Recent studies have estimated that around 5–15% of individuals with chronic hepatitis B virus (HBV) infection are also coinfected with hepatitis D virus (HDV) (Stockdale et al., 2020). HBV and HDV co-infection causes the most severe form of viral hepatitis, chronic hepatitis D (CHD), which often leads to accelerated progression to cirrhosis, hepatic decompensation, and hepatocellular carcinoma compared to chronic HBV mono-infection (Hughes et al., 2011). Although our understanding of the global HDV prevalence remains incomplete, it is apparent that it is unevenly scattered, with significant hotspots in regions such as Mongolia, Pakistan, Central Asia, Middle East, and Eastern Europe (Khodjaeva et al., 2019). Considering that the hotspots are mostly in developing countries and HDV tests are rarely implemented, the actual global burden of HDV may be significantly underestimated (2024). It is estimated that at least 12 million people globally are living with HDV, though the actual number may be higher due to inadequate testing, particularly in regions with higher prevalence (Da et al., 2021). This suboptimal testing results in the diagnosis of only 20–50% of individuals infected with HDV (Negro and Lok, 2023). According to a previous study, Mongolia shows the highest HDV prevalence rate of 61%, while Pakistan with 16.6% is in second place. Israel, Greece, Saudi Arabia, and Italy showed 5.4, 4.7, 4, and 3.4% prevalence, respectively (Razavi-Shearer et al., 2024).

Estimating the population-level prevalence of viral hepatitis especially HDV is challenging due to substantial biases characteristic in many studies. In most of the countries, national serosurveys are limited, and mostly studies are conducted within particular risk groups or among diagnosed individuals seeking care or long-term treatment (Lazarus et al., 2023). As a result, these studies tend to misjudge the exact prevalence compared to the overall population. This problem is further impaired by the fact that numerous regional serosurveys are conducted in high HDV prevalence areas, which skews the prevalence of national estimations (Stockdale et al., 2020). Additionally, the lack of standardized tests for anti-HDV and the absence of HDV RNA data in many HBV studies further complicate accurate prevalence estimation. Moreover, at the national level, reflex testing-automatically testing all HBsAg+ specimens for anti-HDV at the laboratory level is not regularly implemented. Despite having robust patient registry systems, the lack of reflex testing leads to missed diagnoses of HDV. For example, recent data from different centers in Spain indicate that implementing reflex testing regularly led to a 5-fold increase in the number of HDV-infected individuals (Palom et al., 2022).

Studies based on epidemiological data suggests a decrease in the prevalence of both HBV and HDV, especially in developed countries, with HBV control through vaccination being an important factor. However, the situation remains challenging in developing countries like Pakistan, where inadequate funding and lack of preventative measures impede the control of HBV (Butt et al., 2014). In Pakistan, especially in rural areas, HBV prevalence rates are alarmingly high, ranging from 16 to 57%, and positive individuals of HDV/HBV co-infection are notably more common among young males, particularly in Sindh province (Abbas, 2012). Numerous studies from Pakistan focus on anti-HDV prevalence among HBsAg-positive patients, but these studies do not provide a precise representation of the true viral hepatitis epidemiology (Abbas, 2012; Jalil et al., 2016; Jamil, 2016). Moreover, the vaccination status against HBV is also very low in developing countries, but in Pakistan there is now a reasonable coverage of 50% in infants and around 30% in adults, although this vaccination coverage remains low. On the other hand, limited health knowledge can prevent patients understanding of the importance of regular treatment, while socioeconomic barriers restrict access to required medications and healthcare. This problem is very common in many countries, especially in some Asian countries such as India, Pakistan, Bangladesh, Mongolia, and most of the African countries, where people do not follow the doctor’s protocol properly (Chirambo et al., 2019; Chatha et al., 2020; Ma et al., 2022; Baryakova et al., 2023).

Furthermore, as a protective and preventive measure, spreading knowledge is essential to curb the quick spread of the viral infections especially HBV/HDV. In this regard, both the media, scientific communities, and health-workers should closely collaborate and work together to shape the attitudes of all portions of society. The objective is to control the disease via appropriate practices informed by the knowledge, attitudes, and perceptions surrounding HBV/HDV. A community combined knowledge, attitudes, and perceptions play a significant role in determining how far a virus may spread within a given area (Khattak et al., 2022). Thus, this study was designed to estimate the self-reported HBV/HDV diagnosis, knowledge, risk factors, attitudes, behavioral practices, and perceptions of the Pakistani population regarding HBV/HDV to inform public health policies. By identifying the existing knowledge gaps and misconceptions, this study seeks to offer insights that will help shape targeted educational campaigns, improve community engagement, and strengthen preventive measures against HBV/HDV in Pakistan. Understanding these aspects are important for designing and implementing effective public health interventions, ultimately contributing to the broader goal of safeguarding public health in the face of infectious diseases.

HBV along with HDV, poses a serious public health challenge, accelerating liver cirrhosis and significantly increasing morbidity and mortality (Alfaiate et al., 2020). In Pakistan, HBV and HDV infections remains a major concern. Alarmingly, awareness regarding HBV/HDV transmission, prevention, and associated risk factors are declining in Pakistan, even among affected individuals. A recent meta-analysis reported Mongolia as having the highest HDV prevalence (61%), while Pakistan also exhibits a substantial burden, with 16.6% of HDV-infected individuals (Razavi-Shearer et al., 2024). Despite this, HBV/HDV testing remains limited in Pakistan, leading to a likely underestimation of the true disease burden. A previous study discussed that a key contributing factor maybe the widespread misconception that HBV/HDV is rare and of minimal clinical significance (Abbas and Abbas, 2024). The current large-scale cross-sectional study aims to enhance the current understanding of HBV/HDV infections in Pakistan and underscore their clinical relevance. By investigating positive individual rates, vaccination status, knowledge levels, risk factors, attitudes, behavioral practices, and public perceptions, this study will serve as a critical foundation for future research and public health initiatives targeting HBV/HDV in Pakistan.

The current data were collected from over 980 individuals, including healthcare workers, students, office employees, and others, with the majority of responses coming from postgraduates. We assessed their perceptions of HBV/HDV, vaccination status against HBV, and the self-reported positive cases of HBV and HDV. Additionally, we examined key risk factors, public attitudes, particularly the stigma associated with HBV/HDV infection and overall knowledge about hepatitis. This study is particularly important because, similar to some other Asian countries, many people in Pakistan do not strictly adhere to the medical guidelines (Chatha et al., 2020; Baryakova et al., 2023). This non-compliance increases the risk of many infections, particularly HBV and HDV, highlighting the urgent need to improve awareness and initiate preventive measures. In the current study, our binomial regression model was statistically significant, good fit and explained appropriately 90.3% variance. Our model shows statistically significant data based on χ² (6) = 934.649, p < 0.001 (indicating that the predictors reliably explained our dependent variable). Hosmer-Lemeshow for goodness-of-fit test indicated that the model is a good fit (χ² = 121.628, p = 0.310). Moreover, the model has explained 82.0% of the variance (Nagelkerke R² = 0.820), and correctly classified 90.3% of cases.

The respondent was mostly male of about 776 and the remaining 204 out of 980 were females. The participants were belonging to different provinces such as Punjab 430, Khyber Pakhtunkhwa 141, Sindh 198, Baluchistan 104, Gilgit Baltistan 51, and the capital territory Islamabad 56 respondents out of 980. All participants were responded through an online google form. Our findings indicate that some respondents had a moderate understanding of HBV/HDV transmission and prevention, but 754 out of 980 respondents having no or limited HBV/HDV knowledge (Figure 1; Table 4) (Ahmed et al., 2023). According to previous study, the prevalence of HDV among people in Pakistan was 16.6% (Razavi-Shearer et al., 2024). Our study shows a self-reported prevalence of HBV/HDV infection lowered than the previous study. This difference is likely related to differences in study design, sampling strategy, and population characteristics. However, when we asked respondents about their family history and calculated the prevalence, it shows a higher self-reported prevalence rate (Table 2), suggesting possible family clustering and shared risk factors that may not be sufficiently reflected in population-level assessments. The self-reported prevalence of HBV/HDV across demographics are shown in Supplementary Table S2. We find that the higher prevalence was due to a smaller number of vaccinations against HBV (56.5%, 118/209) (χ² = 41.17, p < 0.001), chronic illnesses, and less focuses on the symptoms related to hepatitis. Furthermore, the risk factors and behavioral practices such as sharing blades at barbershops, using shared needles and medical/dental equipment’s at unlicensed clinics or pharmacies, and no use of gloves while handling blood or body fluids may also be the causes of higher HBV/HDV prevalence in Pakistan. However, comparisons between previous study and our study are limited by different methods of detection (Razavi-Shearer et al., 2024). Therefore, these findings warrant additional validation by a well-designed serological and longitudinal studies. Overall, given our sample size, we believe our estimate to be closer to true prevalence and propose the burden of HBV/HDV in Pakistan may in fact be much higher than previously believed (Aftab et al., 2018).

Moreover, around 400 participants claimed that they have no source of information available about HBV/HDV. Similar findings have been reported in previous studies conducted in other countries, such as Vietnam, where research at designated clinics and healthcare centers identified significant knowledge gaps among medical students concerning HBV transmission, the associated health risks, and available diagnostic tests (Wang et al., 2016). As illustrated in Figure 1, our study similarly found a positive correlation between respondents’ knowledge and their approach to hepatitis management. A lack of understanding and widespread misconceptions about HBV/HDV transmission, particularly the increased risk of chronic infection when the virus is contracted at birth can lead to missed opportunities for prevention, including vaccination, and may also contribute to the stigma and discrimination faced by individuals living with HBV/HDV. Similar patterns have been observed in studies conducted in Ghana (Osei et al., 2019; Adam and Fusheini, 2020). Additionally, another study highlighted a general lack of information regarding HBV/HDV prophylaxis (Le An et al., 2021). These findings suggest that individuals may not have received adequate education for the prevention of HBV/HDV, which could hinder both the general public and hepatitis patients from effectively managing their health. Enhancing screening among healthy blood donors is crucial for both preventing transmission and assessing the disease burden especially in Pakistan, where approximately 1.5 million people donate blood annually (Zahoor et al., 2021). Despite efforts, challenges such as inadequate healthcare facilities, low socioeconomic status, and limited awareness about HBV/HDV transmission persist (Ali et al., 2011). In response, various institutions in Pakistan have launched initiatives to educate the public about hepatitis especially HBV/HDV. In this case, the National Institute of Health (NIH) in Islamabad has identified key environmental risk factors and implemented training programs for lady health workers and their supervisors, aiming to raise awareness and promote preventive measures to combat the spread of hepatitis. Moreover, this study finds the challenges such as limited public awareness, inadequate screening, low vaccination coverage, and poor healthcare infrastructure hinder effective disease control. The government has implemented strategies such as the Expanded Programme on Immunization (EPI), which includes the HBV vaccine, and the Prime Minister’s Health Program, aimed at improving access to treatment (Hasan et al., 2010). This program targets almost 7.5 million children every year throughout the country and may prevent up to 17% of the childhood mortality. However, about 356 out of 980 (36.3%) peoples lack basic information about the government policies according to our survey. Moreover, some respondents answered that awareness campaigns, mass testing as well as mass vaccination program would be helpful in controlling HBV/HDV.

Cultural and societal norms can significantly impact individual identity and mental health in negative ways (Charlesworth and Hatzenbuehler, 2025; Ring and Lawn, 2025). In many Asian countries, the stigma and cultural perceptions associated with hepatitis remain poorly acknowledged. This study explores how such norms affect the quality of life in individuals infected with hepatitis. As illustrated in Figure 3A, both stigma and prevailing cultural attitudes maybe contribute to a decline in life quality, with respondents reporting high levels of stigmatization among infected individuals. However, the results presented in our study reflect self-reported opinions within the study population and should be interpreted with caution, as they may not represent the larger or whole community. According to the modified labeling theory, internal discrimination associated to a socially devalued condition can have harmful psychological and behavioral effects (Kroska and Harkness, 2008; Noor et al., 2016). Furthermore, self-stigma and cultural or societal pressures have been linked to increased disease symptoms, reduced treatment adherence, increased suicidal ideation, and a substantial decrease in overall quality of life (Vrbova et al., 2018; Armoon et al., 2022). The widespread stigma and sociocultural norms surrounding health conditions pose a significant barrier to effective treatment and rehabilitation, particularly for individuals with HBV or HDV (Eilinghoff et al., 2024). Enhancing the quality of life for people with chronic illnesses requires identifying and implementing effective strategies to raise awareness about the harmful effects of stigma and cultural biases (Barqawi et al., 2025).

Taken together, our study shows that family history, perceived risk, knowledge, attitude, and awareness were significantly associated with self-reported HBV/HDV diagnosis, while preventive practices showed no significant association (Table 4). Our findings propose that differences in awareness, risk perception, and attitudes may influence how individuals recognize, perceive, or report HBV/HDV infection (Wang et al., 2016). Furthermore, our results highlight the potential importance of strengthening education, risk communication, and awareness campaigns to support early detection and engagement with prevention services of hepatitis. However, these associations should be interpreted carefully due to the cross-sectional design and the self-reported nature of the data.

Several limitations should be considered when interpreting the results of this study. First, the reliance on convenience sampling may leads to selection bias, potentially limiting the representativeness of the samples. Additionally, the online distribution of the survey via platforms such as Facebook, WhatsApp, and WeChat may have excluded individuals with limited internet access, low education level, or lower socioeconomic backgrounds. As a result, the generalizability of the outcomes to the broader population may be limited. Furthermore, since the study focused upon previously published literature available only in English, language bias may have influenced participants understanding, particularly when addressing technical or complex concepts. This could have affected the accuracy and reliability of their responses. Moreover, respondents may have provided socially desirable answers, tailoring their responses to align with perceived expectations rather than expressing their true attitudes and perceptions. Fourth, the study is susceptible to recall bias, as participants self-reported data may have been influenced by flaws or memory distortions.

Additionally, the majority of residents were from urban areas, which may limit the applicability of findings stratified by the factors discussed above. The gender imbalance with 79.2% of participants being male also raises concerns about the generalizability of the results, particularly regarding gender-specific trends, and should be accepted as a key limitation. Moreover, the questionnaire was designed solely in English, which may have excluded less educated people, especially in a developing country context, further compromising the sample’s representativeness.

Overall, the current study indicate that the Pakistani population have limited knowledge, awareness, and perceptions regarding HBV and HDV. Moreover, gaps in vaccination for HBV, risky practices, and stigma persist. Furthermore, our study may contribute to advancing knowledge about HBV vaccination status among healthcare professionals, the general public, policymakers and others. Besides, it is important to prioritize the quality of life and address the stigmatization of individuals living with chronic illnesses especially viral diseases such as HBV/HDV, with a strong emphasis on their rights, self-respect, and overall physical, mental, and social well-being. A comprehensive public health approach, including mass vaccination, risk management programs, education on cultural norms, and improved hygiene is essential to curb HBV/HDV in Pakistan. The outcomes of this study may highlight the urgent need to improve public education and awareness regarding HBV/HDV and their preventive strategies. Moreover, the findings should be interpreted as indicative insights that may help inform public health department and guide future population-based, or serologically confirmed studies.

The present study has important implications for doctors and researchers working in the field of hepatitis. This study provides valuable insights into the epidemiology, public awareness, and systemic challenges surrounding HBV/HDV infections in Pakistan. By identifying the exact prevalence rate of HBV/HDV by population-based studies with serological confirmation, such as intra-family transmission, and assessing immunization coverage and its associated factors, our study highlighted critical gaps for the prevention of the infections. Moreover, the current study sheds light on the public knowledge, attitudes, risk behaviors, and perceptions, which are essential for designing effective awareness and intervention programs for the control of viral infection especially HBV/HDV. Additionally, our study highlighted the role of government and healthcare measures, as well as identifying key barriers such as limited access to screening, vaccination and treatment services, and the universal influence of cultural norms and stigma. The findings of the current study may offer indicative insights for public health policies, highlighting the need for more comprehensive, culturally sensitive, and accessible hepatitis control strategies in Pakistan.