Table 3. Evidence for the behavioural, psychological and social impact of HBV infection, identified from a systematic literature review.

Factor with impact on HBV infection	Evidence from systematic literature review
Access to appropriate health care and treatment compliance	•   Stigma is associated with reduced uptake of opportunities for diagnostic screening and clinical care 35, 37, 38, 42, 48, 56, 57;     •   There is a low rate of disclosure of HBV status among individuals with HBV to family, other acquaintances, and to HCWs due to fear of stigma 48, 55;     •   Stigma can lead to disengagement from treatment 49 and reduce treatment adherence 55;     •   Anxiety about treatment, or the cost of treatment (potentially not just for one individual but also for other family members), can lead to reluctance to seek clinical care and follow-up 32, 49, 60;     •   Treatment can be seen as futile 55;     •   Stigma can lead to negative experiences of health care such as being ‘labelled’, placed in physical isolation, or criticised by HCWs 55;     •   Stigma may influence the priorities of health professionals and commissioners, leading to certain health issues being addressed whilst others are ignored 42.
Impact on opportunities for education, work and career development	•   Discrimination is reported within schools 35, 45;     •   HBV affects employment and education choices 48, 60; individuals with HBV infection may be discriminated against at work, lose employment, or be unable to find work 29, 34, 42, 54– 56, 60; they may also be concerned about missing work due to illness 33, and may be restricted from particular jobs (e.g. food preparation) 37, 52;     •   As a result of discrimination in education and the work-place, HBV can prevent personal goals or potential from being fulfilled 55.
Impact on mental health	•   People with HBV infection may fear physical consequences of transmission, disease progression and/or treatment side effects 29, 51, 53, including fear of cancer and death 30, 33, 55, 56;     •   Individuals in migrant populations may fear deportation 32, 38;     •   A range of emotional responses is described, included shock and grief following initial diagnosis, and subsequently anxiety, sadness, denial, anger and aggression 30, 52, 56, 57, 62;     •   Negative self-image can be associated with infection, associated with feelings of disgrace, guilt and shame, humiliation, embarrassment, or inferiority 32, 34, 35, 39, 44, 48, 52, 53, 56;     •   Reactions can also include insomnia and depression 49, 53– 56, 60, and suicidal ideation 42, 54;     •   Anxiety is described in association with the economic cost of treatment 29;     •   A fear of disclosure promotes secrecy and isolation 55, 56, 60, 62.
Impact on personal interactions	•   ‘Fear of contagion’ causes isolation; individuals with infection either avoid or are rejected from social activities, including avoidance of sharing utensils / food / towels / soap 35, 37, 42, 43, 48, 51, 53, 54, 56, 57, 60, and may be banned from participation in sports 55;     •   Parents may be unwilling to allow their children to socialise with HBV-infected children 51, 61;     •   Anxiety about spreading infection to family members leads to withdrawal from close relationships 29, 32, 35, 52, 53, 57; and exclusion from social gatherings 60;     •   Individuals with HBV infection perceive themselves, or are perceived by others, as less desirable as a parent or spouse 33– 35, 45, 48, 54;     •   Partner or spouse refuses sexual intercourse or insists on use of condoms 54;     •   Individuals with HBV infection may seek assistance from traditional healers (THs) or faith leaders, seeking ‘purification’; although this can provide important psychosocial support, there is also the potential for harm and/or delaying presentation to clinical care 30.