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

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. Affiliation 1 Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON *Correspondence: shalane.ha@ canada.ca


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 infection (1).Chronic HCV infection is not easy to detect; even when symptoms are present, they are often nonspecific (e.g., fatigue) (2).Chronic HCV infection can lead to cirrhosis or liver cancer.Approximately half a million people die each year from HCV-related liver diseases (3).
In 2011, about 220,000-246,000 individuals were living with chronic HCV infection in Canada and approximately 44% were unaware of their infection (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 Suggested citation: Ha S, Timmerman K. Awareness and knowledge of hepatitis C among healthcare 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 Canada has started to witness a decrease in hospitalizations associated with HCV infection and chronic liver disease (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 2030 (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 treated (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 testing (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.

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,

SCOPING REVIEW
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).

Awareness
There were six studies on awareness of hepatitis C (11,12,14,17,18,24).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 public (11,12,14,17), one on awareness of HCV by MSM (18) and one on awareness of treatment by Canadian health care providers (24).
Two studies found that the general public had some awareness (defined as the knowledge that something exists) of hepatitis C (11,17).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%) (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 infection (12).Two studies found that the general public was not clear about the differences between hepatitis A, B and C (11,19).

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 HCV (16,25,26).In a convenience study of Canadian physicians, 35% reported "knowing a lot" about symptoms associated with HCV (16).In a small study of dental students from Bulgaria, 80% reported knowing that infection with hepatitis B virus (HBV) or HCV may be asymptomatic (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) (25).
Eight studies included information on the public's knowledge about the natural history of HCV (8,9,11,13,14,16,17,19). Two Canadian studies found that 83-90% of participants knew that people with HCV could be unaware of an existing infection (14,16).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 symptoms (8).One study reported that one-third of MSM knew that HCV infection could lead to liver cancer (31%) and liver failure (37%) (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 infection (19).

Knowledge of transmission
Two studies reported on health care providers' knowledge of HCV transmission (22,26).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 drugs (22,26).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 transmission (22).
Ten studies reported information on knowledge of HCV transmission among the general public (8,(10)(11)(12)(14)(15)(16)(17)19,21).One Canadian study reported that the most frequently known HCV transmission routes were blood transfusions, unsafe/ unprotected intercourse and injection drug use/sharing of needles (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%) (14).Furthermore, approximately 54-62% of the general population in Canada knew that HCV is transmitted mainly through blood-to- Abbreviations: HCV, hepatitis C virus; HIV, human immunodeficiency virus a Some studies included more than one population or country blood contact (16).In four studies, a small percentage of the general public indicated that HCV can be transmitted through kissing or casual contact (8,12,14,21).

Knowledge of treatment
Two recent studies, published after the new interferon-free DAA therapies became available, focused on knowledge of the curability of HCV (8,24).
Among health care providers, specialists (i.e., hepatologists, gastroenterologists, hepatology nurses) scored higher on knowledge statements about HCV treatment than general practitioners (GPs) (23,24).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 action (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 HCV (8).However, three studies detected a misconception among the general public about the availability of a vaccine to prevent HCV (11,15,21).About one half of the Canadians interviewed (50%) in one study believed there was a vaccine to prevent HCV (14).
In two US studies, 42% of American baby boomers and 60% of African-American baby boomers believed there was a vaccine to prevent HCV (8,11).
A summary of the findings is shown in Table 2.

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 physicians (23,24).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.

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%)

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 -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)

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

Figure 1 :
Figure 1: Flowchart of study selection process

Table 1 :
Summary of included studies 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.

Table 2 :
Summary of findings on awareness and knowledge of hepatitis C virus among health care professionals and the general public Abbreviations: DAA, direct acting antivirals; HCV, hepatitis C virus; MSM, men who have sex with men Appendix 1: Description of included studies (n=19) 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 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 a A number of studies were included in the systematic review