cards will correspond to the number of respondent wanted. A sum of 4 days will be used thus 20th-24th January in selecting the participants, collecting conducting the HBV test and admonishing questionnaires.
Data Collection Techniques and Tools
Structured questionnaires will be use to collect data from the eligible participant. The questionnaires will be design to collect information on demography as well as knowledge and perception. Open ended questions will be use to answer the research question. Confidentiality and assurance will be given and the purpose of the research will be explain accordingly. Questionnaires will be administered to consented students immediately after taking their blood sample.
Testing HBV infection among Senior High School Students
In conducting the Hepatitis B surface antigen (HBsAg) test, Immunosorbent assay (ELISA) test kit, will be. The test kit is manufactured by the standard Diagnostic Inc. and was approved by the Food and Drug Board of Ghana. Two laboratory technicians from health centres in the district will assist to conduct the test. Manufacturer’s guideline will be follow accordingly in order to record accurate result. The laboratory technicians will put on gloves for infection prevention. The thumb of each participant will be wipe with alcohol pad and a strip of blood will be drown by pricking the thump with a sterilize lancet needle. The results will be interpreted accordingly and those positive will be referred to Krachi District Hospital for further management. Those negative will be counsel and educated accordingly.
TRAINING OF RESEARCH ASSISTANTS
The research team will consist of 3 laboratory technicians, 2 Community Health Nurses and 2 teachers who will be train on the sampling techniques and administration of questionnaires.
Pre- Testing review of instruments
Pretesting of the questionnaires will be done at Oti Senior High School to assess the consistency of the questionnaire that will be administered. Clarity and accuracy of the questionnaires will be examine. After pre-testing, questionnaires will be reviewed according to the information that will be receive.
DATA MANAGEMENT ANS ANALYSIS
Data collected will be checked for completeness and clarity. Coding will be done as well data cleaning. Data will be entered into Excel before importing it into STATA 15. Descriptive analysis will be done for the prevalence of Hepatitis B Virus infection and its associated thus dependent and independent variables. Person’s chi square and Fisher’s exact test will be in bivariate analysis to explore the relationship between the exposure and outcome variables. Adjusted odds ratio (aOR) and their 95% confidence intervals will be calculated. A p-value less than 0.05 will be considered significant