Knowledge, attitudes, and beliefs of patients with chronic liver disease.

Chronic liver disease (CLD) has origins ranging from acquired, infectious, toxic, metabolic, and inherited causes. Long-term consequences include liver cancer, cirrhosis, and liver failure, and the combination of the latter 2 diseases constituted the 12th leading cause of death in the US in 2011.1 In the US, the major etiologies of CLD include alcohol abuse, chronic infections with hepatitis B virus (HBV) and hepatitis C virus (HCV), biliary track diseases, hematochromatosis, nonalcoholic fatty liver disease, drug toxicity, autoimmune chronic hepatitis, and rare autosomal recessive metabolic diseases such as Wilson’s disease. It is difficult to prevent and control CLD due to a wide array of causal factors that contribute to this disease. Of growing concern is non-alcoholic fatty liver disease (NAFLD), which is highly correlated with obesity and diabetes. NAFLD is the most rapidly increasing type of CLD in the western world due to escalating rates of obesity.2 NAFLD incidence rates are expected to continue to rise, which would add considerably to the CLD burden.3 Despite the fact that approximately 150 million people worldwide were infected with chronic HCV in 2012,4 and an estimated 30% of the world’s population (approximately 2 billion persons) have serologic evidence of current or past HBV infection,5 global public discourse and political action surrounding viral hepatitis is limited, perhaps due in part to low public awareness of transmission risks and consequences for developing liver cancer, as well as associated stigma of infection that is documented in the literature.6,17 The stigma that accompanies viral hepatitis infections is a detrimental modifying factor that is a major perceived barrier for treatment. For these reasons, coupled with the fact that latency periods for the diagnosis of sequelae of the virus can be decades, chronic viral hepatitis is often referred to as the “silent epidemic.”6 A report from the US Centers for Disease Control called attention to the growing health burden of viral hepatitis in the US, estimating that annual deaths due to HCV surpassed HIV deaths in 2007; it is also estimated that some 3.2 million Americans are chronic HCV carriers, most of them unknowingly.7 These trends are triggering intense deliberations in the public health community regarding whether or not to recommend routine HCV screening and the populations that such screening would target. This is likely to stimulate pressure for liver cancer screening among those who test HCV-positive, as hepatocellular carcinoma is a major consequence of HCV infection. Given these trends – a growing viral hepatitis burden, multiple risk factors, increased needs for screening, and the absence of a vaccine for HCV – the Institute of Medicine identified“a lack of knowledge and awareness about chronic viral hepatitis among at-risk populations, members of the public, and policy-makers” as major barriers to prevention and control.8 In the context of the Health Belief Model,9 patient education could be an important component of prevention and control efforts, as improving an individual’s knowledge is imperative in improving attitudes and beliefs and thus action and behavior change towards proper management of disease. Patient education has been shown to impact a wide range of patient behavior, including increased uptake of vaccinations10 and changes in personal behavior related to chronic disease prevention,11 breast cancer,12 and cervical cancer.13 Therefore, the Health Belief Model serves as an appropriate framework for understanding how individuals with CLD acquire health knowledge, how they are personally impacted by such knowledge, and how they are best prompted to implement behavioral changes to actively engage in their own care.9 To our knowledge, no prior qualitative study has assessed CLD patients’ knowledge about liver cancer, perception of their risk of liver cancer, health behaviors associated with liver cancer progression, and barriers to liver care. Therefore, our study, guided by the Health Belief Model, aimed to assess these factors among patients at a tertiary care center.