Table 2. Factors underpinning stigma in HBV infection, identified from a systematic literature review.

Factor underpinning stigma	Evidence from systematic literature review
Cultural understanding and relevant language	•   Lack of common cultural understanding of HBV is indicated by an absence of any word in local languages to define HBV 31, 41 and missing terms ‘hepatitis B’ and ‘carcinoma’ from English vocabulary in migrant populations 29, 41;     •   There is confusion between HBV and other infections, including malaria, yellow fever and HIV 31, 32; HBV may be seen as synonymous with ‘jaundice’ 29, 41, 43, or believed to be associated with nutritional status 41;     •   One study describes the assumption that hepatitis A, B and C infections are ranked by letter in order of severity, or represent the chronological development of a single infection 43.
Knowledge about diagnosis, treatment and symptoms of chronic HBV infection	•   Poor understanding of the chronic nature of HBV infection, and lack of insight into the asymptomatic nature of HBV infection and its complications, are well described 32, 39, 42, 43, 53, 59;     •   There may be an assumption that lack of symptoms correlates with lack of severity 29;     •   Poor awareness of treatment options can be associated with a ‘passive’ or ‘fatalistic’ attitude towards treatment 32, 53;     •   There are misconceptions that HBV screening tests can be harmful and that HBV infection is not treatable 36;     •   A significant correlation is reported between less knowledge and higher stigma scores 34. However, among individuals with HBV infection, higher levels of HBV knowledge can also be associated with being more worried 32, 41, 52;     •   Improved knowledge of HBV infection is associated with higher levels of formal education 39, 52, 59, 61, and with a close relationship with an individual infected with HBV 35.
Beliefs and insights into transmission of HBV infection	•   Beliefs are widespread that HBV can be transmitted through sharing of utensils, via food and water, or eating together 33– 35, 37, 39, 41, 43, 45, 48, 51– 53, 59;     •   There is a belief that smoking tobacco causes HBV 36;     •   Some studies report beliefs that HBV infection arises as a result of poor sanitation 41, 43 or could be transmitted by sharing water for bathing 46;     •   In some communities, HBV infection is regarded as a genetic trait 34, 56;     •   HBV infection is represented as a consequence of immoral behaviour 40, 42– 44, or as a punishment for sins 55;     •   Some communities believe that HBV infection is caused by witchcraft or evil spirits; this can be associated with pursuit of traditional remedies or religious interventions 29– 31;     •   Poor insights into transmission are associated with lack of precautions for prevention of transmission 35, 56;     •   Awareness of injecting drug use and sexual transmission of HBV can be stigmatising 32, 42.
Sociodemographic factors	•   In some studies older age has been associated with increased stigma 45, 48, 61; however, this is not consistent, as older age has also been associated with decreased levels of stigma 47;     •   People strongly defined by traditional values are more likely to stigmtise HBV infection 55;     •   Unemployed individuals from rural areas are more likely to experience discrimination 51, 60;     •   HBV may be more prevalent in disadvantaged groups who are also stigmatised for other reasons, eg refugees 29;     •   Stigma can be reduced by having a family member with HBV infection; in this case it clarifies misconceptions about the disease, humanizes the affected, and can reduce negative attitudes associated with cultural beliefs 34, 35.
Interactions with HCWs	•   Lacking or inaccurate information may be provided by HCWs regarding HBV diagnosis or treatment, including inappropriate reassurance, or overemphasis of potential complications 49, 53;     •   Some studies describe HCWs expressing discrimination or prejudice towards patients and/ or colleagues with HBV infection 46, 58, which may be more common among those who have poor knowledge or are unfamiliar with providing HBV care 49;     •   Diagnosis of HBV infection is presented as ‘bad news’ which can add to anxiety and stigma 53, 56;     •   Lack of screening or vaccination may be associated with stigma 34, although in contrast, HBV-related discrimination is also described as arising in association with diagnostic screening 51.
Emotional responses	•   HBV infection can be associated with anxiety, fear and depression; see Table 3 for further details and references.