Hepatitis C in Australia Impact of a Mass Media Campaign Ben J. Smith, PhD, Adrian E. Bauman, PhD, Jack Chen, PhD, Stuart Loveday, BCom, Melanie Costello, BSW, Brent Mackie, Grad Dip Com, Gregory J. Dore, PhD Background: Hepatitis C affects over 200,000 Australians. This study evaluated the impact of a public education campaign about this disease in New South Wales (NSW), Australia. Design: Cohort and independent cross-sectional telephone surveys before and after the campaign. Setting/ Participants: Random population samples of adults in NSW. Intervention: Television, radio and newsprint advertisements, posters and public display boards, public awareness events and media releases, and dissemination of information to healthcare professionals in April 2000. Data were analyzed in 2000 and 2005. Main Outcome Measures: Results: Campaign recall, and knowledge and attitudes concerning hepatitis C. Recall of information about hepatitis C increased between baseline and follow-up, from 11.1% to 45.5% in the independent samples and 11.8% to 65.3% in the cohort. The proportion of people who knew that there was a low risk of disease transmission by kissing, sharing food utensils, or breastfeeding also increased significantly. In the cohort sample, a higher number of correct knowledge responses was associated with reporting exposure to information about hepatitis C after the campaign, postsecondary education, and a greater level of knowledge at baseline. Most people reported supportive attitudes toward people with hepatitis C and to prevention programs addressing this disease, and there was little apparent improvement in these. Conclusions: This campaign successfully increased public exposure to information about hepatitis C and improved knowledge about the means of transmission of this disease. There is room for further improvements in community understanding about hepatitis C. Mass media campaigns have a valuable role to play in this endeavor. (Am J Prev Med 2006;31(6):492– 498) © 2006 American Journal of Preventive Medicine Introduction H epatitis C is a serious public health concern in Australia, with estimates of the number of people with hepatitis C exceeding 200,000 and of new infections of up to 16,000 per year.1–3 Hepatitis C is a significant problem not only because of its high prevalence and incidence, but also its serious impact on From the School of Public Health, University of Sydney (Smith, Bauman), Sydney; Simpson Centre for Health Services Research, University of New South Wales (Chen), Liverpool; Hepatitis C Council of New South Wales, Inc. (Loveday), Darlinghurst; New South Wales Department of Health (Mackie), North Sydney; National Centre in HIV Epidemiology and Clinical Research, University of New South Wales (Dore), Darlinghurst, New South Wales; and Family Planning Queensland (Costello), Fortitude Valley, Queensland, Australia. Address correspondence and reprint requests to: Ben J. Smith, PhD, School of Public Health, University of Sydney, Level 2, Medical Foundation Bldg. K25, NSW, Australia, 2006. E-mail: bens@health. usyd.edu.au. 492 quality of life, its association with cirrhosis of the liver and hepatocellular carcinoma, and its potential impact on healthcare resources.1,2,4 To prevent the spread of the disease, a number of strategies have been identified, including screening of high-risk groups and of blood and blood products, infection control procedures in health settings, harmreduction programs for people who inject drugs, and support services for people with hepatitis C.5,6 Given that the disease has been recognized only in the past 20 years, there is also a need for public education about its nature and methods of transmission. In Australia, studies among adolescents7,8 and people infected by hepatitis C3 indicate that inadequate knowledge and misunderstandings about the disease are common. This is consistent with the findings of surveys in other countries.9,10 Community-wide education initiatives are needed for alerting people to the modes of transmission and facilitating a social climate Am J Prev Med 2006;31(6) © 2006 American Journal of Preventive Medicine • Published by Elsevier Inc. 0749-3797/06/$–see front matter doi:10.1016/j.amepre.2006.08.001 where at-risk people feel comfortable to seek testing and where harm-reduction strategies can be implemented.11 The public health experience in the prevention of HIV,12–14 hepatitis B,15,16 and infectious diseases that pose a threat to children17,18 shows that mass media campaigns can contribute to awareness, knowledge, and the use of preventive services. Little has been reported to date about the use of mass media as a strategy for public education about hepatitis C. Community-wide education about hepatitis C has been implemented in France since 2000,19 involving mass media advertisements and an education campaign for general practitioners, but the effect of these efforts has not been reported. Targeted education programs, such as school-based education for adolescents20 and dissemination of written information to healthcare professionals,21 have been reported to be effective in improving knowledge about this disease. In 2000, a mass media campaign was initiated by the New South Wales (NSW) Department of Health in partnership with the Hepatitis C Council of NSW and other agencies to promote understanding and attitudes that would strengthen hepatitis C prevention in that state. This built on a range of effective harm-reduction strategies targeting high-risk groups, including needle and syringe programs, methadone maintenance, and peer education for intravenous drug users.6 This paper presents the findings of the evaluation of this mass media campaign on community knowledge and attitudes concerning hepatitis C. Methods Hepatitis C Campaign The aims of the NSW hepatitis C campaign were to increase knowledge about hepatitis C in the general adult population, create a supportive environment for hepatitis C programs, and reduce discrimination against people with the disease. The theoretical rationale underpinning the campaign was that supportive attitudes are a prerequisite for nondiscriminatory behaviors, and that attitudes are determined by underlying beliefs concerning the positive and negative attributes of hepatitis C and people living with the disease.22,23 In regard to stigma, which is the devaluing or discrediting of an individual on the basis of certain characteristics,24 illnessrelated beliefs about contagion and death are important to address because they evoke fear and revulsion.25 The slogan for the campaign was “Hep C, understanding is the answer.” Campaign activities conducted during April 2000 included three 30-second television commercials that were shown on all metropolitan and regional stations. These achieved a medium-to-high target audience rating point (TARP) score of 550 across the month. In addition to this, a 30-second radio advertisement was broadcast on 14 stations across the state, and posters, bus interior advertisements, brochures, banners, and an online fact sheet were disseminated. Communication strategies for non–English-speaking people included a 30- December 2006 second radio advertisement and large newspaper advertisements in five languages (Cantonese, Khmer, Spanish, Vietnamese, and Arabic). A telephone information helpline was operated by the Hepatitis C Council of NSW and received 4250 calls during the campaign period.26 An information kit about hepatitis C was mailed to ⬎7500 family physicians. Complementing the paid advertising and educational activities were a range of public relations initiatives, including an official launch of the campaign by the NSW Minister for Health and distribution of information kits to news outlets. Regional health authorities also undertook local launches of the campaign, distribution of media releases, and training of health workers. Study Design and Sample The evaluation design consisted of surveys conducted before and 1 month after the campaign of both cohort and independent cross-sectional samples of NSW adults. Data collected from the cohort enabled the examination of changes within individuals while the cross-sectional surveys provided a means of verifying whether the aggregate changes were evident in a sample that had not undergone baseline measurement. Respondents were adults aged ⱖ18 years who were selected at random by sampling of households listed in the telephone White Pages followed by random selection of one eligible adult within each household. Measurements Survey data were collected by computer-assisted telephone interviews. The primary impact variables were hepatitis C–related knowledge and attitudes. Knowledge questions concerned the approximate number of people infected by hepatitis C in Australia, the availability of a vaccine, and the risk of transmitting the disease by various means (kissing, eating from the same plate, breast feeding, use of nonsterile tattooing or body piercing equipment, blood transfusion, and sharing equipment for injecting drugs). Additional knowledge measures were collected by asking respondents to rate their agreement on a 5-point scale with the following statements: ● ● ● ● ● Hepatitis C is very similar to hepatitis B. Many people with hepatitis C will not know they have it for many years. Hepatitis C is spread by sexual activity. Hepatitis C is often spread through blood-to-blood contact. Only people currently injecting drugs are likely to have hepatitis C. Attitudes related to this disease were also measured by a 5-point rating of agreement with the following statements: ● ● ● ● People with hepatitis C might often feel discriminated against. Hepatitis control is not important because the people at most risk are those who inject illegal drugs. Increasing services such as needle and syringe programs would reduce the number of new cases of hepatitis C. Injecting drug users are as entitled to treatment as anybody else with hepatitis C. Am J Prev Med 2006;31(6) 493 Table 1. Demographic characteristics of the independent and cohort samples Gender Male Female Age group (years) 18–39 40–54 ⱖ55 Language spoken at home English Other language Marital status Married/de facto Other Educational attainment Up to year 10 in high school Completed year 12 or vocational course University/college degree Independent baseline sample (nⴝ1114) % Independent follow-up sample (nⴝ1027) % Cohort sample (nⴝ900) % 45.2 54.8 42.8 57.2 44.3 55.7 32.0 30.0 38.0 37.7 25.7 26.5* 31.0 32.1 36.9 93.0 7.0 93.4 6.6 94.7 5.3 62.6 37.4 58.8 41.2 64.6 35.4 42.4 31.3 26.3 41.4 31.4 27.3 40.4 33.1 26.6 *p⬍0.05, chi-square test (bolded). Exposure to the campaign was measured by an open-ended question about whether respondents had seen or heard any messages about hepatitis C in the media in the past 4 weeks. Demographic data collected about respondents included age, gender, language spoken at home, marital status, and educational attainment. Statistical Analyses For the independent samples, the categorized outcomes were cross-tabulated by the time of the surveys, and the associations were explored using Pearson chi-square and Fisher’s exact test. For the cohort sample, the McNemar chi-square was used to examine changes in knowledge and attitude variables. A principal component analysis was undertaken to explore any potential underlying psychometric constructs in the knowledge and attitude responses, but as none were clearly identified, each variable was analyzed independently. In additional analyses with the cohort sample, negative binomial regression techniques were used to identify factors, including demographic characteristics, knowledge at baseline, and reported exposure to information about hepatitis C, which were independently associated with a higher number of correct knowledge responses at follow-up. Similar analyses examined factors independently associated with a higher number of supportive attitude responses at follow-up, substituting the number of supportive attitudes at baseline for the number of correct knowledge responses. The negative binomial regression model that was applied allowed the relaxation of the equality of mean and variance assumption held in Poisson regression. Data were analyzed in 2000 and 2005 using STATA, version 6.0 (StataCorp, College Station TX, 1999) and SPSS 6.1 (SPSS Inc., Chicago IL, 1996). Results Characteristics of Survey Respondents There were 1114 people surveyed at baseline (response rate of 81.5%). Of these, 972 people (87.2%) agreed to 494 be included in the evaluation cohort, and 900 (80.8%) were successfully followed. The post-campaign independent sample included 1027 people (response rate 82%). Table 1 shows that there were slightly more women than men in the independent and cohort samples, and a fairly even distribution of respondents in the age groups 18 to 39 years, 40 to 54 years, and ⱖ55 years. Most respondents were English speaking, around 60% had a partner, and just over 25% had postsecondary education. The samples were similar in all characteristics with the exception of the proportion of those aged ⱖ55 years, which was lower in the post-campaign independent sample. Campaign Recall Table 2 shows the proportion of people who reported that they had seen any messages about hepatitis C in the previous month. This increased significantly from just over 11% at baseline to 45.5% in the independent Table 2. Recall of any messages about hepatitis C in previous month, by gender and age Independent sample Cohort sample Baseline Follow-up Baseline Follow-up Total 11.1 Gender Male 11.3 Female 11.1 Age groups (years) 18–39 9.5 40–54 9.2 ⱖ55 14.1 45.5* 11.8 65.3** 43.0* 45.7* 11.8 11.9 64.3** 66.4** 44.2* 41.3* 47.1* 9.4 10.1 15.6 65.9** 66.8** 63.7** *p⬍0.01, Fisher exact test; **p⬍0.01, McNemar test (all bolded). American Journal of Preventive Medicine, Volume 31, Number 6 www.ajpm-online.net Table 3. Prevalence of accurate knowledge and supportive attitudes related to hepatitis C at baseline and follow-upa Independent samples Knowledge and attitude variables Hepatitis C knowledge Over 200,000 Australians are infected with hepatitis C—agree Hepatitis C is very similar to hepatitis B—disagree Many people with hepatitis C will not know they have it for many years—agree Possible vaccine against hepatitis C—disagree Hepatitis C is spread by sexual activity—disagree Hepatitis C is often spread through blood to blood contact—agree Only people currently injecting drugs are likely to have hepatitis C—disagree Risk of catching hepatitis C by kissing someone with hepatitis C—low Risk of catching hepatitis C by eating off the same plate—low Risk of catching hepatitis C by breastfeeding a baby—low Risk of catching hepatitis C by unsterile tattooing or body/piercing equipment—high Risk of catching hepatitis C by receiving a blood transfusion—low Risk of catching hepatitis C by sharing drug/injecting equipment—high Hepatitis C attitudes People with hepatitis C might often feel discriminated against—agree Hepatitis control is not important because the people at most risk are those who inject illegal drugs—disagree Increasing services such as needle and syringe programs would reduce the number of new cases of hepatitis C—agree Injecting drug users are as entitled to treatment as anybody else with hepatitis C—agree Cohort sample Baseline Follow-up Baseline Follow-up 23.0 58.5 89.0 27.8 40.4 86.2 84.1 40.9 47.1 16.0 81.7 27.0* 65.8** 87.5 30.8 43.5 88.8 86.1 47.0** 54.1** 23.4** 85.9** 23.8 63.0 89.6 28.6 40.4 86.9 85.0 43.2 49.3 16.9 82.5 36.3** 61.9 90.3 37.8** 41.7 92.5** 87.7 51.1** 61.1** 26.5** 85.2 59.7 95.3 58.7 95.1 62.2 96.7 66.3* 96.0 76.4 85.4 76.1 90.2 78.7 88.3 84.3** 88.9 70.2 69.6 71.0 77.1** 84.1 85.1 84.9 87.8* a p values for the independent sample are based on the Fisher exact test while the p values for cohort sample are based on the McNemar test. *p value ⬍0.05; **p value ⱕ0.01 (all bolded). sample and 65.3% in the cohort sample at follow-up. These increases were consistent between the gender and age groups. Knowledge and Attitudes Concerning Hepatitis C There were small but significant increases in both the independent and cohort samples in the proportion of people who had correct knowledge that ⱖ200,000 Australians are infected with this disease, and that there is little or no risk that it could be transmitted by kissing an infected person, eating off the sample plate or breastfeeding (Table 3). The independent sample comparison showed an increase in the proportion of people with knowledge that hepatitis C is not very similar to hepatitis B, which was not evident in the cohort sample, possibly because of the higher baseline levels of this variable in this group. On the other hand, in the cohort sample there was a significant increase in the proportion of people with correct knowledge that there is no vaccine for this disease. There were high proportions of people at baseline (⬎80%) who knew that many people with hepatitis C are not aware of their disease status and that the disease can be transmitted by nonsterile tattooing or bodypiercing equipment, sharing injection-drug equipment, or blood-to-blood contact. In spite of this, there were increases in the proportion of people in the cohort sample who knew that the disease could be spread by December 2006 blood-to-blood contact and, in the independent samples, who knew that it could be transmitted by nonsterile tattooing or body-piercing equipment. Only the cohort sample showed an increase in the proportion of people who knew that the risk of catching hepatitis C by blood transfusion is low. Responses to the attitude questions revealed that most people (⬎70%) were supportive of those infected with hepatitis C and of harm-reduction strategies to prevent transmission of the disease (Table 3). In the cohort sample there were significant increases in the proportion who agreed that people with hepatitis C might feel discriminated against, that needle and syringe programs could reduce the number of new cases, and that injection-drug users have equal entitlement to treatment compared to others in the community. Multivariate Analyses of Factors Related to Knowledge and Attitudes at Follow-Up In the cohort sample, the number of correct knowledge responses at follow-up was independently associated with having postsecondary education (incidence rate ratio [IRR]⫽1.07, p⫽0.04), a higher number of correct responses at baseline (IRR⫽1.03, p⬍0.001), and reporting exposure to information about hepatitis C after the campaign (IRR⫽1.07, p⬍0.001) (Table 4). In this analysis, the only variable associated with the number of Am J Prev Med 2006;31(6) 495 Table 4. Factors associated with number of correct knowledge and supportive attitude responses at follow-up in the cohort sample Correct knowledge responses Gender Male Female Age groups (years) 18–39 40–54 ⱖ55 Language spoke at home English Other than English Marital status Married/de facto Other Education Up to year 10 in high school Completed year 12 or vocational course University/college degree Recall of campaign No Yes Responses at baselinea Supportive attitude responses IRR 95% CI p value IRR 95% CI p value 0.98 0.95–1.01 0.24 0.98 0.93–1.04 0.55 0.98 0.96 0.94–1.03 0.92–1.01 0.46 0.09 0.95 0.97 0.88–1.02 0.90–1.04 0.17 0.40 0.94 0.86–1.01 0.10 0.99 0.87–1.14 0.92 0.99 0.95–1.02 0.45 0.99 0.93–1.05 0.71 1.00 1.07 0.96–1.04 1.00–1.09 0.98 0.04* 0.99 1.01 0.92–1.06 0.94–1.09 0.69 0.76 1.07 1.03 1.03–1.10 1.02–1.03 <0.001** <0.001** 1.01 1.04 0.95–1.07 1.02–1.06 0.79 0.001** a Baseline variable is the number of correct knowledge responses for analysis of respondent knowledge and number of supportive attitude responses for analysis of respondent attitudes. *p ⬍ 0.05; **p ⬍ 0.001 (all bolded). IRR, incidence rate ratio. supportive attitude responses was having a higher number of supportive responses at baseline (IRR⫽1.04, p⫽0.001). In additional modeling concerning attitudes (results not shown), improvement in knowledge from baseline to follow-up was included as a covariate, but this was not related to the number of supportive attitude responses given. Discussion and Conclusion Although hepatitis C is a prevalent disease, it has received far less public attention in Australia than other communicable diseases, notably HIV and the diseases addressed by childhood immunization campaigns. The focus of hepatitis C prevention efforts to date has been on people engaged in high-risk behaviors, and this is the first report of the impact of a mass media campaign addressing community beliefs and attitudes related to this disease. Marked increases were found in recall of information relevant to campaign messages from baseline to followup. Given that this was measured using unprompted recall questions, which reflect a higher degree of cognitive engagement than prompted recognition questions,27 it appears that the messages had good salience and accessibility. Corroborating evidence of reach and exposure achieved comes from the threefold increase in callers to the Hep C Helpline during the 496 campaign that has been previously reported, with about one third of callers mentioning mass media as the source from which they learned of the helpline.26 Factors that are likely to have contributed to the levels of campaign recall included the use of television as the primary communication channel, with its extensive reach, the medium-to-high TARPs attained through the advertising placements, and the consistency of the messages delivered.27 Against its objectives—increasing knowledge about hepatitis C and promoting support and nondiscrimination toward those who are infected—the campaign was most effective in conveying knowledge about hepatitis C and its modes of transmission. Both the independent and cohort sample findings showed an increase in the proportion of people who had a correct understanding that the disease could not be transmitted through kissing, eating off the same plate, or breastfeeding. Accurate knowledge of this type is a foundation for appropriate preventive action and helps to lower fear and stigma toward those who carry the disease. There was also an increase in the proportion of respondents who were aware that over 200,000 Australians are infected with hepatitis C. This fosters an understanding that the disease is not confined to one small segment of the population, and that there is a need for public health funds to be directed to its prevention and control. American Journal of Preventive Medicine, Volume 31, Number 6 www.ajpm-online.net While these improvements were encouraging, there were still substantial proportions of people after the campaign (45% to 75%), who did not have knowledge of the number of people infected, or that the disease is not transmitted by casual contacts or breastfeeding. Furthermore, the majority of respondents did not know that the risk of hepatitis C infection through sexual activity is low or that there is not a vaccine to prevent infection. This indicates that there continues to be a need for public education about this disease. On the other hand, an unexpected finding from the baseline survey was that some facts about hepatitis C were widely known (by more than 80% of respondents)—namely, that many people who are infected will not know this for many years; that the disease is transmitted by sharing injecting drug treatment, bloodto-blood contact, and use of nonsterile tattooing or body-piercing equipment; and that it is not only people who inject drugs who are infected in the population. This suggests that the limited dissemination of information and media discussion about the disease to date appears to have resulted in substantial knowledge uptake, which may have been facilitated by the novelty of this strain of hepatitis compared to better-known strains of hepatitis A and hepatitis B. Overall, the achievement of improved knowledge about hepatitis C was an important outcome from this campaign. Literature on risk perception states that infectious diseases have many qualities that can evoke a response of dread, and even panic, due to their invisibility, their perceived potential to infect in a random and sudden way, and the difficulty that laypeople have in understanding quantitative estimates of risk.28 –30 The early mass media campaigns about HIV in Australia have been criticized for generating unnecessary hysteria,31 resulting in low-risk people seeking HIV testing, and the stigmatization of at-risk groups. Given that there has been limited public discussion about hepatitis C, there was some potential for a campaign to generate reactions of this kind, but the clear and sober way in which information was portrayed prevented this. The baseline data concerning community attitudes showed that most people supported nondiscrimination toward those infected with hepatitis C and were in favor of harm-reduction strategies. The understandings promoted by two decades of community education about HIV in Australia, which has addressed nondiscrimination toward people living with HIV and the benefits of addressing this as a public health rather than a moral issue, are likely to have contributed to this. There was little evidence that the hepatitis C campaign further increased the proportion of people with supportive attitudes related to the disease. In the cohort sample there were some improvements shown in three of the attitude variables, but as these were not shown in the independent samples, it is difficult to rule out the possibility that the changes were the result of pre-test December 2006 sensitization or social desirability bias. Given that a number of behavioral theories propose that attitudes are a determinant of intentions and subsequent actions,23,32 these findings suggest that the campaign is not likely to have contributed to changes in supportive behaviors toward people with hepatitis C. In this campaign, it appears that a reduction in the prevalence of incorrect beliefs about hepatitis C was not sufficient to influence the prevalence of supportive attitudes toward people living with the disease. Programs concerned with reducing stigma toward HIV/ AIDS33 and mental illness34 have found that exposing the target population to people living with the illness, in addition to providing information, is an important strategy for achieving attitude change. This exposure can be by direct face-to-face contact or media presentations. Greater involvement of people with hepatitis C in future campaigns could therefore be useful in normalizing the disease and achieving further improvements in attitudes. Combining a cohort and independent samples design was a strength of the evaluation of this campaign, enabling verification of impacts across different samples as well as the examination of factors associated with positive changes within individuals. Reliance on findings from only the cohort sample may have lead to erroneous findings because of the possibility that repeat measurement influenced the responses given. In the knowledge domain, where there were improvements shown in both the independent and cohort samples, it was found that higher educational attainment and greater knowledge at baseline were independently associated with greater knowledge improvements in the cohort sample. This finding is consistent with the knowledge gap hypothesis35 that information disseminated in mass media campaigns is more rapidly acquired by better-educated people. It is not, however, inevitable that campaigns will perpetuate this gap,36 and there is a need to develop more effective methods of communicating information about hepatitis C to people with lower education and health literacy. An encouraging finding from these analyses was that improvements in knowledge were not differentiated by age, gender, or the other demographic descriptors, and were associated with reporting exposure to information about hepatitis C since the implementation of the campaign. One of the weaknesses of the evaluation of this campaign was that measurements were conducted in English only; hence, people of non–English-speaking backgrounds were under-represented in the survey samples. Non–English-speaking migrants, particularly those coming from southeast Asia to Australia, have been found to have a higher prevalence of inaccurate knowledge about hepatitis C.37 In this campaign, radio and print advertising was conducted in five major languages other than English. While data collected by Am J Prev Med 2006;31(6) 497 the Hep C Helpline showed an increase in callers from non–English-speaking people during the campaign,26 it is not known whether there were also positive changes in knowledge and attitudes in this target population. Another limitation is that the absence of a control group means that it is not possible to rule out the possible effect of secular trends on the changes observed. However, given the limited timeframe between measurement points and the relationship found between exposure and knowledge improvements, this is unlikely to have had an influence on the findings. This evaluation has shown that the NSW hepatitis C awareness campaign achieved wide community reach and was successful in building on existing knowledge about the disease. There is, however, still scope for understanding of hepatitis C and attitudes toward those affected by the disease to be improved. 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J Gastroenterol Hepatol 2004;19:792– 8. American Journal of Preventive Medicine, Volume 31, Number 6 www.ajpm-online.net