Community-based HCV screening: knowledge and attitudes in a high risk urban population

Sites were chosen from a list of community-based HIV/sexually transmitted diseases testing sites utilized by the local public health department (Wake County Human Services). These sites- a homeless shelter, drug rehabilitation center, and drop-in center- were chosen because they serve poor, marginalized communities, of whom many are/were persons who injected drugs (PWID), thereby putting them at-risk for HCV. The S. Wilmington Street shelter is the largest homeless shelter in Raleigh, North Carolina with 234 beds, serving only men. The Raleigh Rescue Mission, another homeless shelter, serves both men and women and has 100 beds. The Healing Place (for men and women) is a recovery and rehabilitation facility for homeless people with alcohol and drug dependency. There are 180 beds at the men’s facility and 95 at the women’s facility. The Women’s Center of Wake County is a multi-service resource center that addresses issues of poverty, homelessness, and substance abuse for single women and women with families. A convenience sample of persons attending each of these settings was surveyed. The leaders of each community center advertised the study for one week prior to the event, and members chose whether to attend the program. All interviews and education took place at each site during regular hours of operation. Participation was voluntary; interest was overwhelming. The study period took place from January 2012 to May 2012. The inclusion criteria were: 1) speak/understand English; 2) age 18 or older; (3) willingness to complete a pre and post-test survey instrument and participate in a short educational intervention. The survey was anonymous and clearly labeled as to its purpose (research study), and verbal consent was performed. No identifying information was obtained from subjects, and they were compensated for participation with a five dollar grocery store gift card. The study was exempted from institutional review board review by the Duke University Medical Center Institutional Review Board.

An educational intervention was given as well as pre- and post-intervention surveys. Pre- and post-intervention survey instruments were administered verbally to participants to assess knowledge and attitudes surrounding hepatitis C disease, testing, and treatment.

The survey instrument assessed socio-demographic information, access to healthcare, knowledge of HCV, and attitudes toward community HCV screening. The survey was first piloted among patients in the Duke Infectious Diseases clinic to assess question comprehension, and revisions were made accordingly. To ensure full comprehension, study investigators verbally administered the survey instruments to all participants. The post-intervention survey was performed directly after the educational intervention and consisted of a subset of the pre-intervention questions.

The educational intervention consisted of a brief (approximately 15 minute) standardized discussion of the epidemiology of HCV, clinical significance, care and treatment options, and preventative strategies, followed by a question/answer session. A spiral-bound flip-book with diagrams was used with the discussion. The intervention was designed with the assistance of professional health educators and was directed toward a fifth grade education level. The same investigator (B.N.) delivered the educational program at each site in order to maximize the consistency of the educational intervention across sites.

The study was powered on the primary objective: assessment of screening acceptability. We chose a sample size that would permit adequate assessment of whether a majority (i.e., >50%) of participants felt that HCV screening would be acceptable in their community. Assuming that the true rate of HCV testing acceptance in the community was 60% in the underlying population, we needed 153 participants to exclude an acceptability rate of <50% with 80% power at a 5% type 1 error rate, using a one-sided significance test. The study was stopped early due to overwhelming acceptance of screening.

Continuous variables were summarized using medians/quartiles or means/standard deviations, as appropriate to the distribution. Categorical variables were summarized with frequency counts/proportions. Changes in knowledge and acceptance of HCV testing were assessed using the McNemar test to compare baseline and post-education responses. Answers of "not sure" were considered not correct (knowledge) or negative for acceptance. We created a composite knowledge score from 18 knowledge-related questions, assigning each correct answer one point. Bivariate associations between baseline knowledge and pre-selected predictor variables were assessed using t-tests with categorical variables or Pearson correlations with continuous variables. All variables significantly associated with knowledge at an alpha of <0.05 were then entered into a multivariable linear regression model, centering the age variable in the model.

One hundred forty participants were surveyed at 5 sites, including 2 homeless shelters, 2 drug rehabilitation centers, and a women’s "drop-in" center. The majority of participants were male (66%) and African American (57%) (Table 1). The median age was 43 years old, with a range of 18 to 62 years. Participants varied in education levels, with 16% having stopped education after elementary school. Most people had no health insurance (73%), and less than half stated they had a regular doctor (49%). Ninety-five percent of participants had heard of HCV, 56% said they knew someone with the disease, and 18% of participants stated that they had been diagnosed with HCV. Though all of these participants were surveyed at community centers serving high-risk individuals, 36% of participants still believed they were "not at all" likely to get HCV.

Baseline attitudes and knowledge regarding HCV and HCV screening are presented in Table 2. Baseline acceptance of community-based screening was almost universal. Ninety-seven percent of participants stated they would get a free HCV test if it were offered, with 90% reporting that they would still want to be tested even if they were not able to receive treatment. When told that, if positive, they would be offered free vaccines against hepatitis A and B, or lifestyle advice on how to stay healthy with HCV, additional people wanted to be tested even if treatment was not accessible to them (95% and 96% respectively).

Baseline knowledge about HCV acquisition was variable. Although 90% of people knew that injecting drugs and getting a homemade tattoo are risk factors for HCV, 22% of people did not think sexual acquisition was possible, 17% thought HCV was transmitted from public toilets, and 28% thought HCV was transmitted from coughing or sneezing. Many people did not know what risk factors were associated with disease progression. Participants’ baseline knowledge concerning HCV treatment was also low. Sixty five percent of participants did not think HCV could be cured or did not know if it could be cured, yet 76% believed that everyone diagnosed with HCV needed to be treated. Ninety-eight percent of participants said they would want treatment if they tested positive for HCV; however, 63% did not know about treatment side effects or thought that side effects of therapy were minimal.

The brief educational intervention significantly improved knowledge about HCV (Table 3). Eighty-one (81%) percent of participants understood that treatment was not compulsory for everyone with HCV, as compared to 10% pre-education (p < 0.0001). Ninety percent (90%) of participants gave correct responses regarding HCV cure rates after the educational intervention, as opposed to 33% pre-education (p < 0.0001). After learning about the deleterious effects of alcohol in patients with HCV, significantly more participants believed that people in the community who tested positive for HCV would drink less alcohol (p = 0.003). Attitudes toward personal acceptance of HCV testing did not change after education since almost all participants wanted to be tested on the pre-intervention survey. However, the participants’ perceived acceptability of HCV screening among other members of the community did increase after education. Importantly, after education, participants were significantly less likely to believe that offering community-based HCV screening without guarantee of universal treatment would be problematic (49% pre-intervention believed this would be problematic vs. 35% post-education, p = 0.02).

The mean baseline knowledge score was 9.9 (SD 3.3), ranging from 0–18. Characteristics associated with greater knowledge were male gender, white race, younger age, and knowing someone with HCV (Table 4). Interestingly, participants who did not want to be tested for HCV if they were not guaranteed treatment had significantly lower knowledge scores than people who wanted to know their HCV status despite availability of treatment (p = 0.003). When dichotomizing age based on the CDC screening recommendations, participants greater than 45 years old (baby boomer generation) had mean knowledge scores that were lower than younger participants, though this did not reach statistical significance (9.5 vs. 10.4, p = 0.08). In multivariable analysis, white race, male gender, knowing a person with HCV, and wanting HCV testing even if treatment could not be offered remained associated with higher knowledge scores (Table 5).