Survey of hepatitis B knowledge and stigma among chronically infected patients and uninfected persons in Beijing, China

Factors associated with hepatitis B knowledge among people of Vietnamese ethnicity in Australia

Despite high hepatitis B (HBV) prevalence among people of Vietnamese ethnicity in Australia and elsewhere, there is limited research on levels of HBV knowledge and factors associated with such knowledge. The aim of this study was to examine HBV knowledge and associated demographic and attitudinal factors among people of Vietnamese ethnicity in Australia. People of Vietnamese ethnicity (n = 966) were recruited through community events and social media groups to complete online surveys measuring HBV knowledge, attitudes towards HBV, levels of mistrust in Western medicine, and demographic characteristics. Findings of this study indicate that levels of knowledge are mixed, with gaps in knowledge related to transmission and treatment of the virus. Those with greater knowledge of HBV tended to be older, have higher levels of formal education, have been tested for HBV, and know someone living with HBV. Those with lower levels of knowledge tended to have more negative attitudes towards the virus and greater levels of mistrust in Western medicine. Given that health literacy is connected to effective communication from health providers, we suggest that there is a need for the development of health promotion and education resources targeted at people of Vietnamese ethnicity and translated into Vietnamese. We propose that such resources be developed in consultation with Vietnamese communities and health providers to ensure that they are culturally appropriate and sensitive to people of Vietnamese ethnicity living in Australia.

Racial discrimination, knowledge, and health outcomes: The mediating role of hepatitis B-related stigma among patients with chronic hepatitis B

It is well described in current literature that Hepatitis B virus (HBV) affects Asian Americans more than any other racial group in the United States and that there is a stigma attached to this condition. The effects of stigma can be lasting, penetrating physiologically and psychologically, yet few studies have focused on the consequences of this phenomenon. The purpose of this study was to examine the mediating role of stigma in the effect of racial discrimination and knowledge (of HBV sequelae) on health status of Korean Americans with chronic hepatitis B (CHB). Three hundred sixty-five CHB patients were recruited and enrolled from two clinics in Philadelphia and Los Angeles. Depressive symptoms were measured using the Patient Health Question-9 (PHQ-9), physical health via self-rated health survey and stigma via hepatitis B quality of life (HBQOL)-stigma survey. Perceived racial discrimination and knowledge of CHB sequelae were independent variables. The cohort had an average age of 60.1 years (range 19-84, SD 10.7), 56% were male and 94% were born in South Korea. Mediational analysis found that stigma was a significant mediator between both racial discrimination (indirect effect = .037, Bootstrap 95% CI = [.010-.064]) and sequelae knowledge (indirect effect = .097, Bootstrap 95% CI = [.018-.176]) and depressive symptoms. Stigma also had a direct effect on depressive symptoms (β = .136, p < .01) and self-rated health (β = .018, p < .05). In addition, age, gender, education and employment were related to health outcomes. The findings of this study indicate that HBV-related stigma is an important mediator of mental health outcomes in this population. Future studies should identify other psychosocial factors to develop effective intervention programs to reduce stigma and improve quality of life among CHB patients.

Influence of language barrier and cultural background in hepatitis B disease knowledge in a Chinese community of Spain

Introduction

Hepatitis B infection (HBV) is prevalent in China. Due to language barriers and cultural differences, it is not always straightforward to evaluate disease knowledge in liver clinics. We aimed to assess the awareness on HBV and its mechanisms of transmission in HBV-infected Chinese patients and their household contacts.

Methods

HBV-infected Chinese patients and their contacts were interviewed by a native Chinese nurse regarding their knowledge on HBV transmission mechanisms, use of preventive measures and vaccination status. Non-Chinese HBV-infected patients and their household contacts served as a control group.

Results

In total 182 patients and 398 contacts participated with 85 (47%) patients and 240 (60%) contacts being from China. Language barrier was reported in 80% of Chinese patients and 44% of their contacts. Knowledge on parenteral and sexual HBV transmission was high in all patients (~90%) but Chinese were more aware of vertical transmission than controls (94% vs. 68%; p < 0.01). Regarding the use of preventive measures, Chinese patients were more forewarned in their use to avoid parenteral transmission (93% vs. 74%, p < 0.01). When assessing household contacts, Chinese used preventive measures more frequently than controls for parenteral and sexual transmission (79% vs. 65 and 81% vs. 48%, p < 0.05). Vaccination coverage was slightly lower in Chinese contacts compared to controls (78% vs. 86%, p = 0.05).

Conclusion

Despite relevant language barriers, Chinese patients are well informed on the mechanisms of HBV transmission. Cultural differences may explain a higher use of preventive measures among the Chinese population. HBV vaccination of household contacts should be reinforced in both groups.

Experience and impact of stigma in people with chronic hepatitis B: a qualitative study in Asia, Europe, and the United States

BACKGROUND

People with chronic hepatitis B (CHB) commonly experience social and self-stigma. This study sought to understand the impacts of CHB-related stigma and a functional cure on stigma.

METHODS

Adults with CHB with a wide range of age and education were recruited from 5 countries and participated in 90-minute qualitative, semi-structured interviews to explore concepts related to CHB-associated stigma and its impact. Participants answered open-ended concept-elicitation questions regarding their experience of social and self-stigma, and the potential impact of reduced CHB-related stigma.

RESULTS

Sixty-three participants aged 25 to 71 years (15 from the United States and 12 each from China, Germany, Italy, and Japan) reported emotional, lifestyle, and social impacts of living with CHB, including prejudice, marginalization, and negative relationship and work experiences. Self-stigma led to low self-esteem, concealment of CHB status, and social withdrawal. Most participants stated a functional cure for hepatitis B would reduce self-stigma.

CONCLUSIONS

CHB-related social and self-stigma are widely prevalent and affect many aspects of life. A functional cure for hepatitis B may reduce social and self-stigma and substantially improve the health-related quality of life of people with CHB. Incorporating stigma into guidelines along with infectivity considerations may broaden the patient groups who should receive treatment.

Investigating the relationship between hepatitis B virus infection and postpartum depression in Chinese women: a retrospective cohort study

Background

Postpartum depression (PPD) is associated with several psychological and obstetric factors. Hepatitis B virus (HBV) infection has been linked with a high risk of depression, but little is known about the relationship between maternal HBV infection and PPD. We aimed to investigate the association between HBV infection and PPD.

Methods

This retrospective cohort study included 3,808 mothers who gave birth in a hospital in southern China. Self-reported Edinburgh Postnatal Depression Scale (EPDS) was used to assess PPD. Multivariate logistic regression was used to determine whether maternal HBV infection was associated with PPD risk.

Results

Of the 3,808 participants, 11.9% of mothers had PPD at 6 weeks postpartum. Two hundred and seventy-eight (7.3%) and 3,530 (92.7%) were in the HBV and control groups, respectively. Women with HBV infection were more likely to test positive for PPD (14.7 vs.11.7%). The multivariate logistic regression analysis showed that HBV-infected women did not have a significantly higher incidence of PPD (OR = 1.23; 95% CI, 0.82-1.84) than those without HBV infection in the study cohort. Parity and postpartum hemorrhage were found to be associated with PPD. In addition, our study showed that e antigen positivity was not associated with PPD risk (OR = 0.56, 95% CI 0.19-1.63).

Conclusions

To our knowledge, this is the first investigation of the relationship between maternal HBV infection and PPD. In a cohort of women without prior history or family history of mental illness, having HBV infection was not significantly associated with self-reporting of PPD compared to not having HBV infection.

Measuring public attitudes towards people living with chronic diseases in Arabic-speaking populations: adaptation and development of the Social Stigma Scale of Chronic Diseases (SSS-CD)

BACKGROUND

A large proportion of the population in Arab countries suffer from chronic diseases. According to the statistics by the Global Health Estimates, chronic illnesses contribute by 71% to total deaths in the Arab region. While chronic illnesses have been demonstrated to carry high levels of social stigma, it is only recently that little research attention has been given to this topic in the Arab world. It is well-established that the social stigma construct is culturally-dependent. Therefore, the lack of an Arabic measure highlighted the urgent need for developing a culturally adapted and valid instrument to assess social stigma toward people living with chronic diseases. In this study, we aimed to examine the psychometric properties of the Arabic translation, adaptation and development of "the Social Stigma Scale of Chronic Diseases" (SSS-CD).

METHOD

Fifteen items derived from the literature and assessing social stigma towards chronic diseases have been administered to 570 Arabic-speaking adults from the Lebanese general population (aged 24.59 ± 6.75years; 68.6% women). Items were translated into Arabic using a forward-backward translation method. Exploratory factor analysis (EFA) using a principal-axis EFA on the first split-half subsample, followed by a confirmatory factor analysis (CFA) tested on the model extracted from the EFA on the second split-half subsample, were conducted to examine the construct validity of the SSS-CD. Fit indices were deemed adequate if the normed model chi-square (χ²/df) ≤ 3, the Steiger-Lind root mean square error of approximation (RMSEA) ≤ 0.08, the Tucker-Lewis Index (TLI) and the comparative fit index (CFI) ≥ 0.90.

RESULTS

Findings revealed that the 10-item SSS-CD has a unidimensional factor structure, with the following fit indices: χ²/df = 92.95/34 = 2.73, RMSEA = 0.077 (90% CI 0.059, 0.096), SRMR = 0.062, CFI = 0.939, TLI = 0.919. A good internal consistency was demonstrated by a McDonald's omega value of 0.73 for the total score. Findings also supported invariance across gender, with men exhibiting higher levels of social stigma attached to chronic diseases than women. All three dimensions of stigmatization (social, psychological and evolutionary stigmatization) were positively correlated with SSS-CD scores (Social self-interest [r = .40; p < .001], Evolutionary self-interest [r = .37; p < .001], Psychological self-interest [r = .42; p < .001]), demonstrating relatively strong convergent validity.

CONCLUSION

Our findings suggest that the SSS-CD has robust psychometric qualities. We thus preliminarily suggest that the scale is valid, reliable and suitable for use among Arabic-speaking people from the general population to measure public attitudes towards people living with chronic diseases. Providing this psychometrically sound measure will hopefully enable to foster research in this area in order to draw a clear overview of the prevalence and characteristics of social stigma attached to chronic diseases in Arabic-speaking communities. However, given that this was the first study to examine the psychometric properties of the SSS-CD, the present findings and conclusions should be considered tentative pending future cross-national validation studies.

Measuring stigma associated with hepatitis B virus infection in Sierra Leone: Validation of an abridged Berger HIV stigma scale

Stigma associated with hepatitis B virus (HBV) is common in endemic countries; however; instruments are lacking to accurately measure HBV-related stigma. We therefore aimed to develop and validate a concise instrument for measuring perceived HBV-related stigma in Sierra Leone. We enrolled 220 people living with HBV (PWHB) aged ≥18 years from August to November 2022. The initial Likert-scale instrument entailed 12 items adapted from Berger's HIV Stigma Scale. We included four additional items adapted from the USAID indicators for enacted stigma. The proposed scale's psychometric properties were assessed. After item reduction, the final HBV Stigma Scale consisted of 10 items and had good internal consistency (overall Cronbach's α = 0.74), discriminant, and construct validity. Exploratory factor analysis produced a three-dimensional structure accounting for 59.3% of variance: personalized stigma driven by public attitudes (six items), negative self-image (two items), and disclosure concerns (two items). Overall, 72.8% of respondents reported perceived HBV-related stigma (mean score 29.11 ± 4.14) and a similar proportion (73.6%) reported at least one instance of enacted stigma. In assessing criterion-related validity, perceived HBV-related stigma correlated strongly with enacted stigma (r = 0.556) and inversely with having family/friends with HBV (r = -0.059). The 10-item HBV Stigma Scale demonstrated good internal consistency and validity and is suitable for screening for HBV-related stigma in Sierra Leone. The psychometric properties of the scale can be optimized with item additions/modifications and confirmatory factor analysis. The scale may help in combating stigma as a barrier to achieving HBV global elimination goals.

Measuring Stigma Associated with Hepatitis B Virus Infection in Sierra Leone: Validation of an Abridged Berger HIV Stigma Scale

Stigma associated with hepatitis B virus (HBV) is common in endemic countries; however; instruments are lacking to accurately measure HBV-related stigma. We therefore aimed to develop and validate a concise instrument for measuring perceived HBV-related stigma in Sierra Leone. We enrolled 220 people living with HBV (PWHB) aged ≥ 18 years from August to November 2022. The initial Likert-scale instrument entailed 12 items adapted from Berger's HIV Stigma Scale. We included 4 additional items adapted from the USAID indicators for enacted stigma. The proposed scale's psychometric properties were assessed. After item reduction, the final HBV Stigma Scale consisted of 10 items and had good internal consistency (overall Cronbach's α = 0.74), discriminant and construct validity. Exploratory factor analysis produced a 3-dimensional structure accounting for 59.3% of variance: personalized stigma driven by public attitudes (6 items), negative self-image (2 items), and disclosure concerns (2 items). Overall, 72.8% of respondents reported perceived HBV stigma (mean score 29.11 ± 4.14) and a similar a proportion (73.6%) reported at least one instance of enacted stigma. In assessing criterion-related validity, perceived HBV-related stigma correlated strongly with enacted stigma (r = 0.556) and inversely with having family/friends with HBV (r = -0.059). The 10-item HBV Stigma Scale demonstrated good internal consistency and validity and is suitable for screening for HBV-related stigma in Sierra Leone. The psychometric properties of the scale can be optimized with item additions/modifications and confirmatory factor analysis. The scale may help in combating stigma as a barrier to achieving HBV global elimination goals.

Impact of Virtual Seminars on Hepatitis B Knowledge and Attitudes Among Preclinical-Year Medical Students

Background A limited understanding of hepatitis B virus (HBV) disease transmission contributes to fear of routine contact and can stigmatize affected individuals. To reduce potential HBV-related discrimination, there is a need to increase awareness among medical students on HBV knowledge and transmission. We aimed to assess the impact of virtual education seminars on first- and second-year medical students' understanding of HBV and their attitudes toward HBV infection. Methods Pre- and post-seminar surveys were designed and administered to first- and second-year medical students in the February and August 2021 virtual HBV seminars to assess basic knowledge and attitudes toward HBV infection. The seminars consisted of a lecture on HBV followed by case study discussions. Paired samples t-test and McNemar's test for paired proportional differences were used for analysis. Results This study included 24 first-year and 16 second-year medical students who completed both pre- and post-seminar surveys. After attending the seminar, participants demonstrated an increase in correct responses to transmission modes including vertical transmission (p≤0.001) and sharing razors or toothbrushes (p=0.031) rather than sharing utensils or shaking hands (p<0.01). Using 5-point Likert means, improved attitudes were observed in concerns of shaking hands or hugging (pre=2.4, post=1.3, p<0.001) and caring for someone with infection (pre=1.55, post=1.18, p=0.009), and acceptance of an HBV-infected coworker in the same workplace (pre = 4.13, post= 4.78, p<0.001). Conclusion The virtual education seminars clarify misconceptions about transmission and bias towards individuals with HBV infection. Implementation of educational seminars in medical students' training is important to improve overall knowledge of HBV infection.

Hepatitis B-related stigma among Chinese immigrants living with hepatitis B virus in Australia: A qualitative study

Chinese immigrants in Australia are overrepresented among people with chronic hepatitis B virus (PWCHB) but experience poor access to healthcare. Given the historical discriminatory policies against PWCHB in mainland China, this study aimed to explore the lived experiences of stigma and discrimination surrounding hepatitis B virus (HBV) among Chinese immigrants originally from mainland China. Semi-structured in-depth interviews were conducted by a researcher with a Chinese background in 2019-2020. Sixteen Chinese immigrants living with HBV were recruited across Sydney and Melbourne through advocacy and support groups. This study is positioned in social constructionism. Data analysis was informed by the Health Stigma and Discrimination Framework that highlights the interaction between layered stigmas. This study revealed the historical, social and cultural construction of HBV-related stigma among PWCHB and demonstrated how this stigma was manifested across socioecological levels in China and Australia. Findings show that HBV-related stigma has mostly been driven by knowledge deficits about HBV and fear of HBV infection. HBV-related stigma was mostly demonstrated around social isolation including isolation imposed by family and the community and employment restrictions in the Chinese workplace. In the Australian context, HBV-related stigma was related to the ethnic and cultural background of PWCHB, and primarily occurred as anticipated stigma in the community and in employment. The findings provide significant insights for crosscutting research and policy endeavours to develop and test cross-disciplinary initiatives that more broadly address the complex lived realities of Chinese immigrants living with hepatitis B virus.

Gender disparity and stigma experience of patients with chronic hepatitis B virus infection: A prospective cross-sectional study from a hospital in Nigeria

Backgound

Hepatitis B virus (HBV) infected persons often suffer stigma. Stigma can come from the society or be self-induced. This study assessed the gender differences and stigma experience of patients with HBV.

Methods

Prospective cross-sectional design with a qualitative element using a pretested interviewer administered questionnaire and an in-depth oral interview of HBV infected patients. Quantitative data obtained were entered into SPSS version 20 and analyzed using simple descriptive and inferential statistics, while content analysis was used for the qualitative data.

Results

Total of 242 respondents answered the quantitative questionnaire. There were 142(58.7%) males and 100 (41.3%) females; age range was 18-72 years with mean (SD) of 35.4(10.7) years. Overall stigma rate was 23.1%. Stigma resulted from a positive HBsAg test, and the experience was unaffected by other markers of HBV infection. Stigma was higher in the domain of disease transmission for both single and married respondents and was particularly higher among males than females. Stigma among females affected pre-marital engagements and also caused marital disharmony among married respondents. In-depth oral interview of 23 HBV infected respondents revealed that many exhibited self-stigma, had wrong knowledge of HBV infection modes, complications, and interpretation of HBV internet information which aggravated stigma reactions.

Conclusions

Stigma of HBV is high and majorly in the domain of disease transmission. It is higher in males than females. Enlightenment campaign targeting singles and married couples and HBV infection modes is advocated.

Early Maladaptive Schemas and Self-Stigma in People with Physical Disabilities: The Role of Self-Compassion and Psychological Flexibility

Self-stigmatizing thoughts may be rooted in one's core beliefs, and in turn be associated with early maladaptive schemas (EMS). Psychological flexibility, an ability to distance and accept one's thoughts, is reported to diminish EMS's effect on well-being, while self-compassion, a mindful attitude towards one's suffering, often reduces self-stigma. The objective of this study was to examine associations between EMS, self-stigma, psychological flexibility and self-compassion in individuals with disabilities, as they are at higher risk of experiencing self-stigma. Participants were 238 persons with disabilities. The Self-Stigma Scale, Young's Schemas Questionnaire, the Self-Compassion Scale Short and the Acceptance and Action-II Questionnaire were used. Hierarchical regression and mediation analysis were used to establish (1) predictors and (2) potential mediators of self-stigma in people with disabilities. Hierarchical regression showed that EMS alone accounted for 39% of the variance explained by self-stigma, and with the addition of psychological flexibility-an additional 2% was explained. Parallel mediation analyses indicated that psychological flexibility partially mediated the relationship between EMS domains and self-stigma. It appears that psychological rigidity is related to self-stigma and should be addressed in treatment through evidence-based approaches such as Schema Therapy and Acceptance and Commitment Therapy to enhance individuals' healthy life patterns, flexibility and self-compassion.

Cognitive and emotional illness representation of people with chronic hepatitis B in Ghana: A qualitative inquiry

Hepatitis B remains a public health concern in Ghana, with an estimated prevalence of 8.4% in adults and 14.3% in adolescents. This study explored the cognitive and emotional illness representations of persons with chronic hepatitis B who sought care at a tertiary hospital’s liver clinic in Ghana. A qualitative exploratory descriptive design was adopted, and 15 participants were purposefully chosen for in-person interviews. The data was analyzed using the content analysis procedure. The findings revealed that participants’ cognitive representations of hepatitis B infection varied. Some believed they got the infection through unsafe sexual practices, while others thought it was from their mother or spiritual sources. Participants’ predominant emotional representations included shock, confusion, and fear. Education about the causes and management of hepatitis B should be addressed as part of patient care.

Elucidating a Silent Illness: Hepatitis B Knowledge Among Asian Individuals in an Urban Center

BACKGROUND

Despite comprising less than 6% of the US population, Asian individuals make up more than half of the approximately 1.6 million chronic hepatitis B virus (HBV) infections in the United States. The purpose of this investigation was to identify characteristics associated with HBV knowledge in this disproportionately affected population.

METHODS

A cross-sectional, multilingual survey study using convenience sampling was conducted in a Midwestern urban city to collect information on respondents' demographics, health care access, and HBV knowledge. Hepatitis B virus knowledge was categorized into epidemiology, natural history, transmission, and vaccination. Data were analyzed using Kruskal-Wallis and Spearman correlation tests.

RESULTS

Of the 174 individuals who completed surveys, 139 (79.9%) were Asian. Characteristics of univariate analyses associated with higher knowledge scores included younger age (18-49 years), proficiency in reading English, college education, current employment status, physician using preferred language, last physician's visit in 2018 or prior, perceived lack of time to see a physician, use of emergency department, prior HBV vaccination, prior HBV testing, higher level of self-reported knowledge about HBV, and acquiring health information from the Internet, messaging applications, friends, and family (P < .05). In the multivariable analysis, shorter residency in the United States (0-10 years), current employment status, having heard of HBV, and confidence in their HBV knowledge were associated with higher knowledge scores.

CONCLUSION

Knowledge deficits existed in our study population regarding HBV transmission, vaccination, and epidemiology, while knowledge was higher regarding HBV natural history. Education efforts should be designed to improve knowledge deficits about HBV for individuals with risk factors using culturally sensitive Internet and social media platforms.

The loss and return of self: An interpretative phenomenological analysis of coping and recovery from chronic hepatitis B in China

Chronic hepatitis B (CHB) is a prevalent disease with various negative consequences. The lived experience of coping and recovery of a patient with Chronic hepatitis B was explored in this study. A semistructured interview was conducted with one participant who had been recovered from Chronic hepatitis B for 10 years. Data were analyzed using interpretative phenomenological analysis. Five superordinate themes emerged, including lingering in the shadow of death anxiety, diminished functioning of the self, adopting a highly disciplined lifestyle, receiving social support, and the return of the self with scars. The findings revealed that the disease is deeply associated with moral standing, which means the diagnosis of Chronic hepatitis B might imply a loss of moral face for Chinese people living with the condition. Our findings point to the need for increasing knowledge about chronic hepatitis B, decoupling the disease from a moral standpoint, and providing a supportive environment.

The unvirtuous cycle of discrimination affecting people with hepatitis B: a multi-country qualitative assessment of key-informant perspectives

Background

An estimated 296 million individuals live with chronic hepatitis B worldwide, most have not been diagnosed and remain at risk of liver disease and cancer. People with hepatitis B often face discrimination that denies them employment or education opportunities, results in unfair treatment at work or in school, limits their ability to emigrate to certain countries, and in some cases prohibits them from serving in the military. Discrimination specific to hepatitis B has not been widely documented within the literature. This study aims to investigate and describe hepatitis B related discrimination, document discrimination occurring around the globe, and provide initial recommendations for addressing discrimination using key informant interviews.

Methods

Purposive and snowball sampling were used to identify potential key informants for qualitative interview. Key informants identified as community health leaders, public health scientists, doctors, and researchers, many of whom were also living with hepatitis B. Using a semi-structured guide, participants were asked to describe their experience and any challenges for people living with hepatitis B including marginalization and its’ consequences. A codebook was used to guide the organization of data for analysis, and all transcripts N = 17 were double coded.

Results

The overarching themes identified from interviews demonstrate explicit experiences with discrimination of those directly affected, the psychological responses, and the negative health outcomes associated with the unvirtuous cycle of discrimination. All key informants reported on the substantial quality of life implications and often poorer health outcomes resulting from hepatitis B discrimination. Participants also identified the significant impact of hepatitis B discrimination occurring within a range of education-based services across several countries as well as military exclusion or removal if individuals are found to have hepatitis B.

Conclusion

Our data demonstrate that hepatitis B discrimination has a significant impact. Discrimination can occur at various points in life from education, to seeking employment, to marriage, to restrictions on entry, travel and stay in other countries. This study demonstrates the impact of discrimination and the need for future research that can lead to policy change and protections for people living with and impacted by hepatitis B.

Knowledge and beliefs about hepatitis B virus infection and associated factors among Chinese migrants in Australia: The result of a quantitative study

Chinese immigrants to Australia have an increased prevalence of hepatitis B virus (HBV) infection compared to the general population. Despite this, engagement with HBV screening and healthcare for chronic hepatitis B (CHB) among immigrants of Chinese background is relatively low. This study investigated knowledge about HBV among this high-risk community and explored sociodemographic factors that might influence this knowledge. During February to September 2019, first generation Chinese immigrants from mainland China and their immediate descents residing in Sydney and Melbourne were recruited via convenience and snowball sampling and completed a survey in either English or Chinese. Survey items included HBV knowledge, attitudes towards people living with CHB and demographic information. Three hundred and ninety-six participants completed the survey. The median HBV knowledge score was 53% correct, indicating that knowledge about HBV was low to middle range among participants. While participants had the most knowledge in the domain of perceptions and understandings of HBV, this was still low. Participants also had limited knowledge about HBV prevention, transmission and treatment. Those with higher English proficiency, post-secondary education, lower levels of HBV-related stigma and those who had contact with people living with CHB appeared to have greater HBV knowledge. This study showed that HBV knowledge among Chinese people originally from mainland China living in Australia is limited and even deficient in some key areas. Additionally, the relationships between HBV knowledge and particular sociodemographic variables, knowing someone living with HBV and stigma associated with HBV provides key information to assist in the development of targeted health promotion to increase HBV knowledge and change stigmatising attitudes towards HBV among the Chinese community in Australia.

Understanding how to live with hepatitis B: a qualitative investigation of peer advice for Chinese people living with hepatitis B in Australia

BACKGROUND

Hepatitis B is a chronic viral infection, a leading cause of primary liver cancer and identified as a major public health priority by the World Health Organization. Despite a high proportion of people in Australia who have been diagnosed with hepatitis B, significant gaps remain in health care access and in accurate knowledge about hepatitis B. Most people with hepatitis B in Australia were born in China, where the infection has an intergenerational impact with significant social implications resulting from the infection. Understanding how people of Chinese ethnicity with hepatitis B understand and respond to hepatitis B is imperative for reducing morbidity, mortality, and the personal and social impact of the infection.

METHODS

Qualitative semi-structured interviews with people with hepatitis B of Chinese ethnicity recruited through a specialist service identified the advice people with hepatitis B thought was important enough to inform the experience of people newly diagnosed with hepatitis B. A thematic analysis of the data privileged the lived experience of participants and their personal, rather than clinical, explanations of the virus.

RESULTS

Hepatitis B infection had psychological and physical consequences that were informed by cultural norms, and to which people had responded to with significant behavioural change. Despite this cohort being engaged with specialist clinical services with access to the most recent, comprehensive, and expert information, much of the advice people with hepatitis B identified as important for living with hepatitis B was not based on biomedical understandings. Key suggestions from people with hepatitis B were to form sustainable clinical relationships, develop emotional resilience, make dietary changes, regulate energy, and issues related to disclosure.

CONCLUSIONS

The study highlights conflicts between biomedical and public health explanations and the lived experience of hepatitis B among people of Chinese ethnicity in Australia. Beliefs about hepatitis B are embedded within cultural understandings of health that can conflict with bio-medical explanations of the infection. Acknowledging these perspectives provides for insightful communication between health services and their clients, and the development of nuanced models of care informed by the experience of people with hepatitis B.

Psychological stress; knowledge, attitude and practice and acceptance of antiviral therapy in pregnant women with hepatitis B in Zhejiang, China: a case comparison study

OBJECTIVES

To determine knowledge, attitude and practice (KAP) and antiviral therapy's acceptance during pregnancy of pregnant women with hepatitis B and influencing factors.

DESIGN

Case-comparison study.

SETTING

The study was conducted in Zhejiang province, China, from September 2019 to December 2020.

PARTICIPANTS

Pregnant and postpartum women with chronic hepatitis B.

PRIMARY AND SECONDARY OUTCOME MEASURES

The stress scores, self-assessed health score, KAP, antiviral therapy's acceptance rate during pregnancy and influencing factors were analysed. The Perceived Stress Scale-10 was used to assess stress. Logistic regression was used to analyse influencing factors on antiviral therapy.

RESULTS

The self-assessed health score of pregnant women without liver diseases (82.4±9.3) was significantly higher than that of pregnant women with chronic hepatitis B (75.5±9.5) and postpartum (75.1±14.1). Psychological stress of pregnant women with chronic hepatitis B was significantly high with a 14.9±3.6 score, but there was no significant difference between hepatitis B postpartum and non-liver disease women (12.7±3.5 vs 12.9±3.5, p=0.75). The acceptance rate of pregnant women with hepatitis B for antiviral therapy was 84.2%, while that of postpartum women was even higher. Logistic regression analysis showed that patients with positive hepatitis B e antigen (HBeAg) (OR, 3.35; 95% CI, 1.21 to 9.26) and higher scores on hepatitis B-related knowledge (OR, 3.52, 95% CI, 2.18 to 5.69) were more likely to accept antiviral therapy during pregnancy.

CONCLUSIONS

Pregnant women with hepatitis B in Zhejiang have heavy psychological stress and a high antiviral therapy acceptance rate during pregnancy. Acceptance is related to HBeAg status and level of understanding of hepatitis B during pregnancy. It is necessary to provide education on hepatitis B to reduce psychological stress and increase acceptance of antiviral therapy during pregnancy.

Unemployment and Illiteracy Are Predictors of Hepatitis B Virus-Related Stigma and Discrimination

BACKGROUND

HBV is a serious threat to society in India as around 1,00,000 people die from HBV every year. However, very few studies from India have evaluated the magnitude of stigma faced by HBV patients. So, there was an unmet need to estimate the HBV-related stigma to design the preventive strategies. Hence, the aim of this study was to quantitatively assess the proportions of stigma and discrimination and factors predicting them among HBV patients.

METHODS

A cross-sectional study was conducted from May 2016 to October 2019. A total of 350 HBV patients and 100 healthy respondents were interviewed for knowledge and awareness about HBV and various stigma characteristics.

RESULTS

The mean age of HBV subjects was 45.10 ± 11.70 years, and controls were 36.20 ± 12.27 years; males constituted 60% of HBV subjects and 71% of controls. Negative symptoms such as shame, avoidance, and putting others in danger were felt by 70-90% of HBV patients. Around 60% of HBV patients felt that hepatitis B could be transmitted by sharing utensils thinking that saliva is the mode of transmission. The knowledge about transmission of HBV by sexual intercourse, intravenous drug use, and mother to child was present in 88%, 75%, and 52% of HBV patients and 32%,38%, and 40% of healthy individuals, respectively. Multivariate logistic regression revealed that male gender (AOR-2.38, CI 1.48-3.81, P < 0.01), under matriculates (AOR-2.03, CI 1.22-3.44, P < 0.01) and unemployed (AOR-2.16, CI 1.33-3.53, P < 0.01) were significant independent predictors of significant discrimination.

CONCLUSION

The magnitude of HBV-related stigma is high in the Indian population, and illiteracy and unemployment were significant predictors of a severe grade of discrimination associated with HBV.

Cure everyone and vaccinate the rest: The patient perspective on future hepatitis B treatment

Those living with chronic hepatitis B virus (HBV) require years, if not decades, of regular monitoring to prevent liver complications from occurring. An estimated 292 million people were living with chronic HBV globally in 2018 with approximately 2.4 million of those residing within the United States (US). This study is one of the first of its kind that aims to explore the treatment preferences for those living with chronic HBV through qualitative interviews. Participant data were collected by in-depth telephone interviews using a semi-structured discussion guide. A codebook guided the organization of data, and codes were developed by review of the literature (a priori) and through line-by-line reading of a subsample of queries. All data transcripts (N = 19) were independently double coded. Overarching themes identified from the data specific to the treatment modalities and implications of a functional HBV cure included the concern about side effects, treatment modality, frequency, duration, cost-effectiveness and overall impact on their lives. Qualitative data analysis revealed the significant impact that an HBV functional cure would have on quality of life. Benefits of a cure were described as not having a finite course of treatment, improving overall vitality, and reducing the fear and anxiety associated with lifelong infection and potential development of liver cancer. Many individuals expressed the desire for a cure for HBV, stating it would be life-changing, and a 'miracle'. As new therapies are in development, more research should examine in detail the treatment preferences of those living with HBV.

Public awareness and influencing factors regarding hepatitis B and hepatitis C in Chongqing municipality and Chengdu City, China: a cross-sectional study with community residents

OBJECTIVE

Hepatitis B and hepatitis C cause a heavy disease burden in China. This paper aims to investigate the public's knowledge on hepatitis B and hepatitis C in Chongqing municipality and Chengdu City, China.

DESIGN

A cross-sectional study was conducted from December 2016 to April 2017.

SETTING

Two communities from Chongqing and Chengdu were involved in this study.

PARTICIPANTS

Data from 928 community residents were analysed.

OUTCOME

Demographic characteristics, knowledge on hepatitis B and hepatitis C and sources of hepatitis knowledge were obtained from questionnaires. The participants' scores ranged from 0 to 24, and a test score about more than 14.4 (60% of the total score) was defined as sufficient knowledge.

RESULTS

Among the participants, only 36.10% presented sufficient knowledge on hepatitis B and hepatitis C, and about 40% were unaware of the two antidiscrimination policies in China. The sources of information about hepatitis were mainly from doctors and the internet. Unmarried individuals, people with secondary education and above and those with an annual income above US$2108 tended to exhibit a higher level of knowledge on hepatitis B and hepatitis C.

CONCLUSIONS

The community members demonstrated limited awareness and level of knowledge on hepatitis B and hepatitis C, particularly in relation to the antidiscrimination policies. Extensive health education should be provided to the public, particularly to those with low educational status and income.

Hepatitis B virus related stigma among Chinese living in mainland China: a scoping review

Stigma related to hepatitis B virus (HBV) has a detrimental impact on health outcomes of people living with HBV. A scoping review of published peer-reviewed articles focused on the Chinese population in mainland China published between 2010 and 2019 was undertaken. This review consists of five stages: identifying the research question, identifying relevant literature, study selection, charting the data, and collating, summarizing and reporting the results. Articles in Chinese were identified from the collection of Core Journals in the database of CNKI (China Academic Journals Full-text Database). Publications in English were identified in Global Health, Scopus, PsycINFO, Proquest and Web of Science. Forty-five peer-reviewed articles were selected for inclusion. Most studies under review focused on negative individual attitude and discrimination against people living with HBV (PLHBV) in employment, education, community and healthcare settings. There is limited information on lived experiences of those living with HBV and how they manage this stigma. The reviewed studies provide evidence for the existence of different forms of HBV-related stigma in a variety of settings. Knowledge about HBV and the level of education of research participants were the most frequently identified factors related to this stigma. These findings are useful to support HBV responses in China and countries with migration from China.

Will COVID-19 Vaccinations End Discrimination against COVID-19 Patients in China? New Evidence on Recovered COVID-19 Patients

(1) Background: By April 2021, over 160 million Chinese have been vaccinated against coronavirus disease 2019 (COVID-19). This study analyzed the impact of vaccination on discrimination against recovered COVID-19 patients and the determinants of discrimination among intended vaccinated people. (2) Methods: A self-designed questionnaire was used to collect data on COVID-19 associated discrimination from nine provinces in China. Pearson chi-square tests and a multivariate ordered logistic regression analyzed the determinants of COVID-19-related discrimination. (3) Results: People who intended to be COVID-19 vaccinated displayed a high level of discrimination against recovered COVID-19 patients, with only 37.74% of the intended vaccinated without any prejudice and 34.11% displaying severe discrimination. However, vaccinations reduced COVID-19-related discrimination against recovered COVID-19 patients from 79.76% to 62.26%. Sex, age, education level, occupation, geographical region, respondents' awareness of vaccine effectiveness and infection risk, and COVID-19 knowledge score had a significant influence on the COVID-19 related discrimination (p < 0.05). (4) Conclusions: Vaccination significantly reduced COVID-19 associated discrimination, but discrimination rates remained high. Among the intended vaccinated respondents, females, the older aged, people with high school and above education level, retirees, migrant workers, and residents in central China were identified as key targets for information campaigns to reduce COVID-19 related discrimination.

Regional differences of hepatitis B discrimination in rural China

Background: Hepatitis B (HB) is the most serious and common viral hepatitis in China. Previous studies on HB discrimination mainly have focussed on stratified analysis, and there has been no consideration of the impact of geographical-environmental factors on HB discrimination from a spatial perspective.Objective: This study conducted a large nationwide village-based survey to test whether there were significant regional differences in HB discrimination, and to explore the relationship between different socio-economic geographical factors and HB discrimination.Methods: The sample comprised 22618 rural adults, aged over 18 years old, from villages in seven provinces, representing central, southern, and eastern coastal regions of China. Using face-to-face interviews, we surveyed participants' discrimination against HB patients or carriers. Chi-square tests were used to analyze the effects of the region on differences in proportions between three discrimination levels (low, medium, and high). A geographical detector was used to explore the relationship between different socio-economic and geographical-environmental factors and HB discrimination.Results: The distribution of HB discrimination levels across the 42 villages was statistically significant. The level of HB discrimination in the central and southern regions was generally low, and the level of HB discrimination in the eastern coastal regions was higher. Both socio-economic and geographic-environmental factors had a significant relationship with HB discrimination. Most of these relationships were not linear.Conclusions: Developing the economy and accelerating urbanization did not automatically eliminate discrimination against HB. We recommend government HB publicity and education campaigns to inform the population of HB causes and effects, and strengthen the education of students so that they can have a clear and correct understanding of HB from a young age, both of which will address HB discrimination.

Psychological distress and self-management behaviours among patients with chronic hepatitis B receiving oral antiviral therapy

AIMS

To assess the prevalence and associated factors of psychological distress among patients with chronic hepatitis B receiving oral antiviral therapy and explore the association between psychological distress and self-management behaviours among this population.

DESIGN

A cross-sectional study.

METHODS

A convenience sample of 188 patients with chronic hepatitis B receiving oral antiviral therapy was recruited from March-October 2018 to complete a self-report questionnaire including the Chinese version of Depression Anxiety Stress Scale-21 and Chronic Hepatitis B Self-Management Scale. Logistic regression analysis and hierarchical multiple regression analysis were used to determine the factors associated with psychological distress and the association between psychological distress and self-management behaviours respectively.

RESULTS

The prevalence of depression, anxiety, and stress symptoms were 33.0%, 38.3% and 17.6% respectively. Depression was associated with older age, female gender, lower education level and longer treatment duration; anxiety was associated with female gender and longer treatment duration; and stress was associated with age of 31-40 years, female gender and unmarried status. There were significant associations between depression and anxiety symptoms and self-management behaviours.

CONCLUSION

Psychological distress was prevalent among patients with chronic hepatitis B receiving oral antiviral therapy and had a negative impact on self-management. Interventions targeting depression and anxiety symptoms may be beneficial to improve self-management behaviours for this population.

IMPACT

This study explored the factors associated with psychological distress in patients with chronic hepatitis B receiving oral antiviral therapy. The findings showed psychological distress was more common in patients who were with older age, female, less educated, unmarried and receiving longer duration of treatment and psychological distress was significantly associated with self-management behaviours. Nurses and other healthcare providers should provide interventions to reduce the risk of psychological distress and improve self-management behaviours for this population.

Stigma in HBV-infected pregnant women in disclosed situations: Current status, influencing factors, and impacts on the quality of life

OBJECTIVE

Few studies have reported the status of stigma and the impact of stigma on the quality of life of HBV-infected pregnant women in disclosed situations. This study aims (a) to investigate the current status of the stigma of HBV-infected pregnant women in the situation of disease exposure, (b) to explore the influencing factors of the stigma, and (c) to identify the impacts quality of life.

METHOD

Using cross-sectional descriptive design and convenience sampling, 270 HBV-infected pregnant women from two infectious hospitals were investigated using the Chronic Hepatitis B Virus Infectors' Discrimination Measurement Scale, the Medical Outcomes Study Short-Form-36v2, and a demographic questionnaire. The collected data were analyzed by SPSS20.0.

RESULTS

The total stigma score is (74.05 ± 11.26). The variables of education, the payment method of medical expenses, living with family members, and spouse with hepatitis B virus infection accounted for 35.7% of the variance in the stigma altogether. Stigma is significantly negatively correlated with the quality of life and accounted for 18.1%-20.0% of the variance in scores for quality of life of HBV-infected pregnant women in disclosed situations.

CONCLUSION

The level of stigma and quality of life is serious in China. the stigma can significantly reduce the quality of life of affected individuals. Health care policy-maker and professionals should pay more attention to this issue and through improving health education, increasing the reimbursement rate of antiviral drugs and the number of professional medical staff to reduce stigma and promote their quality of life.

Hepatitis B Infection: A Mixed Methods of Disclosure Pattern and Social Problems in the Nigerian Family

Background

Hepatitis B virus (HBV) infection has a high prevalence rate in Nigeria. Disclosure of infection status to close partner and the public attracts support for infected people. This study looks at disclosure and social challenges of infected persons.

Methods

Mixed methods of patients' administered questionnaire and an in-depth interview conducted on HBV-infected respondents in a hospital in Nigeria were used. The study recruited all participants who satisfied the inclusion criteria. Data were entered into SPSS version 20 and analyzed using simple and inferential statistics and content analysis for the in-depth interview.

Results

A total of 205 participants completed the questionnaire study. Mean (standard deviation) age was 35.3 (±11.0) years. There were 121 married, 37 singles with noncohabiting partners and 47 singles without partners with disclosure rates being 96.7% versus 97.9% versus 89.2%, respectively. Singles disclosed infection more to their parents while married respondents disclosed infection more to their spouses. Singles had high rate of denial of sexual relationship (22.6%), emotional trauma (34.5%), broken relationships (11.4%), and surreptitious use of contraception for protection (67.6%). Married respondents had the highest rate of HBV vaccination of their family members (40.1%). Infection prevention and allaying fears of family members were their counseling needs. In-depth interview revealed that infected respondents usually expressed shock and depression at a positive test leading to fear and deception that put close associates at risk.

Conclusion

Hepatitis B virus-infected respondents have high rate of disclosure. Family problems of these people can therefore be solved through public enlightenment and individual counseling.

A Patient-Centered Hepatitis B Virus (HBV) Educational Intervention Improves HBV Care Among Underserved Safety-Net Populations

GOALS

To evaluate the impact of a prospective patient-centered hepatitis B virus (HBV) educational intervention on improving HBV care.

BACKGROUND

Improving patients' HBV knowledge has the potential to improve adherence to HBV monitoring and management, particularly among underserved safety-net populations.

METHODS

Consecutive chronic HBV adults at a single-center safety-net liver clinic were recruited from July 2017 to July 2018 to evaluate the impact of an in-person, language concordant formal HBV educational intervention on improvements in HBV knowledge and HBV management: appropriate HBV clinic follow-up (≥1 visit/year), HBV laboratory monitoring (≥1 HBV viral load and alanine aminotransferase test/year), hepatocellular carcinoma surveillance (≥1 liver imaging test/year among eligible patients), and HBV treatment among treatment eligible patients. HBV knowledge and management were assessed before and after the intervention and compared with age-matched and sex-matched HBV controls who did not receive an education.

RESULTS

Among 102 patients with chronic HBV (54.9% men; mean age, 52.0±13.8), HBV education improved HBV knowledge scores by 25% (P<0.001), HBV clinic follow-up from 25.5% to 81.4% (P<0.001), HBV laboratory monitoring from 62.8% to 77.5% (P=0.02), and appropriate HBV treatment from 71.5% to 98.5% (P<0.001). Compared with 102 HBV controls, receiving HBV education was associated with higher rates of HBV clinic follow-up (81.4% vs. 39.2%; odds ratio, 7.02; 95% confidence interval, 3.64-13.56; P<0.001) and appropriate HBV laboratory monitoring (77.5% vs. 42.2%; odds ratio, 4.94, 95% confidence interval, 2.64-9.24; P<0.001).

CONCLUSION

A formal, in-person, language concordant educational intervention leads to significant improvements in HBV knowledge, resulting in improved HBV monitoring and appropriate HBV treatment.

Effects of Depression, Anxiety, Stigma, and Disclosure on Health-Related Quality of Life among Chronic Hepatitis B Patients in Dalian, China

Chronic hepatitis B virus (HBV) infection is a major public health problem in China. We evaluated the impact of psychosocial factors (stigma, disclosure, depression, and anxiety) on health-related quality of life (HRQoL) among people living with chronic HBV infection (CHB) in the city of Dalian, Liaoning Province, China. In this hospital-based cross-sectional study, 401 patients living with chronic HBV infection were enrolled as study participants. Study measures included the Beck depression and anxiety inventory, the WHO Quality of Life (WHOQOL-BREF) assessment, the Toronto Chinese HBV Stigma Scale, and disclosure of HBV status to sexual partners. The primary outcome was HRQoL score as measured by the WHOQOL-BREF. A linear regression model was used to examine the association between HRQoL and the potential risk factors including stigma, disclosure, depression, anxiety, and sociodemographic variables. Stigma, disclosure, depression, and anxiety were the covariates of interest. A majority of the participants were females (n = 251, 65.6%), married (81.6%), and had a college or higher degree (32.4%). Depression, anxiety, stigma, and disclosure of HBV infection were associated with low HRQoL in all four domains of the WHOQOL-BREF (physical, psychological, social, and environmental domains) (P < 0.05), when all psychological factors were included in the model separately. Depression was found to be independently associated with low HRQoL in people living with HBV, when all psychological factors were included in the model simultaneously (P < 0.0001). Our data indicate the urgent need for healthcare providers (HCPs) and policy-makers to implement psychological interventions to improve HRQoL among people living with CHB.

"To die is better than to tell": reasons for and against disclosure of chronic hepatitis B status in Ghana

BACKGROUND

People with a condition subject to stigmatisation, such as chronic hepatitis B, face the dilemma of whether or not to disclose their status. In Ghana, 12.3% of the adult population has the hepatitis B virus (HBV). One key strategy for breaking the cycle of hepatitis B transmission is the disclosure of hepatitis B status by people with chronic hepatitis B (PWHB). Disclosure can facilitate preventive actions to reduce hepatitis B transmission (e.g., not sharing personal items and avoiding contact with blood and body fluids). Disclosure can also motivate family members of PWHB to get tested, linked to care and clinically managed in order to reduce the progression of hepatitis B to liver cirrhosis and cancer. Given the importance of disclosure, we set out to explore reasons for and against disclosure of chronic hepatitis B status in the Greater Accra and Upper East region of Ghana.

METHODS

In this exploratory qualitative study, 18 participants (10 from the Greater Accra region and 8 from the Upper East region) were recruited for semi-structured interviews. Interviews were recorded and transcribed verbatim. Data were then processed using QSR Nvivo version 10.0 and analysed for themes.

RESULTS

Participants were selective disclosers, disclosing in some contexts and not in others. Reasons for non-disclosure of chronic hepatitis B status were: 1) fear of stigmatisation and 2) previous negative experiences with disclosure. Reasons for disclosure were: 1) wanting close contacts to get tested or vaccinated, 2) trusting the disclosure target(s), and 3) needing social and/or financial support.

CONCLUSIONS

Our findings highlight various reasons for and against disclosure of chronic hepatitis B status in Ghana. Because anticipated, observed, and experienced stigma were important motivations for non-disclosure of chronic hepatitis B status, we recommend the development and implementation of theory and evidence-based stigma reduction interventions that are culturally appropriate, and that prioritize the participation of target populations. We also recommend the provision of counselling and support services that assist PWHB in their disclosure decision-making processes.

The Lived Experience of Chronic Hepatitis B: A Broader View of Its Impacts and Why We Need a Cure

Chronic hepatitis B (CHB) is one of the most widespread liver diseases in the world. It is currently incurable and can lead to liver cirrhosis and cancer. The considerable impacts on society caused by CHB through patient mortality, morbidity, and economic loss are well-recognised in the field. This is, however, a narrow view of the harms, given that people living with CHB can be asymptomatic for the majority of their life-long infection. Of less-appreciated importance are the psychosocial harms, which can continue throughout an affected person's lifetime. Here we review the broad range of these impacts, which include fear and anxiety; financial loss and instability; stigma and discrimination; and rejection by society. Importantly, these directly affect patient diagnosis, management, and treatment. Further, we highlight the roles that the research community can play in taking these factors into account and mitigating them. In particular, the development of a cure for hepatitis B virus infection would alleviate many of the psychosocial impacts of CHB. We conclude that there should be a greater recognition of the full impacts associated with CHB to bring meaningful, effective, and deliverable results to the global community living with hepatitis B.

Impact of Stigma on People Living with Chronic Hepatitis B

Background

People with chronic infectious diseases such as hepatitis B can face stigma, which can influence everyday life as well as willingness to engage with medical professionals or disclose disease status. A systematic literature review was performed to characterize the level and type of stigma experienced by people infected with hepatitis B virus (HBV) as well as to identify instruments used to measure it.

Methods

A literature review was performed using the PubMed, Embase and Cochrane Library databases to identify studies describing HBV-related stigma. For inclusion, articles were required to be published in full-text form, in English and report quantitative or qualitative data on HBV-related stigma that could be extracted.

Results

A total of 23 (17 quantitative and 6 qualitative) articles examined HBV-related stigma. The scope of the review was global but nearly all identified studies were conducted in countries in the WHO Southeast Asia or Western Pacific regions or within immigrant communities in North America. Several quantitative studies utilized tools specifically designed to assess aspects of stigma. Qualitative studies were primarily conducted via patient interviews. Internalized and social stigma were common among people living with chronic HBV . Some people also perceived structural/institutional stigma, with up to 20% believing that they may be denied healthcare and up to 30% stating they may experience workplace discrimination due to HBV.

Conclusion

HBV-related stigma is common, particularly in some countries in Southeast Asia and the Western Pacific region and among Asian immigrant communities, but is poorly characterized in non-Asian populations. Initiatives are needed to document and combat stigma (particularly in settings/jurisdictions where it is poorly described) as well as its clinical and socioeconomic consequences.

A crowdsourced intervention to decrease hepatitis B stigma in men who have sex with men in China: A cohort study

Stigma against people with hepatitis B virus (HBV) is a barrier to prevention, diagnosis and treatment of HBV in China. Our study examined an innovative intervention to reduce HBV stigma among men who have sex with men (MSM) in China. We extracted data from a randomized controlled trial conducted in May 2018, where the intervention consisted of crowdsourced images and videos to promote viral hepatitis testing and reduce HBV stigma. HBV stigma was assessed using a 20-item scale at baseline and four weeks post-enrolment. Participants were divided into three groups based on their exposure to intervention: full exposure, partial exposure and no exposure. Linear regression was used to determine associations between baseline stigma and participant characteristics. Data from 470 MSM were analysed. Mean participant age was 25 years old and 56% had less education than a college bachelor's degree. Full exposure to intervention was associated with significant stigma reduction (adjusted beta = -3.49; 95% CI = -6.11 to -0.87; P = .01), while partial exposure led to stigma reduction that was not statistically significant. The mean stigma score was 50.6 (SD ± 14.7) at baseline, and stigma was most prominent regarding physical contact with HBV carriers. Greater HBV stigma was associated with not having a recent doctor's visit (adjusted beta = 4.35, 95% CI = 0.19 to 8.52; P = .04). In conclusion, crowdsourcing can decrease HBV stigma among MSM in China and may be useful in anti-stigma campaigns for vulnerable populations in low- and middle-income countries.

Progress towards elimination goals for viral hepatitis

The global burden of viral hepatitis is substantial; in terms of mortality, hepatitis B virus and hepatitis C virus infections are on a par with HIV, malaria and tuberculosis, among the top four global infectious diseases. In 2016, the 194 Member States of the World Health Organization committed to eliminating viral hepatitis as a public health threat by 2030, with a particular focus on hepatitis B virus and hepatitis C virus infection. With only 10 years to go until the 2030 deadline is reached, and although much progress has been made towards elimination, there are still some important gaps in terms of policy and progress. In this Viewpoint, we asked a selection of scientists and clinicians working in the viral hepatitis field for their opinions on whether elimination of viral hepatitis by 2030 is feasible, what the key areas of progress are and what the focus for the next 10 years and beyond should be for viral hepatitis elimination.

Stigma among healthcare workers towards hepatitis B infection in Bangalore, India: a qualitative study

BACKGROUND

With about 50 million people infected with hepatitis B (HBV) in India the burden of disease is high. Stigma has been identified to have a major negative impact on screening, diagnosis and treatment of hepatitis B patients. The aim of this study was to assess the stigma in nurses and physicians in Bangalore, India; studies on stigma in HBV have only been published outside of India.

METHODS

Semi-structured in-depth-interviews were conducted in the period of March 20th and April 16th 2018 to study stigma and other problems in the care of hepatitis B patients. Stigma was pragmatically defined as a mark of disgrace associated with having a hepatitis B infection. Thirty physicians and nurses in different clinics and hospitals across the city of Bangalore were selected by purposeful sampling and snowball effect until theoretical saturation was reached.

RESULTS

The following themes were identified during the interviews: feelings when treating a patient; pregnancy and marriage; confidentiality; morality; improvement in care and the difference with HIV. The most stigma was discovered in the theme morality. The majority of our participants mentioned lack of awareness as biggest obstacle in health care of hepatitis B patients.

CONCLUSIONS

This is the first qualitative study in India exploring hepatitis B stigma among health care workers. Stigma was found in certain themes, such as morality. Though, no unwillingness to treat was found. There was a general lack of awareness amongst patients according to our participants and could jeopardize proper treatment. These results will further help in developing strategies to tackle hepatitis B in India.

Efficacy of a self-management program in patients with chronic viral hepatitis in China

Background

Chronic hepatitis, mainly B or C, increases the risk of hepatocellular carcinoma and remains an emerging issue in the globe. China has high rates of liver cancer incidence and mortality in the world. To address such challenges, adequate management of chronic hepatitis is required. Self-management education is one alternative for improving the hepatitis patients’ knowledge of the disease, mental health, and clinical management.

This study aimed to examine the quality of life (QOL), psychological effects, and behavioral changes of a self-management program which allows continuity of care for chronic hepatitis B and C patients.

Method

In a six-month, randomized controlled trial, we invited 73 chronic hepatitis B/C inpatients to receive (i) two face-to-face education sessions provided by a nurse during hospitalization, and monthly telephone counseling at home after discharge; (ii) or usual care treatment (control group). The primary endpoint (patients’ QOL) and secondary outcomes (including self-efficacy, depression symptoms, perceived cognition of illness and behavioral changes) were assessed. In addition, we conducted qualitative data analysis to facilitate the evaluation of the interventions.

Results

Sixty (82.2%) out of 73 eligible patients with chronic hepatitis B/C (aged 34.9 ± 8.9 years) participated in the study. The intervention group (n = 30) significantly improved on outcomes including QOL, self-efficacy, perceived cognition of illness, and behavioral changes, whereas the control group significantly decreased their healthy behaviors. In terms of behavioral changes, alcohol avoidance, dietary adherence, and stress management also improved in the intervention group. However, there were no significant improvements in symptoms of depression. Most participants (80%) in the intervention group stated that they benefited from the program.

Conclusions

This program contributed to patients’ acquisition of self-management skills to cope with their illnesses, and significantly improved their QOL. This program serves as a reminder for nurses who care for patients with chronic viral hepatitis to acquire these skills as it would help them address the daily needs of their patients.

Trial registration

UMIN000025378. Registered December 23, 2016.

Electronic supplementary material

The online version of this article (10.1186/s12912-019-0366-7) contains supplementary material, which is available to authorized users.

Compliance among infants exposed to hepatitis B virus in a post-vaccination serological testing program in four provinces in China

BACKGROUND

Mother to child transmission of hepatitis B virus (HBV) remains the most common form of HBV infection in China. Prevention of HBV vertical transmission involves timely administration of the complete hepatitis B vaccine (HepB) series and hepatitis B immunoglobulin. Post-vaccination serological testing (PVST) is utilized to determine an infant's outcome after HBV exposure and completion of HepB series. We aim to determine the frequency of compliance with a PVST testing cascade for HBV infected mothers and analyze factors associated with infant lost to follow up (LTFU).

METHODS

We conducted a retrospective cohort review of previously collected data in Fujian, Jiangxi, Zhejiang and Chongqing provinces in China from 1 June 2016-31 December 2017. The study population included all HBV-exposed infants and their mothers. SAS software was used for statistical analyses. Bivariate and multivariate regression analyses (presented in odds ratio [OR] with 95% confidence intervals [CI]) were used to compare the proportional differences of factors associated with PVST not being completed.

RESULTS

Among enrolled 8474 target infants, 40% of them transferred out of the study provinces without further information and 4988 were eligible for PVST. We found 20% (994) of infants were not compliant with the testing cascade: 55% of LTFU occurred because parents refused venous blood sample collection or failure of sample collection in the field, 16% transferred out after 6 months of age, and 10% of families chose to have independent, confidential PVST completed without reporting results. High PVST noncompliance rates were more likely to be from Fujian (aOR = 17.0, 95% CI: 9.7-29.9), Zhejiang (aOR = 5.7, 95% CI: 3.2-10.1) and Jiangxi (aOR = 1.9, 95% CI: 1.0-3.4), and from HBV e antigen positive mother (aOR = 1.2, 95% CI: 1.1-1.4).

CONCLUSIONS

This study found that the LTFU rate reached 20% in PVST program, which was a significant problem. We recommend implementing a national electronic information system for tracking HBV at risk mother-infant pairs; encourage further research in developing a less invasive means of completing PVST, and take effective measures nationally to reduce HBV stigma. Without reducing the loss to follow up rate among infants eligible for PVST, elimination of vertical HBV transmission will be impossible.

Chronic Hepatitis B stigma in Ghana: a qualitative study with patients and providers

OBJECTIVE

This study explored beliefs contributing to Hepatitis B stigma, and the ways in which Hepatitis B stigma manifests, from the perspectives of people with chronic Hepatitis B as well as healthcare providers in Northern and Southern Ghana.

DESIGN

We used an exploratory qualitative design with a purposive sampling technique. Face-to-face interviews and focus group discussions were conducted. Data were processed using QSR Nvivo V.10.0 and analysed using inductive thematic analysis.

SETTINGS

Participants were recruited from one tertiary and one regional hospital in Ghana between February and November 2017.

PARTICIPANTS

Overall, 18 people with chronic Hepatitis B (PWHB) and 47 healthcare providers (primary care physicians, nurses and midwives) between the ages of 21 and 57 years participated in the study.

RESULTS

PWHB face stigma in their sociocultural context and the healthcare environment. Three main beliefs underlying stigma were found: (1) the belief that Hepatitis B is highly contagious; (2) the belief that Hepatitis B is very severe and (3) the belief that Hepatitis B is caused by curses. Stigmatisation manifested as avoidance and social isolation (discrimination). In healthcare settings, stigmatisation manifested as excessive cautiousness, procedure postponement or avoidance, task-shifting and breaches of confidentiality.

CONCLUSIONS

Given the prevalence of incorrect knowledge, as reflected in the beliefs about Hepatitis B, we recommend public awareness campaigns that emphasise Hepatitis B transmission routes. Also, given the manifestations of the stigma in healthcare settings, we recommend the development and implementation of a continuing professional development programme on Hepatitis B and adjusted policy on Hepatitis B vaccination for Healthcare providers (HCPs).

Depression and Insomnia Are Closely Associated with Thyroid Hormone Levels in Chronic Hepatitis B

Background

Depression and insomnia in chronic hepatitis B (CHB) patients affect the quality of life, disease diagnosis, and mortality. CHB patients are more likely to have psychological disorders, but the underlying mechanisms have not been elucidated. This study investigated the incidence of depression in patients with CHB and sought to identify risk factors for depression and insomnia in these patients, focusing on changes in liver function and thyroid hormone levels.

Material/Methods

This cross-sectional cohort study used the Hamilton Depression Scale and Athens Insomnia Scale to assess the depressive and insomnia states, respectively, of 209 CHB patients. Liver function, thyroid hormone levels, hepatitis B surface antigen, hepatitis B e-antigen, and hepatitis B virus-deoxyribonucleic acid load were evaluated. Liver cirrhosis was assessed by imaging (color Doppler ultrasound and computed tomography). A multivariate logistic regression model was used to analyze the correlation among various factors and depression and insomnia.

Results

Subclinical and clinical depressive states were found in 23.9% and 5.3% and subclinical and clinical insomnia in 11% and 35.4% of patients, respectively. Depression and insomnia severity were significantly correlated with low FT3 (<3.5 mol/L). The odds ratios of low FT3 for subclinical and clinical depression and clinical insomnia were 3.07 (95% confidence interval (CI), 1.248–7.568), 7.85 (95% CI, 1.839–33.547), and 3.91 (95% CI, 1.417–10.789), respectively.

Conclusions

CHB patients are prone to depression and insomnia. FT3 reduction may be a risk factor for depression and insomnia. In clinical settings, more attention needs to be paid to the mental state of patients with FT3 reduction.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

Countdown to 2030: eliminating hepatitis B disease, China

Hepatitis B virus (HBV) infection is a major public health problem worldwide. China has the world’s largest burden of HBV infection and will be a major contributor towards the global elimination of hepatitis B disease by 2030. The country has made good progress in reducing incidence of HBV infection in the past three decades. The achievements are mainly due to high vaccination coverages among children and high coverage of timely birth-dose vaccine for prevention of mother-to-child transmission of HBV (both > 95%). However, China still faces challenges in achieving its target of 65% reduction in mortality from hepatitis B by 2030. Based on targets of the World Health Organization’s Global health sector strategy on viral hepatitis 2016–2021, we highlight further priorities for action towards HBV elimination in China. To achieve the impact target of reduced mortality we suggest that the service coverage targets of diagnosis and treatment should be prioritized. First, improvements are needed in the diagnostic and treatment abilities of medical institutions and health workers. Second, the government needs to reduce the financial burden of health care on patients. Third, better coordination is needed across existing national programmes and resources to establish an integrated prevention and control system that covers prevention, screening, diagnosis and treatment of HBV infection across the life cycle. In this way, progress can be made towards achieving the target of eliminating hepatitis B in China by 2030.

Socioeconomic Vulnerability to Depressive Symptoms in Patients with Chronic Hepatitis B

Depression is considered one of the most prevalent psychiatric disorders among patients with hepatitis B virus (HBV)-related liver disease and has adverse effects on the disease progression. However, there is a scarcity of studies contributing to the assessement of depression in hepatitis B patients. There is also little research into risk factors, particularly underlying socio-economic factors in Vietnam where the prevalence of hepatitis B is high. This study aimed to examine depression and identify whether differences in socio-economic status is related to the level of depression amongst chronic hepatitis B patients. A cross-sectional study was conducted on 298 patients with chronic hepatitis B at The Chronic Hepatitis Clinic in the Viet-Tiep Hospital, Hai Phong, Vietnam. The Patient Health Questionnaire-9 (PHQ-9) and EuroQol-5 dimensions-5 levels (EQ-5D-5L) were used to assess the severity of depression and health-related quality of life (HRQOL). Of chronic hepatitis B patients, 37.5% experienced depressive symptoms and most of them suffered minimal depressive symptoms (31.4%). According to the result of the multivariate logistic regression model, we found that higher age, lower income level, unemployement, living with spouse/partners were positively associated with having depression. Furthermore, having physical health problems and lower health-related quality of life were also related to a higher risk of depression. We recommend family support, financial support and active participation in consultation should be conducted during treatment to improve the quality of life and the emotional state of HBV patients.

Knowledge and awareness of hepatitis B among households in Malaysia: a community-based cross-sectional survey

BACKGROUND

Hepatitis B (HepB) is a major public health concern in Malaysia yet little is known about knowledge and awareness of this infection in the country. Such information is essential for designing effective intervention strategies for HepB prevention and control. The aim of this study was to characterize knowledge and awareness regarding HepB in Malaysia and to identify their associated sociodemographic determinants.

METHODS

A community-based cross-sectional survey was conducted between January and May 2016 in Selangor state of Malaysia. A two-stage cluster random sampling design was used and one adult member of selected households was interviewed face-to-face. Logistic regression was used to estimate the differences in knowledge and awareness between groups.

RESULTS

A total of 764 households completed the interviews and were included in the final analysis. Only 36.9 and 38.8% of the participants had good knowledge and awareness, respectively. The factors associated with good knowledge were being in the 35-44 year age group, Malay ethnicity, high educational attainment and high family income. Being Chinese, being older and having high educational attainment were determinants of having good awareness towards HepB. Participants who had good knowledge were 2.5 times more likely to also have good awareness (OR: 2.41, 95% CI: 1.78-3.26, p < 0.001).

CONCLUSIONS

This study reveals a low level of knowledge and awareness of HepB among households in Malaysia. This finding highlights the need to improve public knowledge and awareness through well-designed programs targeting vulnerable groups in order to reduce hepatitis B virus transmission and achieve the governmental target of eliminating viral hepatitis as a public health concern by 2030.

Hepatitis B virus contact disclosure and testing in Lusaka, Zambia: a mixed-methods study

OBJECTIVES

The aim of this study was to estimate the frequency of disclosure to and testing of contacts of patients with hepatitis B virus (HBV) in Zambia.

DESIGN

We used a convergent parallel mixed-method research design including a quantitative survey and focus group discussions with patients with HBV.

SETTING

A university hospital in Lusaka, Zambia.

PARTICIPANTS

79 hepatitis B surface antigen (HBsAg)-positive, HIV-negative, adults (18+ years) receiving HBV care completed a quantitative survey and 32 also participated in a focus group discussion.

OUTCOMES AND ANALYSIS

Contacts of patients with HBV were enumerated and patient-reported disclosure, contact testing and contact HBV test results were used to develop a testing cascade. Using multivariable logistic regression, we identified factors associated with disclosure of HBV status. In focus groups, we explored how index patient knowledge and awareness of their condition shaped perspectives on contact disclosure and testing. Focus groups coding and analysis followed a thematic analysis approach.

RESULTS

Among 79 patients with HBV (median age 35 years; 26.6% women), the majority reported disclosure to ≥1 contact. According to the index patients' knowledge, of 776 contacts enumerated, 326 (42.1%) were disclosed to, 77 (9.9%) were tested, 67 (8.6%) received results and 8 (11.9%) were HBsAg-positive. Increased stigma score was associated with reduced disclosure. In focus groups, HBV awareness, knowledge and stigma emerged as barriers to disclosure and referral of contacts for testing. Association of HBV with HIV-related stigma was also reported as a strong barrier to contact disclosure and testing and to taking antivirals for HBV monoinfection.

CONCLUSIONS

HBV contact disclosure and testing were feasible and yielded new diagnoses in Zambia. A better understanding of barriers to seeking HBV testing and treatment is needed to scale-up this important intervention in Africa.

TRIALS REGISTRATION NUMBER

NCT03158818.

A blind spot? Confronting the stigma of hepatitis B virus (HBV) infection - A systematic review

Background: Stigma, poverty, and lack of knowledge present barriers to the diagnosis and treatment of chronic infection, especially in resource-limited settings. Chronic Hepatitis B virus (HBV) infection is frequently asymptomatic, but accounts for a substantial long-term burden of morbidity and mortality. In order to improve the success of diagnostic, treatment and preventive strategies, it is important to recognise, investigate and tackle stigma. We set out to assimilate evidence for the nature and impact of stigma associated with HBV infection, and to suggest ways to tackle this challenge.

Methods: We carried out a literature search in PubMed using the search terms ‘hepatitis B’, ‘stigma’ to identify relevant papers published between 2007 and 2017 (inclusive), with a particular focus on Africa.

Results: We identified a total of 32 articles, of which only two studies were conducted in Africa. Lack of knowledge of HBV was consistently identified, and in some settings there was no local word to describe HBV infection. There were misconceptions about HBV infection, transmission and treatment. Healthcare workers provided inaccurate information to individuals diagnosed with HBV, and poor understanding resulted in lack of preventive measures. Stigma negatively impacted on help-seeking, screening, disclosure, prevention of transmission, and adherence to treatment, and had potential negative impacts on mental health, wellbeing, employment and relationships.

Conclusion: Stigma is a potentially major barrier to the successful implementation of preventive, diagnostic and treatment strategies for HBV infection, and yet we highlight a ‘blind spot’, representing a lack of data and limited recognition of this challenge. There is a need for more research in this area, to identify and evaluate interventions that can be used effectively to tackle stigma, and to inform collaborative efforts between patients, clinical services, policy makers, traditional healers, religious leaders, charity organisations and support groups.

A blind spot? Confronting the stigma of hepatitis B virus (HBV) infection - A systematic review

Background: Stigma, poverty, and lack of knowledge present barriers to the diagnosis and treatment of chronic infection, especially in resource-limited settings. Chronic Hepatitis B virus (HBV) infection is frequently asymptomatic, but accounts for a substantial long-term burden of morbidity and mortality. In order to improve the success of diagnostic, treatment and preventive strategies, it is important to recognise, investigate and tackle stigma. We set out to assimilate evidence for the nature and impact of stigma associated with HBV infection, and to suggest ways to tackle this challenge. Methods: We carried out a literature search in PubMed using the search terms 'hepatitis B', 'stigma' to identify relevant papers published between 2007 and 2017 (inclusive), with a particular focus on Africa. Results: We identified a total of 32 articles, of which only two studies were conducted in Africa. Lack of knowledge of HBV was consistently identified, and in some settings there was no local word to describe HBV infection. There were misconceptions about HBV infection, transmission and treatment. Healthcare workers provided inaccurate information to individuals diagnosed with HBV, and poor understanding resulted in lack of preventive measures. Stigma negatively impacted on help-seeking, screening, disclosure, prevention of transmission, and adherence to treatment, and had potential negative impacts on mental health, wellbeing, employment and relationships. Conclusion: Stigma is a potentially major barrier to the successful implementation of preventive, diagnostic and treatment strategies for HBV infection, and yet we highlight a 'blind spot', representing a lack of data and limited recognition of this challenge. There is a need for more research in this area, to identify and evaluate interventions that can be used effectively to tackle stigma, and to inform collaborative efforts between patients, clinical services, policy makers, traditional healers, religious leaders, charity organisations and support groups.

The experience of discrimination of individuals living with chronic hepatitis B in four provinces of China

OBJECTIVES

To assess chronic hepatitis B (CHB) patients' knowledge about hepatitis B and their experience of discrimination with regard to study, work, and daily life.

METHODS

We administered a questionnaire to 797 CHB patients in four provinces of China and used one-way analysis of variance (ANOVA) and a generalized linear model (GLM) to identify factors associated with discrimination.

RESULTS

CHB patients had low levels of knowledge about hepatitis B. Patients under 40 years of age with a junior college education or above knew more about hepatitis B than CHB patients over 40 years of age who had only a high school education. Three-fourths of patients had experienced discrimination because of their hepatitis B infection, with no differences in the proportion experiencing discrimination by sex or age. People with more education reported less discrimination. Patients in Beijing and Henan province perceived less discrimination than those in Shaanxi and Guangdong provinces. Discrimination was significantly associated with negative emotions. CHB patients had little awareness of China's anti-discrimination laws and policies. Among patients who had experienced discrimination, fewer than 10% knew organizations or institutions that could offer help. Over 60% of CHB patients who experienced discrimination chose not to respond.

CONCLUSION

CHB patients in China commonly experienced discrimination, which was associated with significant, negative emotional stress. To mitigate the damaging effects of discrimination, our study suggests raising general population knowledge about hepatitis B, raising awareness of the availability of legal protection and organizations that can fight discrimination, and providing psychological support for CHB patients.