Awareness of Hep C among health care providers

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Volume 44-7/8, July 5, 2018: Can we eliminate hepatitis C?

Scoping review

Awareness and knowledge of hepatitis C among health care providers and the public: A scoping review

S Ha1, K Timmerman1

Affiliation

1 Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON

Correspondence

shalane.ha@canada.ca

Suggested citation

Ha S, Timmerman K. Awareness and knowledge of hepatitis C among health care providers and the public: A scoping review. Can Commun Dis Rep 2018;44(7/8):157-65. https://doi.org/10.14745/ccdr.v44i78a02

Keywords: awareness, knowledge, hepatitis C, scoping review, health care providers

Abstract

Background: The Global Viral Hepatitis Strategy aims to eliminate hepatitis as a public health threat by 2030. The hepatitis C virus (HCV) can be difficult to detect as infection can remain asymptomatic for decades. Individuals are often neither offered nor seek testing until symptoms develop. This highlights the importance of increasing awareness and knowledge among health care providers and the public to reach the viral hepatitis goals.

Objectives: To conduct a scoping review to characterize current awareness and knowledge among health care providers and the public regarding HCV infection, transmission, prevention and treatment and to identify knowledge gaps that public health action could address.

Methods: A literature search was conducted using Embase, Medline and Scopus to find studies published between January 2012 and July 2017. A search for grey literature was also undertaken. The following data were extracted: author, year of publication, study design, population, setting, country, method of data collection, and knowledge and awareness outcomes. Commentaries, letters to the editor and narrative reviews were excluded.

Results: Nineteen studies were included in this review. The definition of awareness and knowledge varied across studies; at times, these terms were used interchangeably. Health care providers identified injection drug use or blood transfusions as routes of HCV transmission more frequently than other routes of transmission such as tattooing with unsterile equipment and sexual transmission. Among the general public, misconceptions about HCV included believing that kissing and casual contact were routes of HCV transmission and that a vaccine to prevent HCV was available. Overall, there was a lack of data on other high-risk populations (e.g., Indigenous, incarcerated).

Conclusion: Continued public and professional education campaigns about HCV could help support HCV risk-based screening and testing. Future research could assess the awareness of other populations at increased risk and include consistent definitions of awareness and knowledge.

Background

Hepatitis C virus (HCV) causes inflammation of the liver, which can become chronic. Chronic HCV infection can be asymptomatic for decades before symptoms appear. Globally, about 71 million people have chronic HCV infectionFootnote 1. Chronic HCV infection is not easy to detect; even when symptoms are present, they are often nonspecific (e.g., fatigue)Footnote 2. Chronic HCV infection can lead to cirrhosis or liver cancer. Approximately half a million people die each year from HCV-related liver diseasesFootnote 3.

In 2011, about 220,000-246,000 individuals were living with chronic HCV infection in Canada and approximately 44% were unaware of their infectionFootnote 4. Over the past few years, there have been significant advances in HCV treatment, and infection is now curable. Previous treatment regimens consisted of peg-interferon and ribavirin, which involved longer treatment durations and more side effects. The new interferon-free direct acting antiviral (DAA) treatments have been found to be highly effective and have fewer side effects. Currently, most provincial and territorial formularies cover these new treatments and Canada has started to witness a decrease in hospitalizations associated with HCV infection and chronic liver diseaseFootnote 5.

In 2016, the 69th World Health Assembly adopted the Global Health Sector Strategy on Viral Hepatitis with the goal of eliminating both hepatitis B and C as a public health threat by 2030Footnote 6. The goal is to have 90% of viral hepatitis B and C diagnosed and 80% of eligible people with chronic hepatitis B virus (HBV) and chronic HCV infection treatedFootnote 6. Awareness and knowledge of hepatitis C is an important first step in the elimination strategy. The identification of HCV through screening and testing is essential for patients to make appropriate lifestyle changes and to begin treatment.

Limited awareness of and knowledge about HCV have been identified as the key barriers to health care providers offering hepatitis C testing and for patients seeking testingFootnote 7. This lack of awareness and knowledge leads to continued HCV transmission and missed prevention and treatment opportunities. In an effort to improve risk-based screening in Canada and to reduce the number of people who are unaware of their infection, it is important to understand current awareness and knowledge of HCV among health care providers and the public alike.

The objectives of this review are to summarize health care providers' and the general public's awareness and knowledge of the natural history of HCV and HCV transmission, prevention and treatment, and to identify knowledge gaps in both groups that public health action could address.

Methods

We worked with a research librarian to conduct a literature search in Embase, Medline and Scopus for published studies on awareness and knowledge of HCV among health care providers and the public. We also completed a search for grey literature (i.e., reports available on public domains) using Google. The following search terms were used: hepatitis C, HCV, awareness, and knowledge. Studies were included in the review if they were published between January 2012 and July 2017; published in English or French; conducted in Canada or similarly economically developed and well-resourced countries; and focused on the public or health care providers. We restricted the search years to the last five years to capture the most recent information. Commentaries, letters to editors and case studies were excluded. Outcomes of interest included HCV awareness and knowledge, which are defined in various ways based on the study.

After screening the titles and abstracts of potentially relevant articles, we reviewed the full texts of included studies. We developed data extraction forms and extracted data on the following: author, year of publication, study design, population, setting, country, method of data collection, and knowledge and awareness outcomes.

As a scoping review a qualitative analysis of the findings was completed and the results were summarized into themes but we did not conduct a detailed assessment of overall quality or risk of bias.

Results

The literature search identified 141 potentially relevant articles on HCV awareness and knowledge of health care providers and the general public. A manual search of the reference lists identified five additional references. An additional three reports were identified through the grey literature search. After the title and abstract screening and the full text review, 19 studies were included in this review (Figure 1).

Awareness and knowledge were at times used interchangeably in the included studies. Awareness was defined as either awareness of one's own HCV infection, diagnosis or seropositivity or awareness of the existence of HCV, the risk factors or availability of treatment. Knowledge could include the natural history and consequences of HCV, HCV risk factors and transmission routes, or vaccine and treatment availability. Consequently, the results are reported based on how the studies themselves defined awareness and knowledge.

Figure 1: Flowchart of study selection process

Figure 1: Flowchart of study selection process

Text description: Figure 1

Figure 1: Flowchart of study selection process

Figure 1 depicts a flowchart of the study selection process. The top-left box indicates that 141 records were found during the database search, with an additional five studies identified through a manual search, and three identified through a grey literature search. This box leads to the total number of records (n=149).

To the right of the total box is a description of the number of records excluded and why. Of the 149 total, 130 records were excluded. The reasons for exclusion include: 1) Objective was not focused on awareness and knowledge of HCV (n=93), 2) the records did not meet the study design criteria (n=6), and 3) the records were focused on other populations (e.g., people who inject drugs, inmates, methadone maintenance patients, n=31).

The final box shows the total number of records included in this scoping review (n=19).


Characteristics of included studies

The majority of the included studies were conducted in the United States (US; n=8), followed by Canada (n=5) and Australia (n=3). The remainder of the studies were from Germany, Italy, Japan and Netherlands. Most of the studies (n=13) targeted the general population and less than one-third (n=5) focused on health care providers; one study included both populations. Participants were recruited from a variety of settings including hospitals, outpatient clinics, primary care clinics, emergency departments and online panels. Data collection methods most often included questionnaires completed online, in-person or by phone. (For more details about the included studies, please refer to Appendix 1.)

Of the studies that focused on health care providers, job categories included physicians, nurses, residents, dental students and specialists (i.e., hepatologists and gastroenterologists). Of the studies that focused on non–health care providers, population groups included HCV-infected people with or without HIV coinfection, men who have sex with men (MSM), immigrants, the general public and adults born between 1945 and 1965 (Table 1).

Table 1: Summary of included studies
Characteristics Number of studies (n)Table 1 Footnote a
Country
United States 8
Canada 5
Australia 3
Netherlands 2
Germany 1
Italy 1
Japan 1
Other 3
Health care providers
Physicians 3
Nurses 3
Specialists (e.g., hepatologist, gastroenterologist) 2
Medical students 1
Other 1
Non–health care providers
People living with HCV with or without HIV coinfection 4
Men who have sex with men (MSM) 3
General public 2
People born between 1945–1965 2
Immigrants 1
Other 1

Abbreviations: HCV, hepatitis C virus; HIV, human immunodeficiency virus; n, number

Awareness

There were six studies on awareness of hepatitis CFootnote 11Footnote 12Footnote 14Footnote 17Footnote 18Footnote 24. The types of awareness varied across these studies: awareness of risk factors, of treatment, of one’s own infection and of the existence of HCV. Four studies included findings on awareness of HCV by the general publicFootnote 11Footnote 12Footnote 14Footnote 17, one on awareness of HCV by MSMFootnote 18 and one on awareness of treatment by Canadian health care providersFootnote 24.

Two studies found that the general public had some awareness (defined as the knowledge that something exists) of hepatitis CFootnote 11Footnote 17. Compared with the public (27%), Canadian-born baby boomers (33%) were more likely to be aware that injection drug users have an increased risk of HCV compared with the general public (27%)Footnote 14. However, results from the United States’ National Health and Nutrition Examination Survey (NHANES) indicated that fewer than half of Americans who had HCV infection were aware of their infectionFootnote 12. Two studies found that the general public was not clear about the differences between hepatitis A, B and CFootnote 11Footnote 19.

Knowledge

All of the included studies assessed knowledge of HCV. Knowledge was measured using a series of yes/no/don’t know or true/false statements, or one’s perceived knowledge level. Knowledge was assessed in the following topics: natural history of HCV, transmission routes, the availability of a vaccine and the availability of treatment.

The natural history of HCV and its consequences

Three studies included information on health care providers’ knowledge of the natural history and consequences of HCVFootnote 16Footnote 25Footnote 26. In a convenience study of Canadian physicians, 35% reported “knowing a lot” about symptoms associated with HCVFootnote 16. In a small study of dental students from Bulgaria, 80% reported knowing that infection with hepatitis B virus or HCV may be asymptomaticFootnote 26. In addition, residents, physicians, nurse practitioners and physician assistants working in emergency departments in the US were reported to have high knowledge scores regarding the manifestations of HCV (percentage not reported)Footnote 25.

Eight studies included information on the public’s knowledge about the natural history of HCVFootnote 8Footnote 9Footnote 11Footnote 13Footnote 14Footnote 16Footnote 17Footnote 19. Two Canadian studies found that 83–90% of participants knew that people with HCV could be unaware of an existing infectionFootnote 14Footnote 16. Similarly, over half (57%) of US baby boomers knew that HCV can lead to liver cancer and 61% believed that someone with HCV infection can present with no symptomsFootnote 8. One study reported that one-third of MSM knew that HCV infection could lead to liver cancer (31%) and liver failure (37%)Footnote 18. Conversely, in an international study with immigrants from Asia, it was reported that there was confusion about the different types of hepatitis infections and uncertainty about the natural history of the infectionFootnote 19.

Knowledge of transmission

Two studies reported on health care providers’ knowledge of HCV transmissionFootnote 22Footnote 26. The majority of health care providers in the studies identified the main routes of transmission as blood transfusions, exposure to blood during sexual activity and sharing needles while injecting drugsFootnote 22Footnote 26. A small percentage (12%) of nurses working in hemodialysis clinics in Italy believed, incorrectly, that HCV can be transmitted through kissing, and 19% did not know that getting a tattoo could be a means of HCV transmissionFootnote 22.

Ten studies reported information on knowledge of HCV transmission among the general publicFootnote 8Footnote 10Footnote 11Footnote 12Footnote 14Footnote 15Footnote 16Footnote 17Footnote 19Footnote 21. One Canadian study reported that the most frequently known HCV transmission routes were blood transfusions, unsafe/unprotected intercourse and injection drug use/sharing of needlesFootnote 14. Few Canadians identified other routes of transmission such as sharing personal hygiene items (7%), getting tattoos and body piercings (4%), exposure to risk factors while travelling in foreign countries where HCV may be endemic (4%), and mother-to-child transmission through pregnancy (1%)Footnote 14. Furthermore, approximately 54–62% of the general population in Canada knew that HCV is transmitted mainly through blood-to-blood contactFootnote 16. In four studies, a small percentage of the general public indicated that HCV can be transmitted through kissing or casual contactFootnote 8Footnote 12Footnote 14Footnote 21.

Knowledge of treatment

Two recent studies, published after the new interferon-free DAA therapies became available, focused on knowledge of the curability of HCVFootnote 8Footnote 24.

Among health care providers, specialists (i.e., hepatologists, gastroenterologists, hepatology nurses) scored higher on knowledge statements about HCV treatment than general practitioners (GPs)Footnote 23Footnote 24. Of the 10 primary care physicians surveyed, seven were unsure or not aware of the new interferon-free DAAs and were not sure about the mechanisms of actionFootnote 24.

In the US, 51% of baby boomers presenting to emergency departments correctly believed that HCV is curable and 77% had knowledge of new medications available to treat HCVFootnote 8. However, three studies detected a misconception among the general public about the availability of a vaccine to prevent HCVFootnote 11Footnote 15Footnote 21. About one half of the Canadians interviewed (50%) in one study believed there was a vaccine to prevent HCV Footnote 14. In two US studies, 42% of American baby boomers and 60% of African-American baby boomers believed there was a vaccine to prevent HCVFootnote 8Footnote 11.

A summary of the findings is shown in Table 2.

Table 2: Summary of findings on awareness and knowledge of hepatitis C virus among health care professionals and the general public
Outcomes Key Findings
Awareness Public:
The general public was aware of HCV and main risk factorsFootnote 14
MSM had high awareness of HCV treatmentFootnote 18
Knowledge Health care providers:
Specialists were more up-to-date on new HCV treatments than primary care physiciansFootnote 24
Health care providers knew less about some routes of HCV transmission (e.g. unsafe tattooing practices or piercings) compared with the main routes (i.e., injection drug use)Footnote 22Footnote 26
Public:
The general public had misconceptions around risk factors for transmission of hepatitis C (e.g., casual contact, saliva, kissing)Footnote 11Footnote 12Footnote 14Footnote 16Footnote 19
There were also misconceptions about the availability of a vaccineFootnote 8Footnote 14Footnote 16
Overall, there was little knowledge about the interferon-free DAA hepatitis C treatmentFootnote 8Footnote 9Footnote 13Footnote 14Footnote 16
Abbreviations: DAA, direct acting antivirals; HCV, hepatitis C virus; MSM, men who have sex with men

Discussion

To the best of our knowledge, this is the first scoping review that provides a snapshot of what health care providers and the general public know about HCV. Overall, health care providers know about the most common transmission routes and risk factors, whereas specialists are more up-to-date on treatments than primary care physiciansFootnote 23Footnote 24. The general public is aware of HCV; however, some people do not know the difference between hepatitis A, B and C; there are misconceptions around routes of transmission; and some incorrectly believe that an HCV-preventable vaccine exists.

There are some limitations to consider when interpreting our findings. First, there was a lack of standard definitions for knowledge and awareness and the terms were often used interchangeably. Second, only a few studies captured awareness and knowledge of interferon-free DAA treatments. Finally, the findings were based on cross-sectional studies, which only capture data of a study population at a single point in time.

Future research could include assessment of high-risk populations (e.g., Indigenous peoples or incarcerated populations); incorporate clear and consistent definitions of awareness and knowledge; and assess factors that may be associated with differences in awareness and knowledge (e.g., rural versus urban settings, and socioeconomic status). Additional research on health care providers’ knowledge of HCV could also help tailor future knowledge translation and exchange products.

In conclusion, increasing health care providers’ and the general public’s awareness of and knowledge about HCV can facilitate the discussion about whether HCV testing should be considered. The findings and gaps identified in this review can help inform future interventions and public health campaigns to do with HCV and support the Global Health Sector Strategy on Viral Hepatitis.

Authors’ statement

SH – Conceptualization, methodology, writing (final draft), data curation, validation, formal analysis, writing, reviewing and editing, supervision, project administration, visualization
KT– Conceptualization, methodology, reviewing and editing, supervision, project administration, visualization

Conflict of interest

None.

Acknowledgements

We would like to thank Dr. Margaret Gale-Rowe and Dr. Jun Wu for their contributions to the conceptualization and revision of this manuscript, Audréanne Garand for her support in the data collection, extraction and initial analysis of the results, and the Health Canada librarian who helped conduct the literature search.

Funding

This work was supported by the Public Health Agency of Canada.

References

Footnote 1

World Health Organization. Hepatitis C: key facts. Geneva: World Health Organization; 2017. http://www.who.int/en/news-room/fact-sheets/detail/hepatitis-c

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Footnote 2

Westbrook RH, Dusheiko G. Natural history of hepatitis C. J Hepatol 2014 Nov;61(1 Suppl):S58–68. http://dx.doi.org/10.1016/j.jhep.2014.07.012.

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Footnote 3

World Health Organization. Global hepatitis report, 2017. Geneva: World Health Organization; 2017. http://apps.who.int/iris/bitstream/handle/10665/255016/9789241565455-eng.pdf?sequence=1

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Footnote 4

Trubnikov M, Yan P, Archibald C. Estimated prevalence of hepatitis C virus infection in Canada, 2011. Can Commun Dis Rep 2014 Dec;40(19):429–36. https://www.ncbi.nlm.nih.gov/pubmed/29769874

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Footnote 5

Schanzer D, Pogany L, Aho J, Tomas K, Gale-Rowe M, Kwong J, Janjua NZ, Feld J. Impact of availability of direct-acting antivirals for hepatitis C on Canadian hospitalization rates, 2012–2016. Can Commun Dis Rep 2018;44(7/8):150–6. https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-7-8-july-5-2018/article-1-canadian-hospitalization-rates-hep-c.html

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Footnote 6

World Health Organization. Global Health Sector Strategy on Viral Hepatitis 2016–2021: towards ending viral hepatitis. Geneva: World Health Organization; 2016. http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdf?ua=1

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Footnote 7

McLeod A, Cullen BL, Hutchinson SJ, Roy KM, Dillon JF, Stewart EA, Goldberg DJ. Limited impact of awareness-raising campaigns on hepatitis C testing practices among general practitioners. J Viral Hepat 2017 Nov;24(11):944–54. http://dx.doi.org/10.1111/jvh.12724

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Footnote 8

Allison WE, Chiang W, Rubin A, Oshva L, Carmody E. Knowledge about hepatitis C virus infection and acceptability of testing in the 1945–1965 birth cohort (baby boomers) presenting to a large urban emergency department: a pilot study. J Emerg Med 2016 Jun;50(6):825–831.e2. http://dx.doi.org/10.1016/j.jemermed.2016.02.001

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Footnote 9

CATIE. Room for improvement: knowledge exchange needs of people living with hepatitis C. Toronto: CATIE; 2015. http://www.catie.ca/sites/default/files/Hepatitis%20C%20needs%20assessment%20report_final.pdf

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Chen EY, North CS, Fatunde O, Bernstein I, Salari S, Day B, Jain MK. Knowledge and attitudes about hepatitis C virus (HCV) infection and its treatment in HCV mono-infected and HCV/HIV co-infected adults. J Viral Hepat 2013 Oct;20(10):708–14. http://dx.doi.org/10.1111/jvh.12095

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Footnote 11

Crutzen R, Göritz AS. Public awareness and practical knowledge regarding Hepatitis A, B, and C: a two-country survey. J Infect Public Health 2012 Apr;5(2):195–8. http://dx.doi.org/10.1016/j.jiph.2011.12.001

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Footnote 12

Denniston MM, Klevens RM, McQuillan GM, Jiles RB. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology 2012 Jun;55(6):1652–61. http://dx.doi.org/10.1002/hep.25556

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Footnote 13

Eguchi H, Wada K. Knowledge of HBV and HCV and individuals’ attitudes toward HBV- and HCV-infected colleagues: a national cross-sectional study among a working population in Japan. PLoS One 2013 Sep;8(9):e76921. http://dx.doi.org/10.1371/journal.pone.0076921

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Footnote 14

EKOS Research Associates Inc. 2012 HIV/AIDS attitudinal tracking survey. Ottawa: EKOS; 2012 Oct. http://www.catie.ca/sites/default/files/2012-HIV-AIDS-attitudinal-tracking-survey-final-report.pdf

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Footnote 15

Hopwood M, Lea T, Aggleton P. Multiple strategies are required to address the information and support needs of gay and bisexual men with hepatitis C in Australia. J Public Health (Oxf) 2016 Mar;38(1):156–62. http://dx.doi.org/10.1093/pubmed/fdv002

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Footnote 16

Ipsos Healthcare. Survey on hepatitis C knowledge and perception among Canadians and GP, September 2012. Paris: Ipsos; 2012. https://www.ipsos.com/sites/default/files/publication/2013–01/5977-report.pdf

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Footnote 17

Lambers FA, Prins M, Davidovich U, Stolte IG. High awareness of hepatitis C virus (HCV) but limited knowledge of HCV complications among HIV-positive and HIV-negative men who have sex with men. AIDS Care 2014 Apr;26(4):416–24. http://dx.doi.org/10.1080/09540121.2013.832721

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Footnote 18

Lea T, Hopwood M, Aggleton P. Hepatitis C knowledge among gay and other homosexually active men in Australia. Drug Alcohol Rev 2016 Jul;35(4):477–83. http://dx.doi.org/10.1111/dar.12333

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Footnote 19

Owiti JA, Greenhalgh T, Sweeney L, Foster GR, Bhui KS. Illness perceptions and explanatory models of viral hepatitis B & C among immigrants and refugees: a narrative systematic review. BMC Public Health 2015 Feb;15:151. http://dx.doi.org/10.1186/s12889-015-1476-0

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Pundhir P, North CS, Fatunde O, Jain MK. Health beliefs and co-morbidities associated with appointment-keeping behavior among HCV and HIV/HCV patients. J Community Health 2016 Feb;41(1):30–7. http://dx.doi.org/10.1007/s10900-015-0059-4

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Footnote 21

Rashrash ME, Maneno MK, Wutoh AK, Ettienne EB, Daftary MN. An evaluation of hepatitis C knowledge and correlations with health belief model constructs among African American “baby boomers”. J Infect Public Health 2016 Jul-Aug;9(4):436–42. http://dx.doi.org/10.1016/j.jiph.2015.11.005

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Footnote 22

Bianco A, Bova F, Nobile CG, Pileggi C, Pavia M; Collaborative Working Group. Healthcare workers and prevention of hepatitis C virus transmission: exploring knowledge, attitudes and evidence-based practices in hemodialysis units in Italy. BMC Infect Dis 2013 Feb;13(76):76. http://dx.doi.org/10.1186/1471-2334-13-76

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Footnote 23

McGowan CE, Monis A, Bacon BR, Mallolas J, Goncales FL, Goulis I, Poordad F, Afdhal N, Zeuzem S, Piratvisuth T, Marcellin P, Fried MW. A global view of hepatitis C: physician knowledge, opinions, and perceived barriers to care. Hepatology 2013 Apr;57(4):1325–32. http://dx.doi.org/10.1002/hep.26246

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Footnote 24

Naghdi R, Seto K, Klassen C, Emokpare D, Conway B, Kelley M, Yoshida E, Shah HA. A hepatitis C educational needs assessment of Canadian healthcare providers. Can J Gastroenterol Hepatol 2017 10:1-10. https://doi.org/10.1155/2017/5324290

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Footnote 25

Rotte M, O’Donnell R. Knowledge, beliefs, and attitudes of emergency department health care providers towards hepatitis C and rapid hepatitis C testing. Ann Emerg Med 2013;62(4):S103. http://dx.doi.org/10.1016/j.annemergmed.2013.07.108

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Footnote 26

Todorova TT, Tsankova G, Tsankova D, Kostadinova T, Lodozova N. Knowledge and attitude towards hepatitis B and hepatitis C among dental medicine students. J of IMAB 2015;21(3):810–3. http://dx.doi.org/10.5272/jimab.2015213.810

Return to footnote 26 referrer

Appendix 1:

Description of included studies (n=19)
Author(s), year of publication / Country Study design / Population / setting Method of data collection Outcome / Findings
General public (n=14)

Allison et al. (2016)Footnote 8
US

Cross-sectional study
Baby boomers
(1945–1965) (n=915)
Urban emergency department

Structured interview within six weeks of HCV antibody test to assess knowledge

Knowledge

  • Most participants were familiar with the natural history and complications of HCV
  • Most participants were familiar with the risk factors for HCV
  • Some participants had misconceptions about transmission (i.e., kissing)
  • More than half of participants thought that HCV-preventable vaccines existed
  • Many lacked the knowledge about the curability of HCV

CATIE (2015)Footnote 9
Canada

Cross-sectional study
People living with HCV (n=326)
Medical clinics offering HCV infection care

Self-administered questionnaire (paper and online)

Knowledge

  • 23% reported knew a lot about hepatitis C
  • Younger respondents, men and Indigenous people were more likely to report lower levels of knowledge about hepatitis C
  • 20% reported knowing a lot about treatment
  • Younger respondents and Indigenous people were more likely to report lower levels of knowledge about hepatitis C

Chen et al. (2013)Footnote 10
US

Cross-sectional study
HCV infection and HIV/HCV coinfection (n=292)
Outpatient clinic

Cross-sectional survey and pre- and post-educational surveys

Knowledge

  • Overall, HCV knowledge was limited, with less than 50% of the questions answered correctly
  • No differences between the mono-infected and coinfected groups regarding HCV knowledge score or the subscales representing HCV disease and transmission
  • Coinfected participants had a higher mean HCV treatment knowledge score compared with mono-infected participants

Crutzen & Goritz (2012)Footnote 11
Germany and Netherlands

Cross-sectional study
General public in
Germany (n=1989) and Netherlands (n=668)
Online panel

Two large-scale surveys administered to online panels

Awareness

  • High awareness of hepatitis A, B and C (no percentage values/scales provided)

Knowledge

  • Knowledge was very low in both countries (slightly above 50% correct answers)
  • People are aware of the existence of similarities and differences between HAV, HBV and HCV, but they know less about the transmission, consequences and prevention of these infections

Denniston et al. (2012)Footnote 12
US

Cross-sectional study
General public who tested positive for HCV
(n=32,847)
NHANES 2001–2008 data

Phone interview

Awareness

  • Less than half of those who were HCV-positive were aware of their infection

Knowledge

  • Respondents answered most knowledge questions correctly, ranging from 57.1% to 95.7% correct
  • Lower proportion of respondents correctly answered questions related to the transmission of HCV through kissing, sexually and vertically (i.e. mother to child)
  • Responses about vertical transmission had the highest proportion of “don’t know” responses (33.7%)

Eguchi & Wada (2013)Footnote 13
Japan

Cross-sectional study
Japanese working population (n=3,129)
Online

Self-administered questionnaire (online)

Knowledge

  • 19% believed that HBV/HCV is the cause of liver cancer in 90% of cases
  • 39% believed that people who have HBV/HCV may develop hepatic cirrhosis or liver cancer at age 40–60 years
  • 39% believed that treatment can cure HBV/HCV and prevent liver damage

EKOS Research Associates Inc. (2012)Footnote 14
Canada

Cross-sectional study
General public (≥16 years old)
(n=2,000)
Survey panel

Phone interview

Awareness and knowledge

  • Awareness was not clearly defined
  • 13% of Canadians believed they are very knowledgeable about HCV
  • 23% believed that HCV infection can be cured; 55% did not know/gave no response
  • 50% believed that a vaccine is available to prevent HCV; 24% did not know/gave no response
  • 36% indicated that HCV can be transmitted through blood transfusions
  • 25% indicated that HCV can be transmitted through unsafe/unprotected intercourse
  • 23% indicated that HCV can be transmitted through injection drug use/sharing needles
  • <10% indicated that HCV can be transmitted the following ways: casual contact (e.g., kissing, hugging, shaking hands); from mother to child during pregnancy; tattoos, body piercing; sharing personal hygiene items
  • 25% did not know/had no response of how HCV can be transmitted

Hopwood et al. (2016)Footnote 15
Australia

Cross-sectional study
Gay and bisexual men living with HIV and/or HCV (n=474)
Online study

Self-administered questionnaire

Knowledge

  • HCV knowledge was moderate to good
  • 44% believed that being HIV positive makes it more likely to get HCV during sex between men
  • Respondents wanted information on how to avoid transmitting HCV to sexual partners (46%); complementary therapies for HCV (42%); how HIV/HCV coinfection affects health (42%); and how HIV and HCV treatments affect each other (40%)
  • The majority of men said their GP or specialist (85%) or the Internet (69%) were their primary sources of HCV information. Fewer men reported that they had accessed information via hepatitis organizations (52%); other health care workers (38%); and friends (23%)

Ipsos (2012)Footnote 16
Canada

Cross-sectional study
General population (≥18 years) (n=1,000)
(Setting unknown: information not available)

Self-administered questionnaire (online)

Knowledge

  • 90% indicated that someone can have hepatitis C and not know it
  • 62% of Gen Y (18–29 years), 60% of Gen X (30–46 years) and 54% of baby boomers (47–67 years) knew that HCV is primarily transmitted via blood-to-blood contact
  • 23% of Gen Y (18–29 years), 14% of Gen X (30–46 year) and 18% of baby boomers (47–67 years) knew of the curability of HCV infection

Lambers et al. (2013)Footnote 17
Netherlands

Observational study
HIV-positive and
HIV-negative MSM
(n=539)
Various (recruitment campaigns, media, word of mouth)

Self-administered questionnaire (paper)

Awareness

  • 74.1% of respondents were aware that HCV can be transmitted during sex between men; 47.2% were aware that HIV-positive men are more likely to report HCV sexual transmission
  • 57.5% were aware that there is treatment for HCV; 35.6% were aware that HCV treatment could cure the infection
  • 23.0% were aware of spontaneous clearance of HCV without treatment

Knowledge

  • Participants had the highest knowledge scores for HCV transmission and HIV/HCV coinfection
  • Participants had lowest scores for natural history of HCV, testing and prevention, and treatment

Lea et al. (2016)Footnote 18
Australia

Cross-sectional study
MSM (n=405)
Various (social media advertisements, community organization websites)

Self-administered questionnaire (online)

Awareness

  • 70% of HIV-negative and 80% of HIV-positive MSM were aware of HCV
  • More than half of HIV-negative (55%) and HIV-positive MSM (63%) were aware of the existence of HCV treatment

Knowledge

  • 31% knew that HCV could lead to liver cancer
  • 37% believed that HCV could lead to liver failure

Owiti et al. (2015)Footnote 19
Australia, Canada, Mexico, the Netherlands, US

Systematic narrative review
Predominantly Asian immigrants
(n=51)a
(Setting unknown: information not available)

Information not available

Knowledge

  • There were misconceptions regarding the different types of hepatitis (A, B, C)
  • There was uncertainty around the natural history of hepatitis (e.g., liver damage) and confusion about cause (hormones, stress)
  • One of the studies reviewed reported lack of knowledge of effective HCV treatment
  • There was low level of knowledge of main transmission risk factors, especially sexual contact (horizontal transmission) and childbirth (vertical transmission)
  • Cause and transmission were incorrectly attributed principally to lifestyle activities and cultural practices around food

Pundhir et al. (2016)Footnote 20
US

Cross-sectional study
Patients (≥18 years) with HCV infection and with or without HIV coinfection (n=292)
Primary care clinic

Self-administered questionnaire (online and paper)

Knowledge

  • Respondents believed that if their doctor does not talk about hepatitis C, it must not be important to treat
  • Respondents perceived long wait times to see a specialist for treatment as indicating that it was not important to treat
  • HCV knowledge was not associated with appointment-keeping behaviour

Rashrash et al. (2016)Footnote 21
US

Cross-sectional study
African-American baby boomers (b. 1945–1965) (n=137)
Hospital and wellness centre

Cross-sectional survey using audio computer-assisted self-interviewing

Knowledge

  • The average knowledge score was low (48.7%).
    • Areas of high knowledge:
    • 66.4% correctly identified that HCV can be transmitted via blood
    • 81.8% correctly identified that HCV can be transmitted through needle sharing
  • Areas of low knowledge:
    • 45.3% correctly identified that HCV does not affect the bladder
    • 21.2% correctly identified that HCV could not be transmitted via saliva
    • 12.4% correctly identified that there was a vaccine available
>Health care providers (n=6)

Bianco et al. (2013)Footnote 22
Italy

Cross-sectional study
Nurses (n=326)
Hemodialysis units

Self-administered questionnaire

Knowledge

  • 49.8% correctly identified all modes of HCV transmission
  • Most nurses correctly identified the following certain transmission routes: receiving blood transfusion from an infected donor (93.9%); having sex with an HCV-positive partner (91.4%); and sharing needles while injecting drugs (90.7%)
  • 11.5% believed that HCV could be transmitted through kissing
  • 19.2% did not indicate that getting a tattoo was a mode of transmission
  • 21.4% incorrectly believed that avoiding breastfeeding can reduce the risk of HCV transmission
  • 70.8% believed that HCV could be spread via patient-to-patient contact

Ipsos (2012)Footnote 16
Canada

Cross-sectional study
GPs/Family practitioners
(n=300)
(Setting unknown: information not available)

Information not available

Knowledge

  • 96% of GPs agreed that many HCV-infected people are not aware of their infection
  • 35% of GPs know a lot about symptoms associated with HCV infection
  • 10% of GPs know a lot about available treatments
  • 43% correctly identified that hepatitis C is curable; 22% were unsure

McGowan et al. (2013)Footnote 23
Canada, Central/Eastern Europe, Latin America, Western Europe, Nordic countries, Asian/Pacific countries, Middle East/Africa, US

Cross-sectional study
Physicians providing HCV treatment
(n=697)
International market research database

Phone interview or self-administered online questionnaire

Knowledge

  • Overall, a greater proportion of hepatologists knew about HCV treatment than GPs
  • Most physicians understood that different genotypes require different treatment durations
  • Most physicians understood that treatment should be discontinued in patients who fail to achieve an early virologic response
  • The majority of physicians incorrectly believed that HCV RNA levels correlate with liver disease severity
  • The majority of physicians also incorrectly believed that non-responders should receive maintenance therapy
  • 40% of providers believed that they have adequate knowledge of treatment guidelines

Naghdi et al. (2017)Footnote 24
Canada

Cross-sectional study
Primary care physicians, specialists, hepatology nurses and nurse practitioners (n=163)
Convenience sample through provider organizations

Self-administered questionnaire (online)

Knowledge

  • 78% of primary care physicians were not comfortable initiating hepatitis C therapy
  • 70% of primary care physicians expressed discomfort about switching patients from one therapy to another
  • Compared with primary care physicians, hepatologists, gastroenterologists, hepatology nurses and nurse practitioners expressed greater comfort in monitoring patients’ current therapy
  • 22% of primary care physicians had low awareness of current coverage for HCV treatment

Rotte et al. (2013)Footnote 25
US

Observational study
Residents, physicians, nurse practitioners, physician assistants (n=78)
Emergency departments

Self-administered questionnaire (online)

Knowledge

  • Knowledge of HCV consequences was high (percentage not provided)
  • 81% were unaware of medications that can cure HCV are available
  • 58% were aware of the CDC HCV-related guidelines
  • 42% were worried about contracting HCV while working in the emergency department
  • 67% were more worried about contracting HCV from a needle-stick injury than HBV or HIV
  • 71% agreed that rapid HCV testing would be beneficial to their patients
  • 40% denied that health care providers with HCV could transmit HCV to a patient

Todorova et al. (2015)Footnote 26
Bulgaria

Cross-sectional study
Dental medicine students (n=96)
Faculty of Dental Medicine, Medical University of Varna, Bulgaria

Self-administered questionnaire

Knowledge

  • 41.6% had a good knowledge of HBV/HCV (score of 8/10)
  • Aware of possible routes of transmission:
    • 90.6% knew about broken skin or blood transmission
    • 62.5% knew about broken skin or saliva
    • 87.5% knew about needle injury
  • Intact skin in contact with saliva (87.5%) and intact skin in contact with intact skin (90.6%) were correctly considered as not dangerous for HBV/HCV transmission and respectively
  • 80% knew that HBV/HCV carriers may look healthy and not show symptoms

Abbreviations: CDC, Centers for Disease Control and Prevention; HAV, hepatitis A virus; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; Gen, generation; GP, general practitioner; MSM, men who have sex with men; NHANES, National Health and Nutrition Examination Survey; n, number; RNA, ribonucleic acid; US, United States

Annex 1 Footnote a

A number of studies were included in the systematic review

Return to Annex 1 footnote a referrer

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