Inpatients ’ Knowledge about Primary Liver Cancer and Hepatitis

Primary liver cancer is one of the most common malignancies in the world and is one of the leading causes of cancer-related death (El-Serag et al., 2008; Shariff, et al., 2009; Ferlay et al., 2010; Bruix et al., 2011). Developing countries are disproportionally affected by HCC and over 80% of HCCs occur in such countries (Ferlay et al., 2010), China accounts for approximately 55% of the total world’s burden. Despite recent advances in surgical techniques and medical treatment, the 5-year survival rate for liver cancer remains poor. The American Cancer Society (ACS) notes that the overall 5-year survival rate is estimated to be less than 10 per cent, after taking into account patients who have different stages of liver cancer. According to government statistics, HCC is the third most common deadly cancer in China, accounting for about 20% of the total cancer mortality burden. HCC is not the most common cancer in the Chaoshan area, although it is one of the most fatally malignant diseases and the mortality rate is ranked second only to lung cancer in cancer related deaths (Qin et al., 2010). It could be expected that knowledge rates would be substantially greater about a cancer so common in the region where the research was conducted. Approximately, 70% to 80%


Introduction
Primary liver cancer is one of the most common malignancies in the world and is one of the leading causes of cancer-related death (El-Serag et al., 2008;Shariff, et al., 2009;Ferlay et al., 2010;Bruix et al., 2011). Developing countries are disproportionally affected by HCC and over 80% of HCCs occur in such countries (Ferlay et al., 2010), China accounts for approximately 55% of the total world's burden. Despite recent advances in surgical techniques and medical treatment, the 5-year survival rate for liver cancer remains poor. The American Cancer Society (ACS) notes that the overall 5-year survival rate is estimated to be less than 10 per cent, after taking into account patients who have different stages of liver cancer. According to government statistics, HCC is the third most common deadly cancer in China, accounting for about 20% of the total cancer mortality burden. HCC is not the most common cancer in the Chaoshan area, although it is one of the most fatally malignant diseases and the mortality rate is ranked second only to lung cancer in cancer related deaths (Qin et al., 2010). It could be expected that knowledge rates would be substantially greater about a cancer so common in the region where the research was conducted. Approximately, 70% to 80%

Inpatients' Knowledge about Primary Liver Cancer and Hepatitis
Wen-Jing He 1& , Ming-Yan Xu 2& , Rui-Rui Xu 3 , Xiao-Qiong Zhou 1 , Jun-Jie Ouyang 1 , Hui Han 3 , Geng-Zhen Chen 3 * of HCC cases are attributable to chronic infection with hepatitis B virus (HBV). HBsAg screening was performed in 125,474 primary and secondary school students in Shantou city in 2009 and demonstrated an average total positivity rate for HBsAg of 8.1%, comprised of 7.8% (5108) primary school and 8.5% (5047) secondary school students, totalling 10,147 infected students (Zhang et al., 2011). Hence, there is a relatively high infection rate of HBV amongst the younger generation, but only a percentage of them have chronic active hepatitis and the rest are termed "HBV carriers". According to the Shantou Municipal Centre for Disease Control and Prevention's statistics, hepatitis B accounted for 67.64% of the detected total viral hepatitis burden in the period from 1995 to 2005 (Yao et al., 2007).
Prevention means eliminating or minimizing exposure to the causes of cancer, and also reducing individuals' susceptibility to such causes. The World Health Organization (WHO) announced that, "at least onethird of the cancer cases that occur annually throughout the world could be prevented. Primary prevention is an important means to improve public health, and it is by far the most cost-effective and sustainable intervention for reducing the burden of cancer globally." There is innumerable research about HCC and hepatitis, however studies on the preventative issues of liver cancer are rare. The control of HCC requires the effective implementation of individuals' knowledge. To the best of the researcher's knowledge, there has been no research conducted to ascertain the public's awareness of HCC and hepatitis in China, nor have public education programs been conducted. All of the population, including those people infected with the hepatitis virus should be made aware of: the risk factors, the early signs and symptoms, the transmission routes, and the preventative methods for these diseases, in order to prevent or minimise the development of liver cancer. The results of this study can lead to appropriate priority settings being made by health authorities to direct research and cancer control programs, plus new educational strategies being applied to progress the public's awareness of hepatitis and HCC. Adequate education is expected to lead to improved early diagnosis rates, increased disease assistance seeking behaviours, and preferably the prevention of new cases of HBV and HCC amongst the general population.

Study population and design
This study was conducted at two major tertiary hospitals in the Chaoshan area of China from August 2012 to March 2013. These two hospitals provide medical care for residents in that area. Participants were systematically selected from different wards in the inpatient area according to the admission number of each patient. The research proposal was approved by the ethics committee of Shantou University Medical College.
Each of the participants was interviewed by a medical practitioner to assess their level of knowledge regarding liver cancer and hepatitis B, the most common form of hepatitis. The results were recorded in the questionnaire. The total sample size was 1300. A standardized questionnaire was administered by the interviewers to obtain information about: gender, age, income, and other demographic data, risk factors for HCC, symptoms and signs of HCC, prevention and management of HCC, routes of HBV transmission, and practices to prevent transmission. Interviewers used open ended questions to ascertain how participants had gained their knowledge, and how those who were infected with HBV had acquired the infection.

Statistical analysis
This scale used includes 51 items; each item is answered "yes" or "no" or " I do not know". A correct answer is scored 1, a wrong answer scored 0. Total scores range from 0 to 51, with a higher score indicating a greater level of knowledge about HCC and hepatitis. Every participant was scored for all items and their mean knowledge score was recorded. The participants' levels of knowledge, descriptive statistics (frequency and percentage) and the relationship between knowledge and variables such as demographic data, and past history were analysed with SPSS Version 16.0 (SPSS, Inc. Chicago, IL, USA) by descriptive statistics (mean, standard deviation), comparison means (One Way ANOVA Test), and multiple regression analysis.

Questionnaire
The questionnaire developed by the researchers contains two parts; : colon the demographic data, and the data of the participant's awareness regarding liver cancer and hepatitis. The questionnaire was developed by the researchers after reviewing reference books of gastroenterological diseases and related articles and was validated by professors of internal medicine and epidemiology. Demographic data includes: gender, age, occupation, education, income, past medical history and any known family history of cancer. The participants'    awareness regarding liver cancer was categorized into four groups: risk factors (14 statements), symptoms and signs (8 statements), prevention (8 statements), and management strategies (5 statements). Awareness regarding hepatitis was subdivided into two groups: transmission routes (5 statements) and prevention strategies (5 statements). Before the study, a pilot phase was conducted with 20 persons in order to test the reliability and appropriateness of the questionnaire. The pilot group was re-questioned two weeks later and their answers were found to be primarily the same as on the first occasion, verifying the reliability and appropriateness of the study.

One way ANOVA test
The mean knowledge scores were correlated with: education, occupation, income, and any known history of cancer in their family and/or friends (P<0.05). The group with a history of liver disease did not show any significantly higher knowledge score than other groups (P>0.05) ( Table 2).

Multiple regression analysis
The researchers investigated the impact of gender, age, education, vocation (job), and family and friend's history of liver diseases on the total knowledge score by performing a multiple regression analysis. Education as the sole predictor (model1), accounted for 15.3% of the variability in the total score (R 2 = 0.153. When family history was added as a second predictor (model 2 in Table 4), it accounted for 17.7% of the variability (R 2 = 0.177). Friend history accounted for an additional 19.1% of the variability (R 2 = 0.191). When friend history and gender were added (model 3 in Table 4), the 4 predictors accounted for 19.8% of the variability (R 2 = 0.198), which is reasonably higher. However, from model 3 to model 4, adding gender score only increased the variation of the total score by 0.7%. For each regression model, SPSS calculated standardized regression coefficients (β) along with and partial regression coefficients (B, often called slop). The β showed to what degree each predictor affected the outcome when the effects of all other predictors are constant. For example, in model 4, the β values of education, family history, friend history and gender were 0.360, -0.131, -0.128 and 0.082, respectively (Table 5). This means that an increase in education of 1 degree (i.e. a difference of 1 SD of education) was associated with 0.360 units (i.e. 3.40, or 0.360 × 9.46) of variation in the total score. This interpretation is valid when all other predictors in the equation (family history, friend history and gender) were constant.
The factors of family and friend history had little effects upon the total score. A family history was associated with Predictors: X 1 =education; b Predictors: X 1 =education, X 2 = family history; c Predictors: X 1 =education, X 2 =family history, X 3 =friend history; d Predictors: X 1 =education, X 2 =family history, X 3 =friend history, X 4 =Gender; e Dependent Variable: Y= total score a 0.131 units (1.24, or 0.131×9.46) decrease of the total score, and a friend history was 0.128 units (1.21 min, or 0.128×9.46). Gender had a mild impact upon total score. Every 1 SD change for gender predicted a 0.78 change in the total score.

Discussion
The mortality from liver cancer (HCC) has increased in China in recent decades. It is imperative that solutions are found for the current situation. What reasons lie behind the high incidence and the high mortality rates of primary liver cancer in China? Firstly, China has a high occurrence of HBV infection. A survey of national epidemiology was announced in April 2008 by the Ministry of Health which showed that 93 million confirmed people in China had been infected with HBV, which is approximately 7,000 per 100,000 people. Government statistics illustrate that the incidence of hepatitis had increased from 64.91 to 107.30 per 100,000 people in the period from 2000 to 2009. Chronic infection with HBV in China is considered to be a major risk factor for HCC (Liu et al., 2011). The apparent increase in the incidence of hepatitis could also be due to improved testing programmes to detect the virus. Secondly, there are a lack of regular medical physical examinations conducted amongst chronic virus carriers and many other people are asymptomatic and unaware of their carrier status (Lok et al., 1991). Thirdly, there is a lack of public knowledge about factors such as lifestyle which are important for the prevention of hepatitis and liver cancer (Nobili et al., 2008;Giles et al., 2013). Lastly, liver cancer in adults has a poor prognosis, because it tends to be diagnosed at the advanced stages of the disease, and also, many people with liver cancer also develop comorbid liver disease such as cirrhosis, which is frequently fatal, leading to low survival rates.
The development of liver cirrhosis has been recognized as a major step in the pathogenesis of most cases of HCC. as it is found in 80-90% of cases of HCC (Llovet et al., 2003). Risk factors that have been associated with the development of HCC additional to cirrhosis and HBV include: diabetes mellitus, alcohol consumption, cigarette smoking, and aflatoxin exposure (Yu et al., 1991;Yu et al., 2004). Chronic infections with hepatitis B and hepatitis C viruses are the most well established environmental risk factors for HCC worldwide. It is generally believed that 15-40% of HBV carriers will die due to end-stage liver disease (Kao et al., 2010). According to the Shantou Municipal Centre for Disease Control and Prevention's statistics, in the period from 1995 to 2005, hepatitis B accounted for 67.64% of the total viral hepatitis burden (Yao et al., 2007). There is still a relatively high infection rate of HBV in the younger generation in China (Zhang et al., 2011). In July 2011, 179 countries vaccinated infants against hepatitis B as a part of their vaccination schedules -a major increase compared with 31 countries in 1992, the year when the World Health Assembly passed a resolution to recommend global vaccination against hepatitis B. HBV vaccination was introduced into China in 1991, and the government commenced free routine infant HBV vaccination in 2002. The high rate of chronic HBV infection in China is mainly the result of perinatal or early childhood transmission. The distribution of HBV vaccination is fewer in some rural areas and amongst people of middle and older age. Most unvaccinated people lack the knowledge to: seek screening for HBsAg, and to become vaccinated. The interview revealed that many people held the wrong opinion, that vaccination was only available for infants, but not for adults. The authors concluded that the important first step to prevent the transmission of hepatitis B was is to educate the population in order to increase HBV vaccination rates.
The majority of people surveyed identified chronic liver diseases, aflatoxin, tobacco and alcohol as risk factors for HCC, but fewer people were aware of other risk factors such as: obesity, diabetes, micronutrient deficiency, raw seafood, pickled vegetables, and fish sauce, and only 40% of participants regarded cancer as a genetic disease. Dietary habits and other family related behaviours associated with HCC may account for some of the observed familial aggregation of the disease. Genetic lesions play a major role in HCC tumorigenesis and progression (Kim et al., 2005;Li et al., 2012). Firstdegree relatives of patients with HBV-related HCC appear to be at increased risk of HCC and should be considered in the formulation of HCC-screening programs (Yu, et al. 2000). Participants with a history of liver diseases did not show any significantly higher knowledge scores for the risk factors, symptoms and signs, or the preventative strategies against HCC. The majority of participants ate pickled vegetables on a daily basis as side dishes, and yet only 52.51% were aware of the correlation between pickles and cancer. Only 17% of participants regarded eating fish sauce as an unhealthy daily habit, whilst most held the opinion that eating pickles and fish sauce were traditional practices and, even regarded them as healthy foods. It is known that preserved meat and fish sauce are rich in N-nitroso compounds (Deng et al., 1998;Deng et al., 2000;Haorah et al., 2001;Stute et al., 2002). The nitrite from these and other sources, including that purposely added to food, presents a toxic hazard, both because of the direct toxicity of nitrite and by the formation of carcinogenic N-nitroso compounds by reactions with amino compounds (Peter et al., 1975;Wakabayashi et al., 1985). N-nitroso compounds are suspected to be correlated with gastrointestinal tract carcinomas, including liver cancer (Parkin et al., 1991;Mitacek et al., 1999). It is known that dietary exposure to aflatoxins is a risk factor for developing HCC (Montalto et al., 2002). 65.24% of the participants were aware that eating mouldy: peanuts, corn and other foods was harmful.
Tobacco smoking is common amongst Chinese men and is associated with alcohol consumption. Tobacco is responsible for about 50,000 liver cancer related deaths each year in China, chiefly among men with chronic HBV infection and hepatitis (Zhang et al., 1998). The Chaoshan area has high tobacco 'smoking' rates, 70.71% of males and 3.04% of female participants were tobacco smokers, and few people expressed the intention to cease cigarettes. 66.42% of the participants knew the relationship between smoking and liver cancer. Cirrhotic liver damage is chiefly caused by persistent lifelong HBV infection as previously mentioned. In early adult life, such infection generally remains asymptomatic and is therefore unlikely to deter the initiation of tobacco use. Cigarette smoking, positive HBeAg carrier status and chronic hepatitis all contribute synergistically to the development of liver cirrhosis (Yu et al., 1997). A meta-analysis showed that tobacco was associated with liver cancer development (Lee et al., 2009). There was a dose-response relationship between the consumption of alcohol and the development of HCC, 'heavy drinkers' having an approximately 3-4 fold risk increase, compared with non-drinkers (Zhang et al,1998).
The most correctly answered question in the category of 'the symptoms and signs of liver cancer' was for the association of cancer with jaundice (63.17%). The highest percentage of correct answers in the category of 'prevention' was for the association between and the prevention of liver cancer and in the category of management, the most correctly answered question was for the statement that "liver cancer can be cured in the early stage". For the 'transmission of hepatitis', the most correct answer was for the route often being blood transfusion (80.77%). 11.54% of participants held the incorrect opinion that a handshake or hug could transmit the hepatitis virus, which might lead to discrimination in society. Further results showed that even those at high risk of HBV and HCC lacked knowledge about prevention, and the availability of yearly screening for HCC. 20% of those in the healthy group had never been screened for HBsAg and had not received hepatitis B vaccination.
The participants had obtained their knowledge through various media. Television and radio (46.45%) were the most popular media, followed by magazines and newspapers (42.75%).The internet is becoming a popular medium for acquiring knowledge. The least popular way of obtaining information was from medical books. Educational intervention via video material, leaflets, and in verbal format has been proposed as an effective strategy to improve health behaviours and to increase patient's knowledge (Petti et al., 2007;López-Jornet et al., 2012). Education programs can be delivered through multiple channels ways based upon other researchers' results. Flyers and educational pamphlets can be distributed to clinics and can result in improved prevention of liver diseases (Humphris et al., 2003;Elango et al., 2011). Good post test results were shown for group educational programmes regarding breast cancer (Wang et al., 2012). The same would be expected for HBV and HCC. An organized system could initially be developed to improve cancer surveillance and screening and this could ultimately be expanded to other clinical preventive services. Hospital-based programs for example which were focused on vulnerable populations could educate individuals to obtain periodic physical examinations, and adopt healthier behaviours. The researchers concluded that the best media for the delivery of the educational programme would be via television, radio, magazines and newspaper commentaries, as the research demonstrated that around 90% of the respondents' knowledge was obtained from those sources..
Learning can be defined as a relatively permanent change in a behavioral tendency, occurring as a result of reinforced practice (Wedding et al., 2001). Improving a person's knowledge about liver cancer is likely to also change their behavior. According to the American Cancer Society, "if we can effectively promote healthy behaviours, much of the suffering and death from cancer can be prevented or reduced". The authors concluded and highlight the finding that a person's educational level is the most important predictor for their knowledge level. The data obtained from this study highlights the need to better educate the public about health. Cancer prevention and control interventions can be directed at individuals. Regular screening for HCC is of great importance for those at high risk. Encouraging people to obtain regular health checks and to adopt healthy lifestyles can only improve matters. The dissemination of basic knowledge about cancer can lay the basis for better controlling cancer, as it can lead the public towards prevention, early diagnosis and early treatment.
The World Health Organization announced that, despite cancer being a global public health problem, many governments had not included cancer prevention in their agendas. Rates of cancer-related illness and death can be expected to be lowered by education programmes including the media which lead to improved behaviours guided by improved risk perception. The public health system has a responsibility to lead a national approach to cancer control that is comprehensive, strategic, and organized (Plescia et al., 2012). The public awareness campaign will need to be reinforced over time due to the tenacity with which some individuals maintain their habitual behaviours. It would appear most prudent for the authorities to design an education plan appropriate for all of the population with special emphasis upon the highest risk group of people. The government will be rewarded in many ways by adopting a long term commitment to increase the public's knowledge of these liver diseases and to change the behaviour of individuals, in order to decrease the incidence and the mortality of hepatitis and HCC. These diseases cause serious morbidity and mortality and are endemic in the Chinese population. China contains 20% of the world's population and many people travel to and from China annually. Chinese families are spread across the world and the effects of these illnesses are felt globally. HBV, hepatitis and HCC cost the population and the government of China a lot in terms of money and suffering. This study indicates that education is an important avenue to reduce the future burden of these diseases upon the government and the population.
In summary, this reported study investigated a hospitalbased population's awareness of HCC and hepatitis. The results demonstrated a general lack of awareness of: cancer risk factors, symptoms and signs, methods of prevention, hepatitis transmission and prevention, and the importance of early diagnosis and management of hepatitis B virus and hepatocellular cancer. An appropriate and effective cancer education and screening programme needs to be formulated and carried out in China in the future. Appropriate prevention or early treatment of hepatitis B virus infection and hepatocellular cancer will benefit individuals, the community, the nation of China, and the world as a whole.