Abstract
Background
HBV is a serious threat to society in India as around 1,00,000 people die from HBV every year. However, very few studies from India have evaluated the magnitude of stigma faced by HBV patients. So, there was an unmet need to estimate the HBV-related stigma to design the preventive strategies. Hence, the aim of this study was to quantitatively assess the proportions of stigma and discrimination and factors predicting them among HBV patients.
Methods
A cross-sectional study was conducted from May 2016 to October 2019. A total of 350 HBV patients and 100 healthy respondents were interviewed for knowledge and awareness about HBV and various stigma characteristics.
Results
The mean age of HBV subjects was 45.10 ± 11.70 years, and controls were 36.20 ± 12.27 years; males constituted 60% of HBV subjects and 71% of controls. Negative symptoms such as shame, avoidance, and putting others in danger were felt by 70–90% of HBV patients. Around 60% of HBV patients felt that hepatitis B could be transmitted by sharing utensils thinking that saliva is the mode of transmission. The knowledge about transmission of HBV by sexual intercourse, intravenous drug use, and mother to child was present in 88%, 75%, and 52% of HBV patients and 32%,38%, and 40% of healthy individuals, respectively. Multivariate logistic regression revealed that male gender (AOR-2.38, CI 1.48–3.81, P < 0.01), under matriculates (AOR-2.03, CI 1.22–3.44, P < 0.01) and unemployed (AOR-2.16, CI 1.33–3.53, P < 0.01) were significant independent predictors of significant discrimination.
Conclusion
The magnitude of HBV-related stigma is high in the Indian population, and illiteracy and unemployment were significant predictors of a severe grade of discrimination associated with HBV.
Keywords: HBV, stigma, discrimination, hepatitis
Abbreviations: CHB, Chronic hepatitis B; DS, discrimination score; HBV, Hepatitis B Virus
Hepatitis B Virus (HBV) infection is a major global health problem affecting around 257 million people worldwide.1 Around 50 million people in India are with HBV, which contributes to a major share of global HBV infection. There are a few pockets of higher endemicity noted in tribal populations due to illiteracy, and lack of exposure to health services.2 In India, HBV is predominantly transmitted by horizontal transmission and to a minor extent by perinatal transmission.3 Lack of knowledge about HBV transmission and prevention, excessive fear caused by advertisements creates excessive HBV-related stigma.4, 5, 6 Despite stringent antidiscrimination laws, majority of people infected with HBV experience discrimination in employment, education and daily life.7, 8, 9
Chronic hepatitis B (CHB) patients encounter significant psychological stress caused by discrimination, which may have an obvious effect on the course of their illness. Multiple studies have shown that HBV-related discrimination creates excessive fear, anxiety, distress, anguish, and avoidance behavior among the patients of CHB by negatively affecting their feelings.10,11 These behaviors can lead to suppression of one’s HBV status, which delays diagnosis and treatment of the disease. This avoidance of HBV status by the patients can negatively impact health outcomes and can cause continuing HBV transmission.12 Hence, belittling the stigma and discrimination is essential to reduce the transmission of HBV infection, particularly in India, where the significant proportions of the population are living with HBV infection.
The stigma was previously defined as “a social process, experienced or anticipated, characterized by exclusion, rejection, blame or devaluation that results from experience, perception or reasonable anticipation of an adverse social judgement about a person or group”.31 Apart from HBV, people living with hepatitis C infection and human immunodeficiency (HIV) virus also frequently experience stigma in many countries. However, the stigma related to HBV is well characterized as compared to HIV-infected individuals. Stigma in the background of HBV can be classified into social, internalized, and structural types. Social stigma against HBV is due to fixed negative prejudice and prepossessions in society, assuming that HBV subjects had either sexual promiscuity or drug abuse. Internalized stigma refers to the individual fear of social rejection due to their HBV status. Structural stigma refers to denial of admission to universities or employment owing to positive HBV status. Hence, the impact of stigma related to the HBV status of an individual is numerous, both at the social and individual levels.
In the year 2015, World Health Organization issued the Glasgow Declaration for Elimination of hepatitis by 2030.13 Therefore, there is an unmet need for community prevention strategies related to HBV to eliminate hepatitis B. However, lack of consciousness among community members and inadequate knowledge are major obstacles in the proper community prevention programs for HBV patients. Very few studies from India have addressed the issues of HBV-related discrimination and knowledge about HBV transmission. Therefore, we felt an enormous need to assess the discrimination experienced by CHB patients in India. Hence, we conducted a cross-sectional study to quantitatively assess the experience of discrimination among CHB patient and identify the factors responsible for HBV-related stigma, with the goal of developing a preventive roadmap to decrease HBV-related stigma and discrimination in India. This study also aims to estimate the knowledge about HBV and attitude toward HBV patients among the Indian population.
Materials and methods
Study Population
A cross-sectional study was conducted in gastroenterology and hepatology clinics of five tertiary care centers of Odisha from May 2016 to October 2019. All the patients who were positive for hepatitis B surface antigen for more than 6 months and of age more than 18 years with normal cognitive function were included in the study. The patients of HBV with decompensated state or hepatocellular carcinoma and altered cognitive function were excluded from the study. All eligible patients were asked to give their written informed consent to confirm their participation. Of 390 HBV-infected patients who were invited to participate in the study, 350 patients accepted to take part in the study (89.7%). Besides, one hundred healthy individuals were included in the study to assess their knowledge about HBV and estimate their attitude toward HBV patients. The healthy volunteers were functional bowel disease patients attending gastroenterology clinics without HBV infection with normal cognitive function and consented to participate in the study. The study proposal was reviewed and approved by the Kalinga Gastroenterology Foundation, Cuttack. Unemployed is defined as a person who is not currently employed, is actively looking for work, and is currently available for work at the existing wage rate.33 However, UNESCO has defined a literate person as “one who can with understanding both read and writes a short simple statement on his everyday life”32
Data Collection
We reviewed the literature related to HBV-related stigma to identify the items to be incorporate31, 32, 33d into a questionnaire. A team comprising of gastroenterologists and one public health expert assessed the pertinent items to be incorporated into the questionnaire. Data were then collected through face-to-face interviews using these structured questionnaires. First, a small pilot study with ten patients was carried out to test the agreeableness of these question order, language, and demographic characteristics of patients to establish the authenticity and validity of the questionnaire. This small pilot study was not peer reviewed. The questionnaire was then reviewed after this small pilot study for the validity of the questions. The resident doctors and gastroenterologists interviewed the HBV patients and healthy volunteers in their own language after making them comfortable.
Measure of Stigma and Discrimination
Based on the study by Huang et al 2014, Luoma JB 2013 et al and Dorothy Li et al 2012,9,14,15 10 questions were prepared on the basis of four domains: Perception of HBV patients, Interpersonal relations, personal contact, and employment. Based on the four domains, these 10 questions were prepared, and HBV patients were interviewed, which consist of (1) Feel ashamed about having HBV, (2) Feel that they bring trouble to their family members, (3) Put others at risk for HBV, (4) Should avoid close contact with others such as kissing and hugging (5) Should avoid using utensils for food or drinking water (6) Should be isolated from other family members (7) May be viewed by others as having a shameful sexually transmitted disease (8) Are viewed as undesirable as a husband or wife (9) Might be discriminated against at work (10) Might be denied health care/hospital. Each of these questions are given one point if the response is yes, and 0 points if no. Total points obtained were summed up to calculate discrimination score (DS), and accordingly, the patients were classified into three groups. The patient is said to have severe discrimination if DS is 8–10, moderate discrimination if DS is 5–7, and mild discrimination if DS is less than or equal to 4.27,30
Statistical Analysis
The data were analyzed by SPSS 20.0 (SPSS, Inc., Chicago, IL, USA). The categorical variables were expressed as a number with percentage and continuous variables as mean ± SD or median. Continuous data were analyzed using an independent t-test and categorical variables with a chi-square test. Analysis of variance (ANOVA) was used to measure the means of more than two variables. Multivariate logistic regression was employed to estimate the predictive factors for discrimination. P-value <0.05 was considered as statistically significant.
Results
Demographics and Baseline Characteristics
As shown in Table 1, the mean age of HBV subjects was 45.10 ± 11.70 years and controls were 36.20 ± 12.27 years and this was statistically significant. Males constitute 60% of HBV subjects and 71% of controls. HBV subjects were more married (86%) as compared to controls (71%). With regard to education, 20% of HBV subjects and 20% of controls were under matriculates, 32% of HBV subjects and 22% of controls had completed matriculation, and the rest were graduates. About 32% of HBV subjects were unemployed, and 34% were self-employed. Only 23% of controls recall testing for HBV, and at best, 30% of HBV subjects identified themselves as HBV carrier. Moreover, just 14% of controls and 10% of HBV subjects were vaccinated for hepatitis B.
Table 1.
Baseline Characteristics of HBV Patients and Healthy Participants.
| No HBV (n = 100) | HBV (n = 350) | P value | |
|---|---|---|---|
| Age in years | 36.24 ± 12.27 | 45.10 ± 11.70 | 0.001 |
| Sex | |||
| Male | 71 (71.0%) | 215 (60.7%) | 0.06 |
| Female | 29 (29.0%) | 139 (39.3%) | |
| Marital status | |||
| Married | 71 (71.0%) | 306 (86.4%) | 0.01 |
| Unmarried | 29 (29.0%) | 48 (13.6%) | |
| Education | |||
| Under matriculate | 26 (26%) | 72 (20%) | 0.18 |
| Matriculate | 22 (22%) | 114 (32%) | |
| Graduate | 52 (52%) | 168 (48%) | |
| Occupation | |||
| Unemployed | 24 (24%) | 114 (32%) | 0.43 |
| Self-employed | 29 (29%) | 119 (34%) | |
| Employed | 34 (34%) | 103 (29%) | |
| Othersa | 13 (13%) | 18 (5%) | |
| Recalls testing for HBV | 23 (23%) | – | – |
| Self-identified as HBV carrier | – | 30 (8.5%) | – |
| Vaccinated for HBV | 14 (14%) | 38 (10.7%) | 0.36 |
Others include students and retired persons; (−) data on occupation of healthy individuals not available; HBV, Hepatitis B Virus.
Stigma Attributes of HBV Patients
The different stigma characteristics, as shown in Table 2, revealed that 75% of patients felt ashamed of having HBV infection. Almost 85% HBV of patients perceived to bring trouble to their family members. Interestingly, around 90% of patients feared putting others at risk for HBV. Avoiding close contact, such as kissing and hugging, was felt by 80% of HBV patients. Around 60% avoided using shared utensils for food or drinking water. Half of the total patients isolated themselves from other family members to prevent transmission. Merely 32% of patients experienced that they were viewed by others as having the shameful sexually transmitted disease. They were viewed as undesirable by their spouses in 50% of patients. These HBV patients were either discriminated against at workplaces or denied healthcare facilities in 65% of cases due to their HBV status.
Table 2.
Responses of HBV Patients to Different Stigma Characteristics.
| Social characteristics of HBV patients | Frequency (n = 350) |
|---|---|
| Feel ashamed about having HBV | 268 (75.7%) |
| Feel that they bring trouble to their family members | 304 (85.9%) |
| Put others at risk for HBV | 317 (89.5) |
| Should avoid close contact with others such as kissing and hugging | 282 (79.7%) |
| Should avoid using utensils for food or drinking water | 223 (63%) |
| Should be isolated from other family members | 173 (48.9%) |
| May be viewed by others as having a shameful sexually transmitted disease | 115 (32.5%) |
| Are viewed as undesirable as a husband or wife | 141 (39.8%) |
| Might be discriminated against at work (n = 103) | 68 (66.7%) |
| Might be denied health care/hospital | 231 (65.3%) |
HBV, Hepatitis B Virus.
Knowledge About Hepatitis B
The knowledge about hepatitis B among the HBV patients and healthy participants was depicted in Table 3. Around 60% of HBV patients and 20% of healthy respondents thought that HBV could be spread by persons even if they look healthy. The hepatitis B virus can be spread from person to person by eating food prepared by the infected person, was felt by 62% of HBV patients and 20% of healthy respondents. Around 80% of HBV patients and 38% of healthy respondents felt that HBV could spread by sharing a toothbrush with an infected person and around 90% of HBV patients and 25% of healthy respondents had a belief that HBV can get transmitted by sharing food plates with someone who is infected. HBV could be infected by being coughed on by an infected person was felt by 57% of HBV patients and 25% of healthy respondents. HBV could be thought to get transmitted by sexual intercourse, intravenous drug use, and mother to child in 88%,75%, and 52% of HBV patients, respectively, but only in 32%,38%, and 40% of healthy individuals, respectively. Importantly, HBV is a preventable disease by proper vaccination was thought by 75% of HBV patients and 44% of healthy respondents.
Table 3.
Knowledge About Hepatitis B Among HBV Patients and Healthy Participants.
| No HBV (n = 100) | HBV (n = 350) | P value | ||
|---|---|---|---|---|
| Can be spread by someone who looks healthy | Yes | 20 (20.0%) | 218 (61.6%) | 0.001 |
| No | 18 (18.0%) | 64 (18.1%) | ||
| Not sure | 62 (62.0%) | 72 (20.3%) | ||
| Do you think the hepatitis B virus can be spread from person to person by eating food prepared by the infected person | Yes | 16 (16.0%) | 222 (62.7%) | 0.001 |
| No | 30 (30.0%) | 85 (24.0%) | ||
| Not sure | 54 (54.0%) | 47 (13.3%) | ||
| Can spread by sharing a toothbrush with an infected person | Yes | 36 (37.5%) | 283 (79.9%) | 0.001 |
| No | 14 (14.6%) | 16 (4.5%) | ||
| Not sure | 46 (47.9%) | 55 (15.5%) | ||
| Can spread by sharing food plates with someone who is infected | Yes | 24 (25.0%) | 319 (90.1%) | 0.001 |
| No | 24 (25.0%) | 13 (3.7%) | ||
| Not sure | 48 (50.0%) | 22 (6.2%) | ||
| Can be infected by being coughed on by an infected person | Yes | 32 (33.3%) | 202 (57.1%) | 0.001 |
| No | 13 (13.5%) | 72 (20.3%) | ||
| Not sure | 51 (53.1%) | 80 (22.6%) | ||
| Can be infected by sharing razors with an infected person | Yes | 36 (37.5%) | 263 (74.3%) | 0.001 |
| No | 12 (12.5%) | 18 (5.1%) | ||
| Not sure | 48 (50.0%) | 73 (20.6%) | ||
| Can be infected by having sexual intercourse with an infected person | Yes | 31 (32.3%) | 312 (88.1%) | 0.001 |
| No | 15 (15.6%) | 15 (4.2%) | ||
| Not sure | 50 (52.1) | 27 7.6% | ||
| Can be infected when intravenous drug users share needles with each other | Yes | 36 (37.5%) | 265 (74.9%) | 0.001 |
| No | 17 (17.7%) | 17 (4.8%) | ||
| Not sure | 43 (44.8%) | 72 (20.3%) | ||
| Can be infected by shaking hands with an infected person | Yes | 7 (7.3%) | 65 (18.4%) | 0.001 |
| No | 44 (45.8%) | 203 (57.3%) | ||
| Not sure | 45 (46.9%) | 86 (24.3%) | ||
| Can be transmitted from mother to child during birth | Yes | 38 (39.6%) | 183 (51.7%) | 0.097 |
| No | 4 (4.2%) | 15 (4.2%) | ||
| Not sure | 54 (56.3%) | 156 (44.1%) | ||
| HBV is prevented by vaccination | Yes | 42 (43.8%) | 265 (74.9%) | 0.001 |
| No | 4 (4.2%) | 0 (0.0%) | ||
| Not sure | 50 (52.1%) | 89 (25.1%) |
HBV, Hepatitis B Virus.
Predictors of HBV-Related Stigma and Discrimination
Out of 350 HBV-infected patients, 62 had mild discrimination, 146 had moderate discrimination, and 142 had severe discrimination. The comparison of different characteristics of HBV patients according to the degree of discrimination is revealed in Table 4. The percentage of the male gender, married patients, under matriculates, and unemployed were significantly higher in the severe discrimination group as compared to mild and moderate discrimination (P < 0.01); however, age was similar in all the groups. The factors predicting severe discrimination by multivariate logistic regression, as shown in Table 5, demonstrated that male gender (AOR-2.38, CI 1.48–3.81, P < 0.01), under matriculates (AOR-2.03, CI 1.22–3.44, P < 0.01) and unemployed (AOR-2.16, CI 1.33–3.53, P < 0.01) were significant independent predictors of severe discrimination, but age and marital status were not found to be predictors of discrimination status.
Table 4.
Comparison of Characteristics of HBV Patients According to Degree of Discrimination.
| Parameters | Mild Discrimination (n = 62) | Moderate Discrimination (n = 146) | Severe Discrimination (n = 142) | P value |
|---|---|---|---|---|
| Age in years | 44.24 ± 10.42 | 44.87 ± 11.87 | 45.58 ± 11.58 | 0.78 |
| Male gender | 34 (55%) | 79 (54%) | 102 (72%) | 0.002 |
| Married | 57 (92%) | 131 (89%) | 118 (83%) | 0.27 |
| Under matriculate | 9 (15%) | 15 (10%) | 48 (34%) | 0.001 |
| Unemployed | 9 (15%) | 34 (23%) | 71 (50%) | 0.001 |
HBV, Hepatitis B Virus.
Table 5.
Factors Predicting Severe Discrimination in CHB Patients.
| OR | 95% C.I. for OR | P Value | AOR | 95% C.I. for OR | P Value | |
|---|---|---|---|---|---|---|
| Age | 1.009 | 0.99–1.02 | 0.33 | |||
| Male gender | 2.27 | 1.43–3.58 | 0.001 | 2.38 | 1.48–3.81 | 0.001 |
| Married | 0.61 | 0.33–1.2 | 0.11 | |||
| Under-matriculate | 1.98 | 1.19–3.29 | 0.008 | 2.03 | 1.2–3.44 | 0.008 |
| Unemployed | 1.84 | 1.15–2.92 | 0.001 | 2.16 | 1.33–3.53 | 0.002 |
CHB, Chronic hepatitis B; OR, Odds ratio; C. I., Confidence interval; AOR, Adjusted odds ratio.
Discussion
The present study highlights the different socioeconomic aspects of HBV-related stigma and discrimination. The prevalence of negative attitudes among HBV-infected patients like shame, feeling of giving trouble to other family members, and putting them at risk of HBV were felt by 70–90% of patients. HBV patients were discriminated against at workplace and healthcare facilities in 65% of patients. Male gender, unemployment, and lack of education were significant independent predictors for severe discrimination. These important findings will help in developing policies to reduce HBV-related stigma and discrimination.
Inadequate knowledge and perception about hepatitis B may lead to the high prevalence of stigma among HBV-infected patients.16 In the present study, more than two-thirds of HBV-infected patients thought that they can transmit hepatitis B by sharing food plates and if persons consume food prepared by them, and they feel that HBV might be transmitted through sweat and saliva, a common misbelief found in prior studies, may lead to high self-stigmatization.10,17,18 Moreover, fear of transmitting the virus to their spouses and close family members by sharing utensils, hugging and kissing also results in negative behavior such as avoidance, shame, and sin.19, 20, 21 On the other hand, only one-third of healthy respondents in our study were aware that hepatitis B could be transmitted by sexual intercourse and intravenous drug abuse, and 30% of them felt that it could be caused by sharing food utensils. This lack of knowledge in society regarding the mode of transmission of HBV can contribute to considerable stigma and discrimination toward HBV patients.17,22 Hence, educational programs to enhance HBV awareness must be conducted in social media, electronic and print media to reduce the stigma related to HBV infection.
Male gender was one of the prognostic factors for severe discrimination in our study. However, age was not found to be a predictor of stigma and discrimination. Multiple previous studies had confirmed that younger HBV patients suffered more stigma as compared to older due to adjustment to the social stigma over a long period of time.9,23 Males were perhaps more likely to perceive stigma due to their association with high-risk sexual behavior and drug injection. Besides, males are more likely to experience stigma as they outnumber females in workplaces and healthcare facilities in India. As males and younger HBV patients are more accessible to the Internet and social networks, these groups of patients should receive special attention to reduce the stigma and discrimination against HBV-infected individuals.24
Lack of education was another prognostic factor for severe discrimination in our study. Higher education was associated with a lesser degree of stigma, as found in multiple previous studies. Besides, higher education can lead to increased vaccination against HBV, causing reduced fear of getting infected with the virus.10,25,26 In addition, better knowledge about the modes of transmission of HBV can also reduce the stigma associated with this disease.26 Unemployment is a major issue in India and being unemployed was a significant predictor of severe discrimination against HBV. Unemployment leads to the migration of laborers from one state to another in search of work in India.27 A Chinese study had earlier shown that unemployed migrant workers experience severe discrimination due to lack of knowledge about HBV transmission.28 Hence, illiteracy and unemployment were two major challenges in tackling stigma and discrimination associated with HBV infection, therefore educating people and vaccinating them against hepatitis B may help to reduce HBV-related stigma and discrimination.
In our study, around two-thirds of HBV-infected patients experienced discrimination at workplaces and healthcare facilities. The key element for stigma in workplaces and healthcare facilities was due to fear of transmitting infection, motivated by lack of knowledge regarding mode of transmission.29 Various Chinese studies have revealed that almost half of HBV patients face discrimination at different educational intuitions and health care facilities, significantly affecting education, health, and economic prosperity of an HBV patient.30
This study has a few limitations. Social desirability bias is common while replying to interviewer’s question; may be intending to give favorable answers to the question asked. Second, the age of HBV patients and healthy respondents did not match, so knowledge level may vary due to this age mismatch. Third, as discrimination also depends on the knowledge of the employer, this could be one of the limitations of our study. Despite this, our study is a multicentric study from Odisha quantifying the magnitude of stigma faced by HBV-infected patients. The paucity of discrimination studies among HBV-infected patients from India makes a great strength to our study.
In our study, we found that unemployment and lack of education were key factors for HBV-related stigma and discrimination. Income and education are two important social determinants of health affecting many crucial health measures. Hence, community-based learning programs addressed to educate both hepatitis B patients and normal healthy population may reduce the stigma and discrimination related to HBV. Unemployment may lead to the migration of low-income population groups to different distant places in search of work, which results in high-risk sexual behaviors among the laborers. Hence, providing stable occupations for financial needs can reduce the HBV-related stigma in the society. Preventive strategies addressing these two key determinants of health may take the edge off the severe stigma associated with HBV in India.
In conclusion, HBV-related stigma and discrimination is very common in India and can affect the social behavior of an HBV-infected patient. Male gender, unemployment, and lack of education were significant predictors of severe discrimination related to HBV. Educating the high-risk groups through well-designed preventive strategies may reduce the severe stigma and discrimination associated with HBV infection. In addition, vaccinating the community against HBV can reduce the fear of infection and attenuate the enormity of HBV-related stigma and discrimination.
Credit authorship contribution statement
Manas Kumar Behera: Conceptualization, Methodology, Writing- Original draft preparation, PreetamNath: Writing- Reviewing and Editing, Sambit Kumar Behera: Visualization, Investigation, Pradeep Kumar Padhy: Data Curation Ayaskant Singh: Software, Formal analysis, Writing- Reviewing and Editing, Resources, Shivaram Prasad Singh: Conceptualization, Methodology Software, Validation, Supervision.
Conflicts of interest
The authors have none to declare.
Funding
None.
References
- 1.Murhekar M.V., Kumar M.S., Kamaraj P., et al. Hepatitis-B virus infection in India: findings from a nationally representative serosurvey, 2017–2018. Int J Infect Dis. 2020;100:455–460. doi: 10.1016/j.ijid.2020.08.084. [DOI] [PubMed] [Google Scholar]
- 2.Ray G. Current scenario of hepatitis B and its treatment in India. J Clin Transl Hepatol. 2017;5:277–296. doi: 10.14218/JCTH.2017.00024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Puri P. Tackling the hepatitis B disease burden in India. J Clin Exp Hepatol. 2014;4:312–319. doi: 10.1016/j.jceh.2014.12.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Valizadeh L., Zamanzadeh V., Bayani M., Zabihi A. The social stigma experience in patients with hepatitis B infection: a qualitative study. Gastroenterol Nurs. 2017;40:143–150. doi: 10.1097/SGA.0000000000000223. [DOI] [PubMed] [Google Scholar]
- 5.Yu L., Wang J., Zhu D., Leng A., Wangen K. Hepatitis B-related knowledge and vaccination in association with discrimination against Hepatitis B in rural China. Hum Vaccines Immunother. 2016;12:70–76. doi: 10.1080/21645515.2015.1069932. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Liu K. Hepatitis B infection in China: the stigma behind the stigmata. Liver Int. 2016;36:1582–1584. doi: 10.1111/liv.13189. [DOI] [PubMed] [Google Scholar]
- 7.Yang T., Wu M. Discrimination against hepatitis B carriers in China. Lancet. 2011;378:1059. doi: 10.1016/S0140-6736(11)61460-8. [DOI] [PubMed] [Google Scholar]
- 8.Shi J., Chyun D.A., Sun Z., Shou L. Assessing the stigma toward chronic carriers of hepatitis B virus: development and validation of a Chinese college students' stigma scale. J Appl Soc Psychol. 2013;43:10. [Google Scholar]
- 9.Huang J., Guan M.L., Balch J., et al. Survey of hepatitis B knowledge and stigma among chronically infected patients and uninfected persons in Beijing, China. Liver Int. 2016;36:1595–1603. doi: 10.1111/liv.13168. [DOI] [PubMed] [Google Scholar]
- 10.Cotler S.J., Cotler S., Xie H., et al. Characterizing hepatitis B stigma in Chinese immigrants. J Viral Hepat. 2012;19:147–152. doi: 10.1111/j.1365-2893.2011.01462.x. [DOI] [PubMed] [Google Scholar]
- 11.Na L., Na B. A revolutionary road: an analysis of persons living with hepatitis B in China. J Health Commun. 2013;18:71–91. doi: 10.1080/10810730.2012.688449. [DOI] [PubMed] [Google Scholar]
- 12.Han B., Yuan Q., Shi Y., et al. The experience of discrimination of individuals living with chronic hepatitis B in four provinces of China. PLoS One. 2018;12:13. doi: 10.1371/journal.pone.0195455. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Rajamoorthy Y., Taib N.M., Munusamy S., et al. Knowledge and awareness of hepatitis B among households in Malaysia: a community-based cross-sectional survey. BMC Publ Health. 2019;19:47. doi: 10.1186/s12889-018-6375-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Luoma J.B., Nobles R.H., Drake C.E., et al. Self-stigma in substance abuse: development of a new measure. J Psychopathol Behav Assess. 2013;35:223–234. doi: 10.1007/s10862-012-9323-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Li D., Tang T., Patterson M., Ho M., Heathcote J., Shah H. The impact of hepatitis B knowledge and stigma on screening in Canadian Chinese persons. Can J Gastroenterol. 2012;26:597–602. doi: 10.1155/2012/705094. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Lee H., Fawcett J., Kim D., Yang J.H. Correlates of hepatitis B virus-related stigmatization experienced by Asians: a scoping review of literature. Asia-Pac J Oncol Nurs. 2016;3:324–334. doi: 10.4103/2347-5625.195896. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wu H., Yim C., Chan A., Ho M., Heathcote J. Sociocultural factors that potentially affect the institution of prevention and treatment strategies for hepatitis B in Chinese Canadians. Can J Gastroenterol. 2009;23:31–36. doi: 10.1155/2009/608352. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Thompson M.J., Taylor V.M., Yasui Y., et al. Hepatitis B knowledge and practices among Chinese Canadian women in vancouver, British Columbia. Can J Publ Health. 2003;94:281–286. doi: 10.1007/BF03403606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Dam L., Cheng A., Tran P., et al. Hepatitis b stigma and knowledge among Vietnamese in ho chi minh city and chicago. Chin J Gastroenterol Hepatol. 2016;2016:8. doi: 10.1155/2016/1910292. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Alizadeh A.H., Ranjbar M., Yadollahzadeh M. Patient concerns regarding chronic hepatitis b and c infection. East Mediterr Health J. 2008;14:1142–1147. [PubMed] [Google Scholar]
- 21.Wai C.T., Mak B., Chua W., et al. Misperceptions among patients with chronic hepatitis B in Singapore. World J Gastroenterol. 2005;11:5002–5005. doi: 10.3748/wjg.v11.i32.5002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Hajarizadeh B., Richmond J., Ngo N., Lucke J., Wallace J. Hepatitis b-related concerns and anxieties among people with chronic hepatitis b in Australia. Hepat Mon. 2016;16 doi: 10.5812/hepatmon.35566. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Le T.V., Vu T.T.M., Mai H.T., et al. Social determinants of stigma and discrimination in Vietnamese patients with chronic hepatitis B. Int J Environ Res Publ Health. 2019;16:398. doi: 10.3390/ijerph16030398. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ouyang D., Yuan N., Sheu L., Lau G., Chen C., Lai C.J. Community health education at student-run clinics leads to sustained improvement in patients' hepatitis B knowledge. J Community Health. 2013;38:471–479. doi: 10.1007/s10900-012-9631-3. [DOI] [PubMed] [Google Scholar]
- 25.Ma G.X., Shive S.E., Toubbeh J.I., Tan Y., Wu D. Knowledge, attitudes, and behaviors of Chinese hepatitis B screening and vaccination. Am J Health Behav. 2007;32:178–187. doi: 10.5555/ajhb.2008.32.2.178. [DOI] [PubMed] [Google Scholar]
- 26.Kan Q., Wen J., Xue R. Discrimination against people with hepatitis B in China. Lancet. 2015;386:245–246. doi: 10.1016/S0140-6736(15)61276-4. [DOI] [PubMed] [Google Scholar]
- 27.Sanyal T., Maity T.K. On labour migration in India: trends, causes and impacts. Econ Aff. 2018;63:57–69. [Google Scholar]
- 28.Leng A., Li Y., Wangen K.R., Nicholas S., Maitland E., Wang J. Hepatitis B discrimination in everyday life by rural migrant workers in Beijing. Hum Vaccines Immunother. 2016;12:1164–1171. doi: 10.1080/21645515.2015.1131883. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Smith-Palmer J., Cerri K., Sbarigia U., et al. Impact of stigma on people living with chronic hepatitis B. Patient Relat Outcome Meas. 2020;11:95–107. doi: 10.2147/PROM.S226936. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Han B., Yuan Q., Shi Y., et al. The experience of discrimination of individuals living with chronic hepatitis b in four provinces of China. PLoS One. 2018;13 doi: 10.1371/journal.pone.0195455. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Scambler G. Health-related stigma. Sociol Health Illn. 2009;31(3):441–455. doi: 10.1111/j.1467-9566.2009.01161.x. [DOI] [PubMed] [Google Scholar]
- 32.Vágvölgyi R., Coldea A., Dresler T., Schrader J., Nuerk H.C. A Review about functional illiteracy: Definition, cognitive, linguistic, and numerical aspects. Front Psychol. 2016;7:1617. doi: 10.3389/fpsyg.2016.01617. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Dooley D., Fielding J., Levi L. Health and unemployment. Ann Rev Pub Health. 1996;17:449–465. doi: 10.1146/annurev.pu.17.050196.002313. [DOI] [PubMed] [Google Scholar]