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Attitude and Vaccination Status of Healthcare Workers against Hepatitis B Infection in a Teaching Hospital, Ethiopia.

1. Introduction

Hepatitis B infection has been a major public health threat that affects nearly two billion people worldwide with 350 million chronic cases and more than 2 million deaths every year [1]. The disease is mainly transmitted by percutaneous or mucosal exposure to infected blood or other bodily fluids and numerous forms of human contact have been suggested to transmit hepatitis B virus (HBV): perinatal/mother-to-child, nonsexual, sexual, needle-sharing, and occupational/healthcare-related forms [2]. The disease causes chronic infection, resulting in cirrhosis of the liver, liver cancer, liver failure, and death. Furthermore, extrahepatic lesions can occur in other organs of the body, particularly in the kidney [3].

Since contact with body fluid of an infected person is one of the principal modes of transmission of the causative virus of hepatitis B infection, healthcare workers (HCWs) constitute one of the high-risk groups for this infection because of their repeated exposure [4]. World Health Organization (WHO) estimated that, of the 35 million HCWs worldwide, 3 million experience percutaneous exposure to blood pathogens each year and 2 million of those HCWs are exposed to hepatitis B virus [5-8]. In general, prevalence of HBV infection among healthcare providers is approximately ten times greater than the general population [9]. More importantly, HCWs in developing countries are at serious risk of infection from blood-borne pathogens because of the high prevalence of such pathogens in many poorer regions of the world, especially in endemic areas like Sub-Saharan Africa [10].

Due to the absence of medical treatment that can cure hepatitis B virus (HBV) infection, hepatitis B vaccine is the single most effective and safe strategy for the prevention of the disease if appropriate doses are given during a period of 6 months. The vaccine provides more than 90% effective protection after all doses [11, 12]. As part of occupational safety measures, WHO, Centers for Disease Control and Prevention (CDC), and the Ethiopian Federal Ministry of Health (FMOH) infection-prevention guidelines recommend that all health professionals should be vaccinated against HBV before they started the clinical attachments during their stay in the medical school [13-15]. However, in spite of higher vulnerability among health professionals, the WHO estimate showed that HBV vaccination coverage among HCWs is only 18-39% in low- and middle-income countries compared to 67-79% in developed countries [13].

In Ethiopia, hepatitis B infection cases account for 12% of the hospital admissions and 31% of the mortality in medical wards of Ethiopian hospitals [16]. Specifically, studies conducted on health professionals revealed 9.7% prevalence of hepatitis B surface antigen (HBsAg) [17]. On top of that, some studies also reported lower coverage of hepatitis B vaccination among health professionals [18-21]. Therefore, this study aimed to assess the attitude and vaccination status of health professionals against hepatitis B virus infection and factors associated with complete immunization.

2. Methods

2.1. Study Design and Setting. The study was conducted at Adama General Hospital and Medical College, Adama, Ethiopia. The city is located 99 km away from Addis Ababa, the capital city of Ethiopia, to the southeast. This teaching hospital has catchment population of about 5 millions, serving as referral hospital for all nearby hospitals and adjacent regions. It has more than 500 healthcare workers providing the service in different units. This is an institution-based cross-sectional study conducted from December 2016 to February 2017.

2.2. Study Participants. All health professionals working at Adama General Hospital and Medical College were included into the study irrespective of their working unit and duration of stay to minimize the risk of selection bias.

2.3. Variables and Measurement. Complete immunization against hepatitis B virus and attitude of healthcare workers towards hepatitis B infection and its vaccination were the outcome variables measured in the study, whereas various sociodemographic variables (age, profession, working unit, and years of work experience) and occupational variables (training on infection-prevention and history of exposure to risky behavior) were the independent variables. Complete immunization was measured using the following question: "how many doses of the vaccine have you taken?" Taking three or more doses of the vaccine was defined as complete immunization. Attitude was measured on the cumulative score of thirteen questions designed to assess healthcare workers' attitude towards hepatitis B infection and its vaccination. Each attitude question contains ordinal categorical response rated in 5-point Likert scale [i.e., 1 = strongly disagree; 5 = strongly agree] and these questions were adapted from previous literatures [19, 22, 23]. Overall, the scores for each participant were summed and study participants who have responded to >60% of attitude questions positively were regarded as having favorable attitude.

2.4. Sample Size and Sampling Procedure. Single population proportion formula was used to calculate the sample size given the prevalence of hepatitis B vaccination for healthcare workers of 50% to obtain a relatively larger sample size, confidence level of 95%, and marginal error of 5%. The final sample size was 403 after adjustment for 5% nonrespondent rate. The total sample size was proportionally allocated to each of the working departments in the hospital. The list of health professionals working in each department was obtained from the hospital and simple random sampling technique was employed to select the study subjects from the list.

2.5. Data Collection and Quality Control. Data were collected using self-administered questionnaire distributed at the participant's work unit. Data collection was performed by three nursing professionals through distributing and recollecting the questionnaire prepared in English. Pretesting was performed on 5% of the total sample size in other health facilities and a necessary adjustment was made prior to the actual data collection. The questionnaire was also tested for internal consistency (reliability) by Cronbach's Alpha test using Statistical Package for Social Sciences (SPSS) version 20.0. Similarly, content validity was cross-checked by a public health expert. The completeness, consistency, and accuracy of the collected data were examined by principal investigator every day.

2.6. Data Processing and Analysis. The data were coded, cleaned, and entered into Epi Info version 7 and it was exported to SPSS version 20 for statistical analysis. First, descriptive statistics were generated followed by binary and multiple logistic regressions to examine the possible association between the determinant and the outcome variable. In this model, P value < 0.05 was used to declare the presence of statistically significant association. The result was reported strictly following STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) statement (supplementary file (available here)).

3. Result

3.1. Sociodemographic Characteristics of the Study Participants. A total of 386 participants completed the questionnaire, making a response rate of 97%. More than half (198 (51.2%)) of participants were male and the age of study participants ranged from 21 to 64 with the mean age of 28.45 ([+ or -]3.2) years. The professional background of respondents was dominated by nurses (203 (52.7%)) followed by medical doctors (52 (13.5%)) (Table 1).

3.2. Attitude towards Hepatitis B Infection and Its Vaccination. More than three-fourths (77.8%) of study participants strongly agreed that hepatitis B is a major public health threat. Similarly, more than half (51.2%) of healthcare workers strongly agreed that hepatitis B vaccine should be obligatory to take. There was tendency among participants to believe that their profession will put them at increased risk of acquiring the disease (strongly agreed: 75.9%). Participants also stated that following the infection-prevention guideline has a potential benefit on reducing the chance of contracting hepatitis B infection (strongly agreed and agreed: 85.2%) (Table 2).

3.3. History of Occupational Exposure and Perceived Risk of Disease Acquisition. Healthcare workers were asked to rate their perceived risk of acquiring the infection. The respondents reported that they have very high (51 (13.3%)), high (80 (20.7%)), medium (101 (26.1%)), low (142 (36.9%)), and very low (12 (3%)) risk of contracting the disease. Nearly half (182 (47.3%)) of healthcare workers had history of occupational exposure to risky conditions. Unprotected mucocutaneous fluid contact on intact skin (121 (66.7%)), sharp-needle injury (72 (39.6%)), and body fluid splash through body openings (51 (28.1%)) represent the three main forms of exposure. The most common (130 (71.3%)) action taken after the exposure was washing the area of exposure with soap, water, or antiseptic (Table 3).

3.4. Vaccination and Postvaccination Testing. Only three in ten (118 (30.4%)) participants had been screened for hepatitis B surface antigen. Regarding the vaccination status of study participants, more than half (223 (57.7%)) of them reported history vaccination at least once. However, less than half (99 (44.5%)) of these participants received the recommended three doses of the vaccine, of which 36 (36.8) tested after the vaccine to check for the vaccine effect and all of them were protected (anti-HB titer > 10 MIU/ml). Among healthcare workers who did not take the vaccine, vaccine unavailability through government channels (36%), high cost of the vaccine for private access (41%), and not giving much concern about this issue (26%) represent the major reasons stated for not being vaccinated (Table 4).

3.5. Factors Associated with Vaccination Status. Multivariate analysis of factors affecting the practice of full dose vaccination revealed that previous exposure to occupational risks of hepatitis B infection, years of work experience and infection-prevention training were statistically significant with complete vaccination status. Participants whose years of work experience were [greater than or equal to]5 years had 3 times (AOR = 3.1 (.98-5.24)) greater chance of receiving the vaccine. Likewise, previous history of exposure to occupational risks of hepatitis B infection resulted in 5.5 times (AOR = 5.5 (2.86-9.29)) increased practice of receiving full dose vaccine. Similarly, participants who attended infection-prevention training were 2.3 times (AOR = 2.3 (1.24-6.31)) more likely to take the recommended vaccine dose than their counterparts (Table 5).

4. Discussion

Hepatitis B vaccination is one of the most important primary prevention ways of this contagious disease and immunization against this infectious agent provides an optimal protection for individuals at risk [24]. World Health Organization estimated that hepatitis B vaccine's coverage among healthcare providers is 18% in Africa, which represents the least figure [25]. Therefore, this study assessed the coverage of hepatitis B vaccine among healthcare workers of Adama General Hospital and Medical College, Ethiopia.

In this study, it appeared that the proportion of healthcare workers who received hepatitis B vaccine at least once was 57.7%. This finding is in the range of 47%-60% reported in different studies of different areas [20, 26-28]. However, the result is relatively lower compared to the findings reported from Iraq (65.7%), Kuwait (74.4%), India (78%), and Nigeria (91.9%) [29-32]. The complete reason for low vaccine coverage of our survey compared to these studies cannot be completely discernible. However, difference in vaccine accessibility across countries, relatively late addition of hepatitis B vaccine into national immunization program, and certain variability between the sociodemographic characteristics of the study participants might explain this discrepancy. The proportion of healthcare workers who completed the recommended three or more doses of the vaccine constitutes 25.6% of the whole study participants. This figure is lower compared to reports of other studies conducted in Pakistan (57.6%), Malaysia (58.6%), and Libya (72%) [33-35]. This lower rate of complete immunization reflects the need for well effective strategy that enhances increased rate of compliance with recommended vaccine doses. Furthermore, health professionals have to be supported and inspired to check their protection status to make sure whether or not they require additional doses of the vaccine to get protected.

Regarding the attitude of healthcare workers towards hepatitis B infection and its vaccination, the majority of them showed encouraging positive attitude towards the issue. The majority (77.8%) of healthcare workers strongly agreed that hepatitis B is a major public health threat and almost all (96.5%) of them stated that their job puts them at risk of acquiring the disease. Regarding the importance of vaccination, around 75% of healthcare workers agreed that hepatitis B vaccination should be compulsory. These statements are also similarly reported at comparable rate in other studies conducted in Kuwait and Gondar University Hospital [30, 36].

Among healthcare workers who did not receive the vaccine, the most frequently mentioned reason was high cost of the vaccine for private access. Similarly, studies from different areas reported the same finding [20, 22, 37, 38]. Another barrier mentioned was vaccine unavailability, which was reported by 36% of participants. Likewise, this report is in line with the reasons mentioned for vaccine refusal in different articles [19, 28, 39]. This is an input for stakeholders to establish an effective program that focuses on vaccine availability at affordable cost to meet the demand of healthcare workers. According to our study, nearly half (47.3%) of healthcare workers have been exposed to risky situation for hepatitis B infection. Of these, 39.6% reported exposure to sharp-needle injury. A study conducted in Pakistan reported that the percentage of healthcare workers who had experienced at least one sharp injury in a year was 44% and another study conducted in Gondar University Hospital also revealed that 49.2% of healthcare workers had been exposed to occupational risks [36, 40]. This evidence emphasizes the importance of hepatitis B vaccination for this group of people in particular given the extent of their exposure.

This study revealed that healthcare workers who have been exposed to risky conditions of hepatitis B virus had increased chance of receiving complete immunization. This finding is in line with reports from north India, Zambia, and northwest Pakistan [23, 28, 41]. This might be because of increased perceived threat of getting such blood-borne disease after exposure to risky conditions. Years of work experience were another important factor that influenced the complete vaccination status of healthcare workers. Similarly, other studies showed that there was an increased chance to get full vaccination with increasing number of years of work experience [21, 42, 43]. This might be because of the fact that healthcare workers who joined the institutions later might not have benefited from vaccination because of sporadic availability of the vaccine through government channels. Likewise, increased length of work years would result in higher rate of exposure to various risky behaviors, which in turn leads to increased perceived threat of acquiring the disease. Participants who attended infection-prevention training showed increased rate of complete immunization. Studies from Zambia and Nigeria revealed the same finding [23]. This result shows that provision of basic infection-prevention training for all hospital might have a benefit in terms of lifting up the perceived benefit of such preventive strategies among healthcare workers.

5. Limitations

Despite extensive efforts that have been made to minimize possible shortcoming of this study, the finding of this survey will be interpreted in the presence of the following inevitable limitations. The cross-sectional nature of the study does not confirm the definitive cause-and-effect relationship. There is also a possibility of admitting recall bias because of the self-reported vaccination status.

6. Conclusion

Only a small proportion of healthcare workers have taken the recommended three doses of the vaccine at Adama General Hospital and Medical College. Attending infection-prevention training, work experience, and history of exposure to risky condition were the factors that are statistically significant with the completion of the recommended three doses. High cost of the vaccine for private access and vaccine unavailability were the major barriers identified for hepatitis B vaccination. Sustained HBV vaccination programs for HCWs need to be established by collaboration of different stakeholders. Moreover, the Regional Health Bureau should offer the vaccine to HCWs free of charge by coordinating efforts from other concerned bodies. Similarly, the government should design a national strategy that focuses on vaccinating medical and health science students before they are assigned to their work place.

Data Availability

The original raw data analyzed during the current study is available from the corresponding author and can be presented upon reasonable request.

Ethical Approval

Ethical clearance was obtained from the Ethical Review Committee of Institute of Medicine and Health Science, University of Debre Berhan.


The respondents were informed about the purpose of the study and their consent to participate was obtained.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Authors' Contributions

Mohammed Akibu designed the study, supervised the data collection, performed analysis and interpretation of data, and organized the paper and all versions of the manuscript. Sodere Nurgi, Mesfin Tadese, and Wendwesen Dibekulu Tsega were actively involved in supervision of the data collection, data analysis, and preparation of this manuscript. All authors read and approved the final manuscript.


The authors would like to pass their gratitude to the University of Debre Berhan for the ethical clearance. They also want to send their appreciation to the study participants for giving their genuine information.

Supplementary Materials

Supplementary file 1: completed checklist of STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) for cross-sectional studies. STROBE Statement--Checklist: Attitude and Vaccination status of Health care workers against Hepatitis B infection in a Teaching Hospital, Ethiopia. (Supplementary Materials)


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Mohammed Akibu (iD), (1) Sodere Nurgi, (1) Mesfin Tadese (iD), (1) and Wendwesen Dibekulu Tsega (2)

(1) Department of Midwifery, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia

(2) Department of Public Health, Institute of Medicine and Health Science, Debre Berhan University, Debre Berhan, Ethiopia

Correspondence should be addressed to Mohammed Akibu;

Received 4 November 2017; Revised 5 February 2018; Accepted 1 March 2018; Published 2 April 2018

Academic Editor: Paulo Hiiario Nascimento Saldiva
Table 1: Socio-demographic characteristics of health professionals,
AHMC, Ethiopia 2017.

Variable                     Frequency (n = 386)     Percent (%)

  Male                               198                 51.2
  Female                             188                 48.8
Age (years)
  20-30                               33                 16.3
  31-40                               94                 46.3
  >40                                 7                  3.4
Marital status
  Unmarried                          210                 54.4
  Married                            176                 45.6
  Orthodox                           266                  69
  Protestant                          72                 18.7
  Muslim                              35                 8.9
  Other (a)                           13                 3.4
  Nurse                              203                 52.7
  Midwife                             44                 11.3
  Lab technician                      25                 6.4
  General Practitioner                52                 13.5
  Dental Doctor                       14                 3.6
  Pharmacist                          20                 5.2
  Specialist                          28                 7.3
Working department
  Inpatient department                92                 23.8
  Outpatient                         114                 29.5
  Emergency department                36                 9.3
  Delivery unit                       53                 13.8
  Laboratory                          28                 7.3
  OR department                       32                 8.3
  Dental department                   31                  8
Work experience
  <5 years                           227                 58.7
  [greater than or                   159                 41.3
  equal to] 5 years
Training on infection
  Yes                                224                  58
  No                                 162                  42

(a) catholic, woke feta, Adventist.

Table 2: Attitude of health professional towards hepatitis B infection
and its vaccination, AHMC, Ethiopia, in 2017.

Items                  Strongly agree       Agree         Neutral

HBV is serious           300 (77.8%)      70 (18.2%)     4 (1.0%)
public health

All patients             80 (20.7%)      116 (30.1%)    99 (25.6%)
should be tested
for HBV before
they receive

Being a health           292 (75.9%)      80 (20.6%)      8 (2%)
professional puts
you at greatest
risk of HBV

Following                203 (52.7%)     125 (32.5%)     21 (5.4%)
infection control
guidelines will
protect me from
being infected
with HBV and HCV
at work

I deliver the same       46 (11.8%)      148 (38.4%)     32 (8.4%)
standard of care
to patients with
HBV as I do for
other patients

It is appropriate        91 (23.6%)      109 (28.2%)    46 (11.8%)
not to spend much
time when caring

A healthcare             112 (29.1%)     141 (36.5%)     15 (3.9%)
worker can infect
patients with HBV

Health                    25 (6.4%)       32 (8.4%)     63 (16.3%)
professionals who
are hepatitis B
should not give
services to

I do not trust HBV        17 (4.3%)       45 (11.7%)     54 (14%)

HBV vaccine should       198 (51.2%)      91 (23.7%)     25 (6.4%)
be compulsory

HB vaccine is safe       236 (61.1%)      89 (23.2%)     36 (9.4%)
but is expensive

After exposure to        122 (31.5%)      97 (25.1%)    49 (12.8%)
contagious flu-id-
material, the
vaccine reduces
likelihood of
being HBV-

Items                    Disagree       Strongly

HBV is serious          10 (2.5%)       2 (0.5%)
public health

All patients            68 (17.7%)     23 (5.9%)
should be tested
for HBV before
they receive

Being a health            4 (1%)        2 (0.5%)
professional puts
you at greatest
risk of HBV

Following               29 (7.4%)       8 (2,0%)
infection control
guidelines will
protect me from
being infected
with HBV and HCV
at work

I deliver the same     101 (26.1%)     59 (15.3%)
standard of care
to patients with
HBV as I do for
other patients

It is appropriate       72 (18.7%)     68 (17.7%)
not to spend much
time when caring

A healthcare            78 (20.2%)     40 (10.3%)
worker can infect
patients with HBV

Health                 118 (30.5%)    148 (38.4%)
professionals who
are hepatitis B
should not give
services to

I do not trust HBV     109 (28.3%)    161 (41.7%)

HBV vaccine should      64 (16.7%)       8 (2%)
be compulsory

HB vaccine is safe      13 (3.4%)      12 (3.0%)
but is expensive

After exposure to       80 (20.7%)     38 (9.9%)
contagious flu-id-
material, the
vaccine reduces
likelihood of
being HBV-

Table 3: Exposure to occupational risk of hepatitis B among
health professionals, AHMC, Ethiopia, in 2017.

Variable                                  Frequency    Percentage

Occupational exposure
  Yes                                        182          47.3
  No                                         204          52.8
Exposure to sharp injury
  Yes                                         72          39.6
  No                                         110          60.4
Unprotected mucocutaneous fluid
contact on intact skin
  Yes                                        121          66.7
  No                                          61          33.3
Body fluid contact through body
  Yes                                         51          28.1
  No                                         131          71.9
Measure taken after exposure
  Testing the patient right away              71           39
  Washing with soap, water, or               130          71.3
  Immediate report                            80          44.2
  Allowing the injury area to bleed           25           14
  Wait and test myself                        11           6.2

Table 4: Vaccination status and reason for not taking the vaccine
among health professionals, AHMC, Ethiopia, in 2017.

Variables                                      Frequency    Percentage
                                                   N            (%)

Ever screened for hepatitis B
  Screened                                        118          30.4
  Not screened                                    268          69.6
Vaccination for hepatitis B
  Vaccinated                                      223          57.7
  Not vaccinated                                  163          42.3
Vaccination dose
  Once only (incomplete vaccination)               75          33.6
  Received two doses (incomplete                   49          21.9
  Three complete doses (fully                      99          44.5
Complete vaccination status
  Fully vaccinated                                 99          44.5
  Incomplete vaccination                          124          55.4
Have you been tested after full dose?
  Tested for the vaccine effect                    36          36.4
  Not tested                                       63          63.8
Test result
  Protected (anti-HB titer > 10 MIU/ml)            36           100
Reason for incomplete vaccination
  Being busy                                       47          37.9
  I feel I am protected                            15          12.2
  Forget it at all                                 28          22.6
  Waiting for the next dose                        34          27.3
Reason for not taking the vaccine
  The vaccine was not available through            59           36
  government channels
  The vaccine is very expensive for                67           41
  private access
  I did not give it too much emphasis              42           26
  The side effect would be worse                   13            8
  The duration of total dose is too long           25          15.4
  Others (b)                                       6            3.7

(b) I do not think I am at risk, I never thought about it, or I
have no reason.

Table 5: Logistic regression of factors affecting full vaccination
status among HCWs who received at least one dose, AMHC, Ethiopia, in

Variable                              Fully vaccinated

                                        Yes       No
  Male                                   37       49
  Female                                 62       75
Work experience
  <5 years                               28       74
  [less than or equal to] 5 years        71       50
  Nurse                                  35       45
  Midwife                                14       17
  Lab technician                         12       13
  General practitioner                   16       19
  Pharmacist                             5        8
  Dental doctor                          6        9
  Specialist                             11       13
Training on IP
  Yes                                    67       48
  No                                     32       76
Work unit
  Inpatient unit                         12       25
  Dental department                      4        11
  Emergency unit                         13       16
  Delivery unit                          23       21
  Laboratory                             21       7
  OR department                          6        13
  Outpatient unit                        20       31
Exposure history
  Yes                                    73       38
  No                                     26       86

Variable                                   COR (95% CI)

  Male                                           1
  Female                                  3.45 (1.82-6.7)
Work experience
  <5 years                                       1
  [less than or equal to] 5 years        4.8 (2.64-7.44) *
  Nurse                                  0.87 (0.67-2.13)
  Midwife                                 1.5 (0.68-2.75)
  Lab technician                        2.6 (1.36-5.71) *
  General practitioner                    2.1 (0.92-6.37)
  Pharmacist                             1.65 (0.401-4.62)
  Dental doctor                          1.39 (0.44-3.64)
  Specialist                                     1
Training on IP
  Yes                                    3.4(2.77-8.92) *
  No                                             1
Work unit
  Inpatient unit                         2.93 (2.91-7.68)
  Dental department                     0.063 (0.0057-0.84)
  Emergency unit                          1.4 (0.63-3.18)
  Delivery unit                         4.64 (1.43-19.7) *
  Laboratory                            5.45 (1.74-9.27) *
  OR department                          1.39 (0.34-3.24)
  Outpatient unit                                1
Exposure history
  Yes                                    6.4 (3.43-11.58)
  No                                             1

Variable                                   AOR (95% CI)

  Male                                          1
  Female                                 1.06 (0.84-3.62)
Work experience
  <5 years                                      1
  [less than or equal to] 5 years       3.1 (1.98-5.24) *
  Nurse                                  0.22 (0.03-1.45)
  Midwife                                0.6 (0.07-4.64)
  Lab technician                         1.72 (0.89-2.42)
  General practitioner                   0.03 (0.04-2.21)
  Pharmacist                             0.82 (0.27-3.91)
  Dental doctor                          1.57 (0.38-6.19)
  Specialist                                    1
Training on IP
  Yes                                   2.3 (1.24-6.31) *
  No                                            1
Work unit
  Inpatient unit                         1.07 (0.94-3.75)
  Dental department                     0.071 (0.003-1.83)
  Emergency unit                          1.6 (0.71-4.2)
  Delivery unit                          2.48 (0.82-7.29)
  Laboratory                            2.16 (0.018-6.23)
  OR department                          1.56 (0.40-6.24)
  Outpatient unit                               1
Exposure history
  Yes                                   5.5 (2.86-9.29) *
  No                                            1

* indicates statistically significant value.
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Article Details
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Title Annotation:Research Article
Author:Akibu, Mohammed; Nurgi, Sodere; Tadese, Mesfin; Tsega, Wendwesen Dibekulu
Article Type:Survey
Geographic Code:6ETHI
Date:Jan 1, 2018
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