Hepatitis B-related knowledge and vaccination in association with discrimination against Hepatitis B in rural China

Abstract

Hepatitis B virus (HBV) remains a challenging public-health issue in China. Hepatitis B carriers and patients suffer not only physically but also experience strong discrimination and stigma. China's rural population is 629 million. Thus, there is a great need to understand the situation surrounding HBV-related discrimination in everyday life in rural China. We studied 6,538 participants (≥18 y old) from 42 villages across 7 provinces (districts). Many studies have addressed discrimination against those with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). However, few studies have addressed HBV-related discrimination. We found that the fear of HBV infection, not lack of knowledge about it, predominantly leads to HBV-related discrimination (although limited knowledge is also a cause). Notably, receiving the HBV vaccination contributes to reduced discrimination. In addition, the existence of fewer misunderstandings about false HBV transmission routes plays a more important role in discrimination than does understanding of true HBV transmission routes. Therefore, to reduce HBV-related discrimination, policy makers should consider eliminating HBV-related fear, strengthening adult HBV immunization programs, developing large-scale education dissemination about HBV transmission routes and non-transmission routes, and paying greater attention to target populations.

Introduction

Hepatitis B virus (HBV) infection is one of the most serious and prevalent diseases, affecting more than 2 billion people globally.¹ In China, hepatitis B remains a particularly challenging public health issue.² In 2006, the rate of hepatitis B surface antigen (HBsAg)in the Chinese population (aged 1–59 years) was 7.2%, and it is estimated that 93 million people in China are HBV carriers.³ HBV carriers and hepatitis B patients suffer not only physical injury but also experience significant discrimination and stigma. Perceived discrimination negatively impacts individuals' self-identity and quality of life.⁴

Historically, HBV carriers have experienced discrimination when applying for jobs or educational opportunities. Although some companies and schools still require HBV test results,⁵ marked changes have taken place since the Chinese government developed policies banning HBV checkups as a condition for employment and school enrollment. However, there are no indications that HBV-related discrimination in everyday life has lessened. Hepatitis B patients and HBV carriers still experience hardship and feelings of isolation. China's rural population of 629,610,000⁶ is more vulnerable to experiencing lower socioeconomic status and education, among other issues, compared with those living in more urban areas. If serious discrimination against hepatitis B patients existed in rural China, then both patients and HBV carriers would endure even greater hardship. Thus, there is a great need to assess the climate of hepatitis B- and HBV-related discrimination in everyday life among the rural Chinese population. In addition, understanding potential influencing factors is necessary for developing strategies to reduce discrimination.

We defined discrimination against hepatitis B patients and HBV carriers (referred to here as HBV-related discrimination) as (1) negatively judging and unfairly treating hepatitis B patients or HBV carriers and (2) such judgment and treatment being a result of the patients' or carriers' HBV infection status. We generally divide HBV-related discrimination into 2 general types: discrimination in an employment or school enrollment situation and discrimination in everyday life by strangers, neighbors, co-workers, friends or family, and more distant relatives. In this study, we focused only on HBV-related discrimination in everyday life.

The World Health Organization and partners created World Hepatitis Day in 2014 with the theme “Hepatitis, think again.”⁷ To some extent, HBV-related discrimination has become worse than the disease itself. To avoid being labeled a ‘hepatitis B patient’ or ‘carrier,’ individuals usually attempt to hide their infection status, and HBV-related discrimination has become a barrier to regular screening, diagnosis, and treatment.^8,9 Thus, HBV-related discrimination does not effectively protect a vulnerable population from HBV infection, and it might indirectly lead to further spread of HBV infection. It is time to think carefully about HBV-related discrimination.

Although many studies have addressed HIV- or HCV-related discrimination,^10-15 studies on HBV-related discrimination are rare. Even rarer are studies that have assessed factors that contribute to HBV-related discrimination in everyday life. Nearly all studies have presumed that a lack of knowledge about hepatitis B and HBV are the major reasons for HBV-related discrimination.^5,16,17 However, a recent study in China examined HBV-related discrimination in school enrollment and found that fear of infection was the main cause of discrimination.¹⁸ Therefore, this study's primary goal is to explore the factors that contribute to HBV-related discrimination. Vaccines are one of the most useful public health interventions for combating infectious diseases,¹⁹ and the hepatitis B vaccine is the most effective prevention for HBV infection.²⁰ As such, we also sought to assess whether people who had received the hepatitis B vaccination might exhibit lower levels of HBV-related discrimination.

Policy makers need evidence on the effectiveness of interventions, but no study has empirically and quantitatively tested the reasons for HBV-related discrimination. With the intent of providing a clearer picture, we sought to quantitatively assess the HBV-related discrimination situation in rural China, to determine whether lack of knowledge is the key influencing factor and to identify additional factors that may affect the prevalence of HBV-related discrimination.

Results

Figure 1 summarizes the participants' attitudes toward hepatitis B patients and carriers. Of all the participants, only 32.53%, 38.45%, and 27.13% were willing to accept gifts from hepatitis B patients or carriers, hug and shake hands with them, or have dinner with them, respectively. What is more serious is that only 21.63% of the participants thought parents should let their children play with hepatitis B-infected children, and only 7.28% thought parents should allow their children to marry hepatitis B patients or carriers.

Figure 1.

Attitude toward hepatitis B patients and carriers.

Table 2 shows the HBV-related discrimination distribution. The median score was 8, and only 4.79% had no sign of HBV-related discrimination. However, 36.17% scored at the highest level, indicating that they were firmly unwilling to make contact with hepatitis B patients or carriers. According to their HBV-related discrimination index scores, the participants were divided into 3 groups. Table 3 shows the group-based HBV-related distribution, with 57.51% of participants in the severe discrimination group. Table 4 shows the characteristics of the 3 HBV-related discrimination groups.

Table 2.

Hepatitis B discrimination index score

Score	Freq.	Percent	Cum.
0	313	4.79	4.79
1	233	3.56	8.53
2	511	7.82	16.17
3	191	2.92	19.09
4	526	8.05	27.13
5	458	7.01	34.14
6	546	8.35	42.49
7	400	6.12	48.61
8	630	9.64	58.24
9	365	5.58	63.83
10	2365	36.17	100.00
Total	6538	100.00	100.00

Table 3.

Hepatitis B discrimination level

Discrimination Level	Freq.	Percent	Cum.
Mild or without discrimination	1248	19.09	19.09
Medium discrimination	1530	23.40	42.49
Severe discrimination	3760	57.51	100.00
Total	6538	100.00	100.00

Table 4.

Hepatitis B discrimination level of participants with different characteristics (N = 6538)

	Mild/without		Medium		Severe
Variable	n	%	n	%	n	%
Male	561	21.73	609	23.59	1412	54.69
Female	687	17.37	921	23.28	2348	59.35
Age 18–28	242	24.42	300	30.27	449	45.31
Age 28–38	334	24.58	376	27.67	649	47.76
Age 38–48	295	17.45	380	22.47	1016	60.08
Age 48–58	208	16.07	264	20.40	822	63.52
Age 58-	169	14.05	210	17.46	824	68.50
Low education	474	17.34	527	19.28	1732	63.37
Medium education	502	17.50	739	25.77	1627	56.73
High education	272	29.03	264	28.18	401	42.80
Farmer	724	16.83	937	21.78	2641	61.39
Unemployed	89	20.00	108	24.27	248	55.73
Migratory workers	186	21.11	231	26.22	464	52.67
Other occupation	191	25.30	210	27.81	354	46.89
Public officers	58	37.42	44	28.39	53	34.19
Without vaccination history	937	17.70	1184	22.36	3174	59.94
Received vaccination	311	25.02	346	27.84	586	47.14
Household income group 1	150	16.69	197	21.91	552	61.40
Household income group 2	287	20.28	331	23.39	797	56.33
Household income group 3	280	17.85	358	22.82	931	59.34
Household income group 4	294	18.89	371	23.84	891	57.26
Household income group 5	237	21.57	273	24.84	589	53.59
Knowledge of true transm. route 1	392	19.43	406	20.13	1219	60.44
Knowledge of true transm. route 2	499	20.38	637	26.01	1313	53.61
Knowledge of true transm. route 3	357	17.23	487	23.50	1228	59.27
Knowledge of false transm. route 1	241	12.51	407	21.12	1279	66.37
Knowledge of false transm. route 2	499	20.62	635	26.24	1286	53.14
Knowledge of false transm. route 3	508	23.19	488	22.27	1195	54.54
Knowledge of true symptoms 1	742	19.47	830	21.78	2239	58.75
Knowledge of true symptoms 2	302	17.74	472	27.73	928	54.52
Knowledge of true symptoms 3	204	19.90	228	22.24	593	57.85
No fear of being infected with HBV	1059	32.22	1022	31.09	1206	36.69
Fear of being infected with HBV	189	5.81	508	15.63	2554	78.56

The HBV vaccination coverage rate varied across age groups: 18–28 y (45.9%, n = 991), 28–38 (26.3%, n = 1359), 38–48 (15.1%, n = 1691), 48–58 (9.4%, n = 1294), and 58+ (4.4%, n = 1203). For the 2 youngest age groups, the mean discrimination score was lower for vaccinated than for unvaccinated individuals. For the age group of 18–28 years, the mean discrimination scores were 5.59 and 6.38 for the vaccinated and unvaccinated, respectively (p = 0.000). For the age group of 28–38 years, the scores were 5.57 and 6.32 (p = 0.000). For the 3 older age groups, and at conventional significance levels, the means were not different, and Mann Whitney U tests did not indicate that the distribution of discrimination scores differed between the vaccinated and unvaccinated. The joint mean discrimination scores were 6.91 (SE = 0.0776), 7.17 (SE = 0.0897) and 7.49 (SE = 0.0907) for the age groups 38–48, 48–58 and 58+, respectively.

The univariate multinomial logistic regression analysis of HBV-based discrimination and “knowledge of hepatitis B symptoms” levels was not statistically significant and was eliminated when running the multiple multinomial logistic regression analysis. Table 5 shows the results of the multiple multinomial logistic regression of HBV-based discrimination levels against explanatory factors. The results for the outcomes of medium discrimination and severe discrimination were related to the basis outcome, mild discrimination or no discrimination. For the medium discrimination outcome, several estimated coefficients and relative risk ratios (RRR) were statistically significant. For the severe discrimination outcome, nearly all estimated coefficients and RRR were statistically significant, except for household income. To simplify the discussion, we will focus mainly on the results of the severe discrimination outcome.

Table 5.

Multiple polychotomous logistic regression of Hepatitis B discrimination level against explanatory factors (N=6538)

	Medium discrimination				Severe discrimination
	Coef.	SE	RRR	P	Coef.	SE	RRR	P
Female	0.180	0.083	1.197	0.030	0.214	0.078	1.239	0.006
Age 28–38	−0.156	0.120	0.855	0.192	−0.136	0.121	0.873	0.260
Age 38–48	−0.033	0.125	0.968	0.793	0.397	0.122	1.488	0.001
Age 48–58	0.004	0.138	1.004	0.978	0.551	0.132	1.734	0.000
Age 58–	0.080	0.154	1.083	0.603	0.862	0.145	2.369	0.000
Medium education	0.337	0.092	1.400	0.000	0.163	0.086	1.178	0.056
High education	0.017	0.126	1.018	0.890	−0.397	0.122	0.672	0.001
Unemployed	−0.110	0.159	0.896	0.488	−0.295	0.151	0.744	0.050
Migratory workers	−0.002	0.117	0.998	0.986	−0.092	0.112	0.912	0.411
Other occupations	−0.054	0.124	0.947	0.661	−0.232	0.121	0.793	0.056
Public officers	−0.307	0.226	0.735	0.174	−0.790	0.236	0.454	0.001
Received vaccination	−0.114	0.100	0.893	0.256	−0.232	0.098	0.793	0.018
Household income group 2	−0.186	0.139	0.830	0.183	−0.166	0.130	0.847	0.203
Household income group 3	−0.085	0.141	0.919	0.548	0.081	0.132	1.085	0.537
Household income group 4	−0.091	0.142	0.913	0.520	0.049	0.134	1.050	0.714
Household income group 5	−0.170	0.152	0.844	0.265	−0.041	0.144	0.960	0.776
Knowledge of true transm. route 2	0.091	0.097	1.096	0.345	−0.319	0.091	0.727	0.000
Knowledge of true transm. route 3	0.095	0.109	1.100	0.382	−0.181	0.102	0.834	0.076
Knowledge of false transm. route 2	−0.255	0.104	0.775	0.014	−0.687	0.099	0.503	0.000
Knowledge of false transm. route 3	−0.560	0.112	0.571	0.000	−0.989	0.105	0.372	0.000
Fear of being infected	1.030	0.097	2.801	0.000	2.462	0.088	11.727	0.000

The basis outcome is mild or without discrimination.

Discussion

It is clear that hepatitis B patients and carriers need more social support and care. Instead, they suffer from HBV-related discrimination and live difficult lives. These results show that HBV-related discrimination in rural China is widespread. This issue should not be underestimated or ignored.

We found that females had higher discrimination scores. This finding was inconsistent with a previous study in Japan showing that gender was unassociated with prejudice toward HIV-, HBV-, or HCV-infected colleagues.²¹

In the current study, our hypothesis was that income was associated with HBV-related discrimination, but the results were in striking contrast to the hypothesis. Participants' discrimination levels did not significantly differ based on income. This was consistent with the findings of the Japanese study.² However, that study used individual income, whereas we used household income.

Our findings suggested that old age was positively associated with severe HBV-related discrimination. Compared with those aged 18–28 y old, participants aged 38–48, 48–58, and 58+ years old showed more severe discrimination with increasing RRR (1.488, 1.734, and 2.369, respectively). This is contrary to the finding that older age was associated with decreased prejudice toward HBV- or HCV-infected colleagues in the Japanese study.²¹

We found that individuals with higher education tended to have less severe discrimination compared with those with less education (the reference education group), and the severe discrimination rate of those with a medium education level did not differ from that of the low education group. No previous study has assessed the influence of education on HBV-related discrimination, although a study in China showed that providers with higher medical education tended to show higher levels of discrimination against those with HIV.²²

We also determined that occupation affected the level of HBV-related discrimination. Public officers (e.g., civil servants, village doctors, or teachers) were less likely to exhibit severe HBV-related discrimination compared with farmers. However, although village doctors had lower levels of HBV-related discrimination, discrimination was extensively present in this group. Of the 43 village doctors in our sample, only 4 doctors (9.30%) reported having no HBV-related discrimination, whereas 15 doctors (34.88%) reported severe discrimination. Ten (23.26%) of them were afraid of being infected with HBV. According to a study of medical students, positive correlations exist between greater knowledge and positive attitude toward hepatitis B.²³ This is consistent with our finding that village doctors' knowledge of hepatitis B and HBV was limited: only 23 (53.49%) had the highest knowledge of HBV transmission routes, and only 20 (46.51%) knew that mosquito or insect bites and having dinner with patients or carriers cannot lead to HBV transmission. Village doctors play a very important role in disseminating health-related knowledge and promoting health outcomes in rural China. Our results indicate that equipping village doctors with knowledge about hepatitis B and HBV through the provision of in-depth training is of great urgency and importance. A study in China has shown that adequate training is effective in improving Chinese village doctors' hepatitis B-related knowledge. ²⁴

Receiving a vaccination was related to reduced HBV-related discrimination scores, suggesting that HBV vaccination not only effectively protects vulnerable people from HBV infection,^25,26 it also reduces their levels of HBV-related discrimination. This circumstance probably occurs because individuals feel a stronger sense of security because they are not as vulnerable to HBV. Our study also found that older age was positively associated with more severe discrimination and that the HBV vaccination coverage rate decreased with advancing age. Therefore, treating older people as a key population, including encouraging older people to receive the HBV vaccination, is expected to help reduce HBV-related discrimination. Based on a previous study, the hepatitis B vaccination coverage rate among rural-dwelling Chinese adults is 20.8% (those who have received at least one dose), and higher rates are obtainable by reducing the related economic burden of the vaccination.²⁷

A 2013 study indicated that the level of HBV awareness is low in rural Chinese populations.²⁸ In addition, some studies have noted that ignorance about HBV, especially misunderstandings about its transmission routes, is the main cause of discrimination.^5,16 Similarly, our study shows that increasing knowledge about false transmission routes may greatly reduce the probability of severe HBV-related discrimination. However, in our study, the level of discrimination was not associated with knowledge about true transmission routes. Only medium-level knowledge about true routes was statistically significant compared with the low-knowledge group. However, the group with high-level knowledge about the true routes of transmission was not significantly different from the low-level knowledge group. In addition, there was a large gap between the RRRs (0.503, 0.372) for knowledge of false transmission routes and the RRR (0.727) of the true transmission routes, suggesting that correcting individuals' misunderstandings of false transmission routes is more helpful than emphasizing information about true transmission routes. This study also revealed that the variable “knowledge of hepatitis B symptoms” had no relation to HBV-related discrimination. Mother-to-child transmission is the leading cause of HBV infection in China.²⁹ We suggest that informing people that a significant proportion of infection is accounted for by mother-to-child transmission. This perspective might be helpful in reducing HBV-related discrimination.

Very few studies have tested the association between the “fear of being infected with HBV” and HBV-related discrimination. A qualitative study in China showed that the fear of HBV infection risk was the primary cause of HBV-related discrimination.¹⁸ In our quantitative study, the coefficient of the “fear of being infected with HBV” was 2.462, and its RRR relative to the reference group of “no fear of being infected” was as high as 11.727. Thus, it is clear that the “fear of being infected with HBV” was the most important cause of HBV-related discrimination in our study. However, this finding is inconsistent with most previous qualitative studies that have shown that discrimination stems from ignorance about HBV and the way it is transmitted. Further, although our findings suggest that the fear of infection greatly contributes to severe discrimination levels, we did not conduct an in-depth assessment of the origins of that fear. We discuss this issue in detail in the paragraph on limitations.

In conclusion, our findings suggest that HBV-related discrimination in rural China is serious, and this discrimination involves several associated factors. The fear of HBV infection is the main factor associated with HBV-related discrimination, not a lack of related knowledge, although the latter was also a factor to a lesser degree. Notably, receiving the HBV vaccination is associated with less discrimination, and misunderstandings involving false HBV transmission routes plays a more important role than an understanding of true HBV transmission routes. In addition, older adults and those with less education are more likely to exhibit severe discrimination against hepatitis B patients and carriers. Public officers harbor less HBV-related discrimination. Therefore, to accelerate the control of HBV-related discrimination, policy makers should consider eliminating HBV-related fear, strengthening adult HBV immunization programs, developing large-scale dissemination of knowledge about true and false HBV transmission routes, and paying more attention to the key discriminating populations. It also should be noted that the dissemination of knowledge must start with training village doctors. A future in-depth study is planned to examine whether the fear of HBV infection is exaggerated and the factors that cause this fear and will be implemented in the near future.

Although this study is of great significance, due to both the topic and our use of quantitative methods, it is not without potential limitations. First, the measurement of HBV-related discrimination in the real world includes, but is not limited to, people's attitudes toward the 5 items assessed in our questionnaire. For example, we can also speculate that people may tend toward HBV-related discrimination if they are unwilling to work with a colleague who is a hepatitis B patient or carrier. Second, we did not include all possible true or false transmission routes, so the variables “knowledge of true transmission routes” and “knowledge of false transmission routes” may be over- or underestimated. Third and most important is that we simply asked participants whether they feared being infected with HBV when spending time with hepatitis B patients or carriers; we did not assess the factors that may lead to their fear of infection. Are they afraid because there is no cure for HBV? Are they afraid because most are risk averse despite the extremely small risk of infection? Does this fear originate from their sense of responsibility for caring for themselves and their loved ones? Perhaps the fear stems from something else, such as the unique Chinese public opinion environment, social–cognitive factors, or the disease-related economic burden. Clearly, further studies are needed to evaluate the origins of this fear.

Participants and Methods

Study participants and sampling method

The study participants were from 42 villages across 7 provinces with notable regional, economic, and epidemiological diversity: Beijing, Hebei, Shandong, Heilongjiang, Hainan, Ningxia, and Jiangsu. The participant characteristics are shown in detail in Table 1, and all independent variables are explained below. We stratified the counties by the level of economic development (low, medium, high) and then stratified the villages within counties by the distance to hepatitis B vaccination sites (short, medium, long). In larger villages, households were randomly extracted by using household size to create weighted sampling (probability proportionate to size). All households in small villages were sampled. The participation rate was approximately 82%, and the predominant reason for nonparticipation was that all household members had moved to industrialized regions.²⁷ The sample consisted of 32,311 individuals (all ages included) from 8,637 households. After excluding the records that were from a family member on behalf of the intended participant due to their absence, the final sample was 6,538 adults (age ≥18 years). Juveniles were not included on the basis that they have not developed stable opinions. We used a self-designed interview questionnaire with questions about individual and household characteristics, attitudes toward hepatitis B patients and carriers, knowledge about hepatitis B and HBV, and individual vaccination history. Well-trained staff administered the interviews after a pilot survey.

Table 1.

Descriptive statistics for independent variables (N=6538)

Variable	Variable definition	n	%
Male	1 if male; 0 otherwise	2582	39.49
Female	1 if female; 0 otherwise	3956	60.51
Age 18–28	1 if aged 18–28; 0 otherwise	991	15.16
Age 28–38	1 if aged 28–38; 0 otherwise	1359	20.79
Age 38–48	1 if aged 38–48; 0 otherwise	1691	25.86
Age 48–58	1 if aged 48–58; 0 otherwise	1294	19.79
Age 58-	1 if aged 58-; 0 otherwise	1203	18.40
Low education	1 if years of schooling<=6 years; 0 otherwise	2733	41.80
Medium education	1 if 6< years of schooling<=9 years; 0 otherwise	2868	43.87
High education	1 if years of schooling>9years; 0 otherwise	937	14.33
Farmer	1 if farmer; 0 otherwise	4302	65.80
Unemployed	1 if unemployed; 0 otherwise	445	6.81
Migratory workers	1 if migratory workers; 0 otherwise	881	13.48
Public officers	1 if public civil servants, doctors or teachers; 0 otherwise	155	2.37
Other occupations	1 if not farmer, unemployed, migratory workers, or public officers;	755	11.55
Without vaccination history	1 if received 0 dose of HBV vaccine; 0 otherwise	5295	80.99
Received vaccination	1 if received at least 1 dose of HBV vaccine; 0 otherwise	1243	19.01
Household income group 1	1 if household income in the bottom quintile; 0 otherwise	899	13.75
Household income group 2	1 if household income in the second lowest quintile; 0 otherwise	1415	21.64
Household income group 3	1 if household income in the middle quintile; 0 otherwise	1569	24.00
Household income group 4	1 if household income in the second lowest quintile; 0 otherwise	1556	23.80
Household income group 5	1 if household income in the top quintile; 0 otherwise	1099	16.81
Knowledge of true transm. route 1	1 if identify 0/1 true route of transmission; 0 otherwise	2017	30.85
Knowledge of true transm. route 2	1 if identify 2/3 true route of transmission; 0 otherwise	2449	37.46
Knowledge of true transm. route 3	1 if identify 4/5 true route of transmission; 0 otherwise	2072	31.69
Knowledge of false transm. route 1	1 if identify 0 false route of transmission; 0 otherwise	1927	29.47
Knowledge of false transm. route 2	1 if identify 1 false route of transmission; 0 otherwise	2420	37.01
Knowledge of false transm. route 3	1 if identify 2 false routes of transmission; 0 otherwise	2191	33.51
Knowledge of true symptoms 1	1 if identify 0/1/2 true symptoms; 0 otherwise	3811	58.29
Knowledge of true symptoms 2	1 if identify 3/4 true symptoms; 0 otherwise	1702	26.03
Knowledge of true symptoms 3	1 if identify >=5 true symptoms; 0 otherwise	1025	15.68
No fear of being infected with HBV	1 if no fear of being infected; 0 otherwise	3287	50.28
Fear of being infected with HBV	1 if fear of being infected; 0 otherwise	3251	49.72

Definition and measurement of dependent variables

The dependent variable, HBV-related discrimination level, is categorical with 3 outcomes: mild or without discrimination, medium discrimination, and severe discrimination. Specifically, participants were asked about their attitudes toward 5 events, which were used to measure the extent of their HBV-related discrimination. The five events were the following: “Are you willing to accept gifts from hepatitis B patients or carriers?;” “Are you willing to have dinner with them?;” “Are you willing to shake hands with or hug them?;” “Do you think parents should let their children play with hepatitis B-infected children?;” and “Do you think parents should accept their child marrying a hepatitis B-infected person?.” For each event, participants were offered 3 options: “yes” (0), “no” (2) and “it depends” (1). We calculated an HBV-related discrimination index score for each participant as the sum of their response scores for the 5 events (range 0–10). Higher scores indicated greater discrimination. Participants were then categorized in one of 3 HBV-related discrimination levels based on their HBV-related discrimination index score: mild or without discrimination level (scores 0–3), medium discrimination level (scores 4–6), and severe discrimination level (scores 7–10).

Definition and measurement of independent variables

Table 1 presents descriptive statistics for all independent variables. We divided participants into 2 groups based on vaccination status: those who had never received the HBV vaccine were in the “without vaccination history” group, and those who had received one or more doses of the HBV vaccine were in the “received vaccination” group.

Household income was the average annual income of all household members during the past 5 y Five groups were created based on the household's relative position to the quintiles of the household income distribution. The quintiles were 10,000, 20,000, 30,000 and 40,000. Because there were many individuals whose household income was exactly equal to the cut-off points, the sample proportion belonging to each household income group differs from 20%.

Participants were asked to identify the 5 true HBV transmission routes: mother to child, unclean medical or dental equipment, unprotected sex, unhygienic tattooing or ear-piercing, and sharing shaving equipment with an infected person. We counted the number of true transmission routes identified by each participant, and the variable “knowledge of true transmission routes” was divided into 3 levels according to the identified number. Specifically, participants who identified 0–1 true transmission routes belonged to group 1; those who identified 2–3 were in group 2; and those who identified 4–5 were in group 3.

Participants were also asked whether they endorsed either of 2 false transmission routes: whether eating with HBV patients or carriers is an HBV transmission route and whether mosquito or insect bites might lead to HBV infection. These constituted the variable “knowledge of false transmission routes” (range 0–2).

Participants were also asked to identify hepatitis B symptoms. Nine true symptoms were listed (e.g.,, jaundice, yellow urine, fever). The number of true symptoms identified was used to create the variable “knowledge of true symptoms” with 3 levels according to the identified number.

The participants were asked to explain whether they felt fearful and worried about being infected with HBV while spending time with hepatitis B patients and carriers. Two groups were created: “fear of being infected with HBV” and “no fear of being infected with HBV.”

Statistical analyses

All data were double-inputted using Microsoft Access and checked for consistency. Statistical analyses were performed using STATA 12.0. Multinomial logistic regression analyses were used to assess the associations between each independent variable and HBV-related discrimination level. A two-tailed p value of 0.05 was considered statistically significant.

Ethics

Participants were informed that they could refuse to answer any question. The questionnaire did not ask about infection status, and no biological samples were collected. The project was approved by the Medical Ethics Committee at the Shandong University School of Medicine (Grant No. 201001052).

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

Acknowledgments

The authors thank the health workers in all the participating provinces for their support and assistance.

Funding

This work was supported by the Norwegian Research Council (Project no. 196400/S50).