Knowledge Regarding Hepatitis C Among Injecting Drug Users

BOBBY P. SMYTH,¹ JULIE McMAHON,² JOHN J. O'CONNOR³ & JIM RYAN<sup>4

1</sup>AIDS/Drugs Service, Eastern Health Board, Cherry Orchard Hospital, Dublin 10, Republic of Ireland; ²James Connoly Memorial Hospital, Dublin 15, Republic of Ireland; ³Drug Treatment Centre, McCarthy Centre, Pearse Street, Dublin 2, Republic of Ireland; ⁴122 Raheny Road, Dublin 5, Republic of Ireland.

ABSTRACT Hepatitis C (HCV) is very prevalent among injecting drug users (IDU). Control of this infection poses a major challenge to harm reduction services. Education of all IDU regarding HCV constitutes part of the harm reduction programme. We sought to assess understanding of HCV among IDU attending an addiction treatment clinic and to identify whether or not those with increased contact with health professionals demonstrated better understanding. A total of 105 IDU were interviewed to assess their knowledge regarding modes of transmission and chronicity of HCV infection. They had first infected an average of 10.0 years previously. Interviewees were more successful at identifying activities which posed no risk of infection. Over one-third falsely believed that one could contract HCV infection even when injecting "safely". Understanding of the long-term nature of HCV infection was also impaired. A group on methadone maintenance for a median period of 1.4 years failed to demonstrate significantly better knowledge than those attending for a 21-day detoxification. Those in frequent contact with a GP performed less well than those without such contact. Understanding of HCV among IDU is inadequate and must improve if primary prevention efforts are to succeed. We question the value of didactic approaches to educating IDU and call for a more experiential teaching style which may be more successful at countering prevalent misconceptions.

World-wide, infection with hepatitis C (HCV) is common among injecting drug users (IDU) (MacDonald et al., 1996; Thomas et al., 1995; Wodak & Crofts, 1996). Although UK IDU have demonstrated a reduction in risk behaviour (Griffin et al., 1993; Stimson & Hunter, 1996), the prevalence of this infection remains high in injectors who commenced injecting in the current era of harm reduction (Smyth et al., 1998). Some commentators have become quite skeptical about the prospect of reducing rates of HCV among IDU (Wodak & Crofts, 1996). Internationally, harm reduction efforts include the provision of sterile injecting equipment and treatment with methadone. Education regarding safe injecting and the dangers of unsafe injecting such as HIV and HCV, is another crucial component and occurs in treatment settings and through community outreach. All of these approaches are currently in existence in Dublin. At this point in time there has been no public health awareness campaign targeting hepatitis C. Therefore, IDU in Dublin are likely to have acquired information about hepatitis C from one of two main sources, health professionals and via peers (Barendregt & Trautmann, 1996; Wolitski et al., 1996). Health professionals include general practitioners and staff working in specialist addiction treatment centers. The effectiveness of health professionals' attempts to educate IDU regarding HCV has not previously been assessed. If inadequate, it may account in part for the ongoing high incidence of HCV

HCV is though to be spread very readily via sharing needles and syringes. Sexual transmission and vertical transmission can also occur, although the level of risk associated with each of these circumstances is less. Now that blood products are screened for HCV, the risk of infection via blood transfusion is very much reduced, but is not zero. Up to 90% of infected persons are thought to carry the virus indefinitely (Cramp & Williams, 1997; Gully & Tepper, 1997).

Two Australian studies have found knowledge of hepatitis C to be lacking among certain treatment risk groups (prison inmates and high risk drug users), although the populations studied were not confined to IDU (Butler et al., 1997; Carruthers & Loxley, 1995). We sought to measure IDU's level of knowledge regarding HCV in the setting of an addiction treatment clinic and to identify factors influencing this knowledge. We anticipated that those with increased contact with medical services would demonstrate better understanding, i.e. a 'dose-response' type effect. Also, for those of unknown HCV status, we wished to assess their current perceived level of risk of HCV infection.

Patients and Methods

All patients had a history of injecting drug use and a diagnosis of opiate dependance. A researcher (JM), who was independent of treatment services, interviewed patients over a 5-week period during August and September 1997. The patient groups eligible for inclusion were (i) those who commenced a 21-day methadone detoxification during the study period and (ii) those who attending the clinic daily or on alternate days for methadone maintenance at the outset of the study. Patients were asked to consent to a confidential, structured interview lasting 30 min approximately. Due to time constraints, the researcher could not meet all 139 eligible patients and consequently 30 (22%) were not asked to participate. Four of those who were asked to consent to interview refused. The overall participation rate was 75.5%. Those not interviewed did not significantly differ in terms of sex ratio or age. Data were collected on socio-demographics, drug use history, current treatment and contact with GP.

As no standardized instrument exists for assessing patients' knowledge regarding HCV, we developed our own series of questions. A scoring system was also agreed among the research team after consultation with experts in the area of HCV. We chose to focus on two aspects of HCV. These were (i) routes of transmission and (ii) chronicity of infection. Regarding routes of infection, interviewees were initially asked to identify al routes of transmission which they believed could lead to HCV infection without prompting. They were then presented with a list of seven possible modes of spread of hepatitis C and asked to identify those which they thought were true, false or about which they were unsure. In order to calculate an overall 'knowledge score' for each interviewee, the following scoring system was employed. Correct responses were scored 'plus one', incorrect responses scored 'minus one' and 'don't knows' scored zero. We believed it to be appropriate to use a 'negative marking system' as a false belief was considered more hazardous in terms of the individual contracting and spreading HCV infection, than an acknowledgement of being unsure regarding a given mode of possible transmission. The two questions on chronicity of infection followed a multiple choice format, interviewees being presented with a list of possible answers. Correct responses to each scored two points, nearly correct responses scored one point and incorrect responses and 'don't knows' scored zero. The maximum possible 'knowledge score' was 11. For all questions, interviewees were asked not to guess Medical terms such as 'vertical' were not used during questioning with simple lay terminology being substituted.

Results

Seventy-three (70%) of the 105 patients were male. The median age of the group was 29 years (range 16-48). The median period since first injecting was 8 years (range 0.2-30years). Forty-three patients (41%) were on the detoxification programme and 62 (59%) were on maintenance. Those on maintenance had been attending for a median period of 1.4 years (range 0.1-20 years). Overall 84 (80%) reported previously having had a test for hepatitis C, and 75 (89%) of these indicated that the result was positive.
In all, 77 (73%) indicated that they were registered with a GP. Of this group, 70 (91%) reported that their GP was aware of their drug use and 47 (61%) had seen their GP six or more times over the preceding 12 months.
All participants had heard of hepatitis C. Table 1 indicates that the cast majority (90%) spontaneously identified sharing injecting equipment as being a risk activity for transmission of hepatitis C. Sexual intercourse and receiving a blood transfusion were the next two most frequently reported potential modes of transmission.

Table 2 indicates responses when interviews were asked directly about specific activities. In all, 77 (73%) recognized all four of the risk activities (i.e. sharing injecting equipment, sex, transfusion and vertical). The proportions responding correctly dropped when asked about activities with no recognized risk with only 46 (44%) recognizing all three 'safe' activities (i.e. injecting without sharing, smoking heroin and kissing). On the issue of chronicity of infection, only 46 (44%) answered both questions correctly.
Over one-third incorrectly believed that on could contract HCV while injecting safely, i.e. when no sharing of any injecting equipment or associated paraphernalia occurred (Table 2). Those who believed this were subsequently questioned about how this might occur to ensure that they were not misunderstanding the question. Theories about this mode of transmission varied but included; 'if your own blood is exposed to the air when you draw back, you can get it', 'its on your skin and once you push the needle through, you get it' or 'it can just be in the gear (Heroin)'.
Regarding the overall 'knowledge score', these ranged from minus 1 to 11 (mean 7.60, median 8). Only 18 (17%) of interviewees responded correctly to all questions. Table 3 shows the relationship between the mean 'knowledge score'

and various independent variables. Older age and longer history of injecting were each associated with significantly better scores (p<0.01). (It must be noted that the groupings for age tending also to have longer injecting histories (chisquared = 33.9, p<0.001). Those in frequent contact with a GP did significantly worse than those without such contact (p=0.02). Neither younger interviewees nor those with shorter injecting histories were over-represented in the group with frequent GP contact (data not shown, chi squared test, p=0.73 and 0.74, respectively). Gender, remaining longer in education, employment status, having previously tested for HCV and being on the maintenance programme were not significantly associated with better scores.

Of the 21 never previously tested for HCV, only five thought it likely or very likely that they were currently infected.

Discussion

This study has some limitations. Firstly, only 75.5% of the available study population were interviewed due to time constraints imposed on the number of weeks during which the interviewer could attend the clinic. However, we believe that it is unlikely that any sampling bias was inherent in this process. The study population is modest in size and hence limited the power to detect possible independent variables which exert a minor effect on knowledge enhancement. Also in this study population, the mean age is greater and mean length of injecting history longer than the corresponding figures from the national statistics on attendances for treatment of drug misuse (Moran et al., 1997). This suggests that the level of knowledge demonstrated in this study is greater than one would expect of the typical IDU attending for treatment in Dublin. Also, we did not attempt to assess understanding of the various degrees.

independent samples t-test performed. Levene`s test for equality of variances supported validity of use of t-test in each case. <sup>b</sup>For the purposes of data presentation and statistical analysis, quantitative variables were categorized according to their median value. <sup>c</sup>One interviewee was still attending school. <sup>d</sup>Attending a GP more than five times in the preceding 12 months is considered `frequent`.

fying those activities which posed no risk of HCV. We are concerned at the finding that substantial minorities believe that there is risk of exposure even when not sharing any injecting paraphernalia and when only smoking heroin. Perceived personal vulnerability to infections such as HCV is likely to be a factor in leading individuals to avoid practising unsafe injecting (Carruthers & Loxley, 1995). If this vulnerability is diminished by a false belief that one may already have been exposed to HCV when injecting safely or when smoking, the preparedness to share injecting equipment may well increase. Hence such misconceptions may facilitate spread of HCV and HIV. IDUs' underestimation of their level of risk of exposure to HCV was demonstrated and this is a frequent finding in studies of this nature (Carruthers & Loxley, 1995).
Those participants who were on the maintenance programme had been attending for a median period of over 500 days. The maximum attendance period for those on the detoxification programme prior to interview was 25 days, but was much less in most cases (exact period of attendance not recorded for the detoxification group). The fact that those on the maintenance programme did not know significantly more about HCV suggests that prolonged and ongoing contact with a treatment center is not significantly better in terms of knowledge acquisition than a brief contact. The finding that those in regular contact with a GP performed less well than those without such contact was surprising. We were unable to identify any confounding variable which could explain this observation. Overall, we found no evidence that health professional contact and knowledge acquisition demonstrated a positive 'dose-response effect'.

Conclusion

In this highly treated population of IDU, many still demonstrated prominent misconceptions about the ease of transmission and natural history of HCV infection. Simply increased contact with services has not been shown here to lead to any significant gain in understanding. Hence one must conclude that current education approaches in specialist treatment centers and by GPs have deficits. There may be inadequate understanding of HCV among drug service workers and this could be usefully examined in further studies. Alternatively, rather than a lack of knowledge, there may be inadequacies in the way in which information is provided to IDU. Stiernborg et al. (1996) evaluated HIV educational approaches and demonstrated that a didactic teaching style is less effective than an experiential style. It may well be the case that as health professionals, we are more inclined to give facts to patients about what we know to be the risk activities, rather than explore with them what they perceive as risk behaviour. When adopting the latter approach, their misconceptions are more likely to emerge and thereby provide the clinician with the opportunity to correct and educate. This approach is amenable to group work (Stiernborg et al., 1996). If misconceptions are not corrected on contact with health professionals, then the potentially useful peer network will only serve to perpetuate misinformation (Barendregt & Trautmann, 1996).

We accept that even if all IDU were fully informed, injecting risk behaviour would not cease. However, we firmly believe that extensive syringe exchange programmes, without co-existing focused education approaches, will fall far short of their potential impact (Smith, 1987; Strathdee et al., 1997). There is a need for thoughtful education initiatives, which take into account the various myths and misconceptions which are prevalent in each given area world-wide. This means moving away from the typical didactic model of fact provision.

Acknowledgements

The authors wish to acknowledge the co-operation of the staff of McCarthy Centre in facilitating this study. We also wish to express our gratitude to Dr Eamon Keenan for his advice and criticism in the preparation of this manuscript and to Dr Saeed Al-Bloushi and Dr Shay Keating for their advice regarding the scoring system used in this study. We are grateful for the generous funding received from the AIDS/Drugs Service of the Eastern Health Board, Dublin and from the Charitable Trust of The Charitable Infirmary, Dublin.

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