Running head: HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
Hepatitis C virus and the public health approach
Tracy Liichow
October 20, 2013
MPH 500: Foundations in Public Health
Professor Madeline A Meyer
Concordia University, Nebraska
1
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Abstract
The public health approach is to identify the health problem; work to develop interventions to
control or prevent the problem; implement interventions with hopes of mitigating the problem;
and then monitor and evaluate the results of the implementations (Schneider, 2013, p. 6). The
hepatitis C virus (HCV) has been identified as a health problem. Using epidemiology and
biomedical research HCV is being understood so an intervention and prevention can be
developed. An implementation plan can be developed recognizing psychosocial factors and
incorporating the health belief model and ecological model. This implementation would
hopefully result in mitigating the problems with HCV infection. The field of HCV biostatistics
could be and should be used to monitor the results of the interventions. This paper is an
overview of HCV and the public health approach. According to the Centers for Disease Control
and Prevention (CDC) (2008, p. 1), “Hepatitis C virus (HCV) infection is the most common
chronic bloodborne infection in the United States; approximately 3.2 million persons are
chronically infected.” HCV is responsible for acute and chronic liver disease in people.
Keywords: hepatitis c, HCV, liver disease, hepatitis, and HCV epidemic
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Hepatitis C virus and the public health approach
The public health approach is to identify the health problem; work to develop
interventions to control or prevent the problem; implement interventions with hopes of
mitigating the problem; and then monitor and evaluate the results of the implementations
(Schneider, 2013, p. 6). The hepatitis C virus (HCV) has been identified as a health problem.
When an individual’s liver has inflammation it has hepatitis. There are approximately 60
notifiable diseases identified by law at the federal level in the United States, and viral hepatitis is
one of those diseases (Schneider, 2013, p. 49). Viral hepatitis refers to a group of infections that
infect the liver and there are at least five recognized types of hepatitis viruses (Centers for
Disease Control, 2009). This paper is only an overview of one of the five types, namely the
hepatitis C virus (HCV); and this paper will present a public health approach to HCV.
According to the Centers for Disease Control and Prevention (CDC) (2008, p. 1),
“Hepatitis C virus (HCV) infection is the most common chronic bloodborne infection in the
United States; approximately 3.2 million persons are chronically infected.” HCV is responsible
for acute and chronic liver disease in people. HCV’s mode of transmission is usually through
contact with infected blood, and another mode of transmission is through sexual contact with an
infected person (National Institutes of Health, 2013, sec. 1). There is evidence of perinatal
transmission as well (Nelson & Thomas, 2007, p. 929).
The financial cost to the nation of the infection is high. “In 1998, the estimated annual
costs of acute and chronic hepatitis C (medical and work loss) was above $1 billion in the USA”
(World Health Organization, 2013, sec. 4). The World Health Organization (WHO) (2013, sec.
2) estimates “there are more than 170 million chronic carriers who are at risk of developing liver
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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cirrhosis and/or liver cancer.” Therefore, HCV has caused a global epidemic (Ali, Abera,
Mihret, & Abebe, 2012).
HCV Epidemiology and Biomedical Information
The study of epidemics is called epidemiology (Schneider, 2013, p. 9). The field of
epidemiology has been an excellent resource for people infected with HCV. The results and
outcomes from epidemiological resources have produced a wealth of information and enhanced
the health of HCV infected individuals. From epidemiological research science and medicine
have been able to define HCV. HCV “is a small, enveloped RNA virus belonging to the
Flaviviridae family, genus Hepacivirus” (Penin, Dubuisson, Rey, Moradpour, & Pawlotsky,
2004, p. 5).
HCV “is a positive-stranded RNA virus” (Rosenberg, 2001, p. 451). An organism’s
complete set of DNA or RNA, including all of its genes, is called a genome (US National Library
of Medicine, NIH, US HHS, 2013). “The HCV genome is approximately 906 kb in length and
the proteome encoded is a polyprotein of a little more than 3000 amino acid residues”
(Rosenberg, 2001, p. 451). We have classified HCV into six genotypes and as HCV “evolved in
the population, the variations in genome sequences have become more dramatic” (Jensen &
Reau, 2013, p. 3). A proteome is all of the proteins produced by an organism; it is an entire set
of proteins (American Medical Association, 2013). The HCV proteome polyprotein “is
processed by a combination of host and viral proteases into structural and non-structural
proteins” (Rosenberg, 2001, p. 451). Please see figures 1 and 2 below to view the HCV virion
and genome.
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Furthermore, these proteins have functions. The use of analogy to other viruses has
established the functions of most of these proteins (Rosenberg, 2001, p. 451). However,
Rosenberg suggests that:
The development of antivirals for this infectious agent has been hampered by the lack of
robust and efficient cell culture and animal infection systems. Recent progress in the
molecular virology of HCV has come about due to the definition of molecular clones,
which are infectious in the chimpanzee, the development of a subgenomic replicon
system in Huh7 cells, and the description of a transgenic mouse model for HCV
infection. (2001, p. 451)
HCV disperses in several forms in the serum of an infected host, and it subsists within its hosts
as a collection of genetically distinct yet closely related variants (Penin et al., 2004, p. 7). The
HCV envelope proteins behave like “other viral envelope proteins involved in host cell entry”
and stimulate the joining together of the viral envelope and “a host cell membrane” (Penin et al.,
2004, p. 9).
Epidemiologist Kenrad E. Nelson (2007, p. 924) indicated “HCV infections are often
persistent, indicating that the virus has evolved mechanisms to escape immune surveillance.”
There is a consensus in the field of biomedical science regarding HCV that the genetic variation
is a significant obstruction. There is an outstanding obstruction to developing a vaccine for HCV
infection (World Health Organization, 2013, sec. 6). WHO (2013, sec. 6) declares that the
complication to developing a vaccine “is the extensive genetic variation between different strains
and genotypes, . . . The absence of a clearly defined protective immune response after natural
infection complicates the prospects of ultimately developing a vaccine against HCV infection.”
At present, there is no biomedical solution for HCV. According to Arthur Schoenstadt, MD:
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Currently, there is no guaranteed hepatitis C cure. In some cases, a person's body will
fight off the hepatitis C infection -- serving as a natural cure for the disease. However, the
majority of people with hepatitis C have a long-term (chronic) liver infection.
Medications can be used to help the body destroy the hepatitis C virus, but they do not
always cure the disease entirely. Even if treatment does not offer a cure, it may help stop
the swelling, scarring, and other damage to the liver that the disease may cause. (2008,
para. 1)
Consequently, a vaccine is not on the horizon at this time, however, treatment is beneficial.
Nevertheless, through the involvement of epidemiology, we have discovered a sizable
body of knowledge concerning HCV overall. Epidemiology’s investigation of HCV has
produced results and will continue to discover and generate knowledge that will benefit not only
people infected with HCV, but the general public, as well.
Biostatistics
HCV is significant to the field of public health because of its magnitude and impact,
therefore, a wealth of statistical data is available (Gray et al., 2011, sec. Abstract). Vital statistics
include the number of deaths as a result of HCV infection. “Of the three types of viral hepatitis
(hepatitis A, B, and C), hepatitis C accounted for the most deaths and had the highest death rate”
(Centers for Disease Control, 2012). The Centers for Disease Control and Prevention’s Division
of Viral Hepatitis (CDC DVH) surveillance report for the year 2010 states the following:
From 2004 through 2008, the mortality rate of hepatitis C increased from 3.7 deaths per
100,000 population in 2004 to 4.7 deaths per 100,000 population in 2008. From 2004
through 2006, the highest mortality rates were observed among persons aged 45–54
years. In 2007 and 2008, the highest mortality rates (15.7 and 17.7 deaths per 100,000
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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population, respectively) were observed for persons aged 55–64 years. (Centers for
Disease Control, 2013)
Table 1 below presents United States data for the years 2006 to 2010 including demographics
and the number and rate of deaths due to hepatitis C (Centers for Disease Control, 2012).
Anyone of any age can become infected with HCV (Alter, 1997, p. 627). Interestingly, HCV
infection is generally asymptomatic for years. Most HCV infected persons are not cognizant
they are infected until several years later when they develop “symptoms of cirrhosis or a type of
liver cancer, hepatocellular carcinoma (HCC)” (Colvin & Mitchell, 2010, p. 1). Additionally,
Alter (1997, p. 625) indicates that the “highest proportion both of incident cases and prevalent
infections is among whites, but the highest incidence and prevalence rates are among non-white
racial/ethnic groups.” Also, the prevalence of HCV in Injection Drug Users (IDUs) over the
years has been consistently higher than for non-injecting populations (Garfein, Doherty, &
Monterroso, 1998, p. S11). The use of illegal injection drugs is a social behavior, and it involves
psychosocial factors.
Psychosocial factors
An intervention and prevention recognizing psychosocial factors using a health belief
model and ecological model could be implemented in hopes of mitigating the problems with
HCV infection. What are the psychosocial factors involved and why are they relevant to a
discussion of HCV? The psychosocial factors are demographics, socioeconomic status (SES),
culture, race, ethnicity, stress, and social support (Schneider, 2013, pp. 221–225).
Social epidemiologist and research scientist, Bruce G. Link (1995, p. 82) argues that there
is evidence that “clearly establishes a strong and pervasive association between social conditions
and disease.” According to public health educator, Mary-Jane Schneider:
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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While public health does not have much power to change people’s SES, stressful life
events, or social networks, it is hoped that understanding how these factors affect health
may permit more effective interventions to promote healthier behavior. With this goal,
social and behavioral scientists have proposed various theories and models attempting to
explain how psychosocial factors affect health-related behavior. Some of these theories
focus on individual psychology, while others attempt to explain the effect of the social
environment on individual behavior. (2013, p. 226)
Jeannine Coreil (2009, p. 4) author of Social and Behavioral Foundations of Public Health
stated, “The most important challenges for improving health in the 21st century involve social,
cultural, and behavioral change.” The current public health era includes analysis of “changing
social conditions that undermine health as well as the behavioral patterns that put people at risk
of illness and injury” (Coreil, 2009, p. 10). Schneider (2013, p. 227) indicates that “The classic
frame of reference for understanding health behavior, and especially behavior change, is the
health belief model.”
The health belief model (HBM) briefly stated is based upon the individual and his or her
behavior and involves his or her vulnerability perceptions, severity perceptions, perceived
barriers, actionable effective preventive measures, and self-efficacy (Schneider, 2013, pp. 227–
228). The HBM can be applied to the intervention and prevention of HCV infection. Table 2
presents an outline of HBM and health behavior outcomes. What an individual, a community, or
the public knows about a particular disease threat may be different than what the public health
and medical community knows. Boyer and Paharia (2008) present a scenario:
For example, while a stage one presentation of many cancers may be considered less
risky and more likely to result in a cure then Hepatitis C [sic], most individuals without
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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medical training may be more frightened by a cancer diagnosis than by the diagnosis of
hepatitis. (p. 11)
The participants in a study of inner-city adults with a high risk for HIV and HCV “were more
likely to have inaccurate health beliefs about risks factors” (Krauskopf et al., 2011, p. 788) that
cause HCV than those that cause HIV. HBM can address misperceptions about hepatitis C.
Personally tailored messages that address misperceptions can improve assessment, counseling,
and case management of HCV infected persons (Schneider, 2013, p. 227).
The majority of HCV infected individuals live with it developing into a chronic condition
with this consideration comprehending the process of self-management is critical to maximizing
the quality of life as well as improving health outcomes (Fry & Bates, 2012, p. 460). “The
concept of self-management acknowledges that the patient is an active participant in the
management of their condition” (Fry & Bates, 2012, p. 461).
Additionally, the ecological model of health behavior can also be applied to HCV
infection. The ecological model examines “how the social environment . . . supports and
maintains unhealthy behaviors . . . [it] proposes that changes in these factors will produce
changes in individual behavior” (Schneider, 2013, p. 228). Social environment includes the
person who is infected with HCV, the person’s family, neighbors, coworkers, the person’s
employment or school and co-workers, the person’s memberships or church affiliations, and
finally the person is affected by public policies (Schneider, 2013, pp. 228–230).
What are the most effective ways to promote healthier behavior in regards to HCV
infection? The Institute of Medicine (IOM) issued a report in 2010 entitled, Hepatitis and Liver
Cancer: A National Strategy for Prevention and Control of Hepatitis B and C, which offered
recommendations for state and local health departments to include in their respective public
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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health plans (Institute of Medicine, 2010). This report was created as a nationwide “effort to
address these epidemics” (Institute of Medicine, 2010). According to Sue Parini (2001b, p. 18),
a leading Registered Nurse and Infection Control Manager, “An estimated 10,000 deaths each
year in the United States are related to hepatitis C, but that number is expected to triple in the
next few decades as the infection progresses in people who've been asymptomatic.” As
previously stated, HCV causes hepatitis C, which is a liver disease, and HCV can be
asymptomatic for years.
Furthermore, a high risk factor for HCV infection is an individual’s current and past
injection drug use (Garfein, Doherty, & Monterroso, 1998, p. S11). An injection drug user’s
“chances of contracting hepatitis C increase with years of drug abuse: 78% are infected after 1
year, 83% after 5 years, and 94% after 10 or more years of drug abuse” (Parini, 2001a, p. 36).
The IOM (2010, p. 2) indicates “many of the people at highest risk of contracting HBV and HCV
have not been tested due to limited access to health care.” Therefore, social environment is one
of the factors that contribute to a HCV infected individual’s health.
In regards to the ecological model, the stakeholders need to be identified. The first level
stakeholders are all of the HCV infected persons within the Unites States. In table 3 the
stakeholder pool has been narrowed to only include HCV infected injection drug users. The
other stakeholders (interpersonal, institutional, community, and public) are also identified in
table 3. The proposed implementation activities are identified in table 3.
Change of behavior is not easy in any respect. It will require work from all stakeholders.
Yet, the effort is necessary in order to produce healthy outcomes for persons who are HCV
infected injection drug users. HCV is not going away; in fact, the incidents of liver disease due
to HCV will probably increase. HCV prevention and treatment should be on the minds of the
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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entire public health community. The HBM and the ecological model appears to be the best
approach to HCV prevention and treatment when focusing on social and behavioral factors.
However, there needs to be further study, planning, implementation, and evaluation of the
models as they relate to HCV.
In conclusion, as stated above HCV is a global threat. New strategies to assist
intervention and prevention of HCV are currently being developed (Penin et al., 2004, p. 5).
There needs to more epidemiological, biomedical, and social and behavioral research
undertaken. With the public health approach as guide we can make the following observations.
The problem has been identified; work has been done on developing intervention controls; plans
are being written to implement the interventions using psychosocial models; and monitoring and
evaluations have to be made. In the meantime, the biostatistics are driving the motivation to
continue and succeed. The goal is to improve the health of HCV infected persons and prevent
further infections. There is a lot of work to be done and the public health approach is the best
way forward.
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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References
Alter, M. J. (1997). Epidemiology of hepatitis C. Hepatology, 26(S3), 62S–65S.
doi:10.1002/hep.510260711
American Medical Association. (2013, March 20). Proteomics. Retrieved from http://www.amaassn.org//ama/pub/physician-resources/medical-science/genetics-molecularmedicine/current-topics/proteomics.page
Boyer, B. A., & Paharia, M. I. (2008). Comprehensive Handbook of Clinical Health Psychology.
John Wiley & Sons.
Centers for Disease Control. (2008, July 8). CDC DVH - Hepatitis C Information For the Health
Professional. Retrieved September 21, 2013, from
http://www.cdc.gov/hepatitis/HCV/index.htm
Centers for Disease Control. (2012, June 5). CDC DVH - Viral Hepatitis Statistics &
Surveillance - Viral Hepatitis Surveillance – United States, 2010. Retrieved September
21, 2013, from http://www.cdc.gov/hepatitis/statistics/2010surveillance/Commentary.htm
Coreil, J. (2009). Social and Behavioral Foundations of Public Health. SAGE.
DiClemente, R. J., & Crosby, R. A. (2011). Health Behavior Theory for Public Health:
Principles, Foundations and Applications. Jones & Bartlett Publishers.
Fry, M., & Bates, G. (2012). The tasks of self-managing hepatitis C: The significance of
disclosure. Psychology & Health, 27(4), 460–474. doi:10.1080/08870446.2011.592982
Garfein, R. S., Doherty, M. C., & Monterroso, E. R. (1998). Prevalence and Incidence of
Hepatitis C Virus Infection Amon... JAIDS Journal of Acquired Immune Deficiency
Syndromes, 18(Suppl 1), S11–S19.
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Gray, R. R., Parker, J., Lemey, P., Salemi, M., Katzourakis, A., & Pybus, O. G. (2011). The mode
and tempo of hepatitis C virus evolution within and among hosts. BMC Evolutionary
Biology, 11(1), 131. doi:10.1186/1471-2148-11-131
Institute of Medicine. (2010). Report Brief Hepatitis and Liver Cancer: A National Strategy for
Prevention and Control of Hepatitis B and C (Report Brief for State and Local Health
Departments). Retrieved from http://www.iom.edu/Reports/2010/Hepatitis-and-LiverCancer-A-National-Strategy-for-Prevention-and-Control-of-Hepatitis-B-and-C.aspx
Link, B. G., & Phelan, J. (1995). Social Conditions As Fundamental Causes of Disease. Journal
of Health and Social Behavior, 35(Extra Issue), 80–94. doi:10.2307/2626958
National Institutes of Health. (2013, August 16). Hepatitis C. Hepatitis C. Text. Retrieved
October 19, 2013, from http://www.nlm.nih.gov/medlineplus/hepatitisc.html
Nelson, K. E., & Thomas, D. L. (2007). Viral Hepatitis. In C. M. Williams (Ed.), Infectious
Disease Epidemiology: Theory and Practice (pp. 895–939). Sudbury, MA: Jones &
Bartlett Learning.
Parini, S. (2001a). Document Page: Hepatitis C: Speaking out about the silent epidemic. Nursing,
31(3), 36–42.
Parini, S. (2001b). Hepatitis C: Speaking out about the silent epidemic. Nursing Management,
32(6), 18.
Penin, F., Dubuisson, J., Rey, F. A., Moradpour, D., & Pawlotsky, J.-M. (2004). Structural
biology of hepatitis C virus. Hepatology, 39(1), 5–19. doi:10.1002/hep.20032
Rosenberg, S. (2001). Recent advances in the molecular biology of hepatitis C virus. Journal of
Molecular Biology, 313(3), 451–464. doi:10.1006/jmbi.2001.5055
Schneider, M.-J. (2013). Introduction to public health. Jones & Bartlett Publishers.
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Schoenstadt, A. (2008, December 19). Cure for Hepatitis C. eMedTV: Health Information
Brought To Life. Retrieved October 1, 2013, from http://hepatitis-c.emedtv.com/hepatitisc/cure-for-hepatitis-c.html
US National Library of Medicine, NIH, US HHS. (2013, September 23). What is a genome?
Retrieved October 2, 2013, from http://ghr.nlm.nih.gov/handbook/hgp/genome
World Health Organization. (2013). Hepatitis C. WHO. Retrieved October 4, 2013, from
http://www.who.int/csr/disease/hepatitis/whocdscsrlyo2003/en/index4.html
Running head: HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Tables
Table 1: Number and rate* of deaths with hepatitis C listed as a cause of death†, by demographic characteristic
and year — United States, 2006–2010
Demographic characteristic
Age
Group
(years)
Race
0–34
Sex
No.
2007
Rate
No.
2008
Rate
No.
2009
Rate
No.
2010
Rate
No.
Rate
128
0.09
131
0.09
124
0.09
116
0.08
117
0.08
35–44
1,083
2.49
999
2.32
878
2.07
828
1.99
712
1.73
45–54
5,802
13.43
5,937
13.53
5,758
12.98
5,469
12.26
5,171
11.49
55–64
4,191
13.28
5,145
15.72
5,967
17.71
6,683
19.21
7,431
20.37
65–74
1,500
7.93
1,621
8.37
1,709
8.49
1,824
8.77
1,901
8.75
≥75
1,241
6.76
1,273
6.85
1,332
7.11
1,333
7.01
1,293
6.97
White§
10,783
4.05
11,798
4.31
12,261
4.37
12,682
4.43
Black¶
2,567
7.50
2,686
7.59
2,829
7.82
2,908
7.80
595
3.61
622
3.59
678
3.78
663
3.61
White, nonHispanic
10,575
4.03
Black, nonHispanic
2,981
7.72
Hispanic
2,318
6.83
Asian/Pacific
Islander
440
3.30
American
Indian/Alaskan
Native
248
9.90
Non-White, nonBlack**
Race/
Ethnicity
2006
Male
9,724
6.30
10,561
6.64
11,116
6.82
11,517
6.91
11,781
6.81
Female
4,221
2.52
4,545
2.65
4,652
2.65
4,736
2.65
4,846
2.63
4.70 16,627
4.65
Overall
13,945
4.35 15,106
4.58 15,768
4.66 16,235
Note: * Rates for race, sex, and overall total are age-adjusted per 100,000 U.S. standard population.
†Cause of death is defined as the underlying cause of death or one of the multiple causes of death and is based
on the International Classification of Diseases, 10th Revision (ICD-10) codes B17.1 and B18.2 (hepatitis C).
§Included white, non-Hispanic and white Hispanic.
¶Included black, non-Hispanic and black Hispanic.
**Included all other racial/ethnic groups.
Source: Centers for Disease Control. (2013, August 19). CDC DVH - Viral Hepatitis Statistics & Surveillance 2011 Surveillance - Table 4.5. Retrieved September 22, 2013, from
http://www.cdc.gov/hepatitis/Statistics/2011Surveillance/Table4.5.htm
Running head: HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Table 2: an outline of HBM and health behavior outcomes
HCV Infected Injection Drug
User
Individual feels invulnerable
low risk of infection
Perceived severity of threat
low
Perceived barriers to reduce
the risk high
Perceived benefits low
Belief that there is no cure
Low self-efficacy – no point in
trying – no control
Action
Changed Behavior
Personally tailored educational
message concerning HCV
Informed of specify
consequences of the risk of
HCV infection
Identify barriers and remove or
reduce
Correct misinformation, give
incentives and assistance
Identify and point out positive
outcomes and effects that are to
be expected
Introduce harm reduction
measures and provide clean
needles
Provide opportunity to receive
community based organizational
case management
Provide training and
demonstrate desired behaviors
as well as reduce anxiety
Individual feels vulnerable
risk perception changed
Individual realizes threat
is severe
Certain actions will equal
prevention
Barriers removed or
reduced
Less likely to infect others
Receives treatment
Health improves
Enters a community based
organizational case
management program
High self-efficacy
Sources: Schneider, M.-J. (2013). Introduction to public health. Jones & Bartlett Publishers.
Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health Behavior and Health Education:
Theory, Research, and Practice. John Wiley & Sons.
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Table 3: Ecological model stakeholders with implementation plan
Stakeholders
The HCV infected
injection drug user
Levels (each level is a
potential target for health
promotion intervention)
Intrapersonal
Implementation
Enhance self-efficacy: major
campaigns directed to individual and
promote self-demonstrations
Family, friends, and
Interpersonal Relations
Group programs to education and
peers
correctly inform family and friends
Schools and
Institutional Factors
Employer or school health promotional
workplaces
activities and incentives
Churches, community Community Factors
A CBO program could “screen
based organizations
injection drug users for hepatitis C and
(CBO), and Facebook
then provide prevention case
(social media)
management to people testing positive”
(DiClemente & Crosby, 2011, p. 35)
Local, state, and
Public Policy and
Establish a state and local health
national governments
Regulations
promotion plan that include HCV
Public service announcements and
campaigns
Sources: Schneider, M.-J. (2013). Introduction to public health. Jones & Bartlett Publishers.
DiClemente, R. J., & Crosby, R. A. (2011). Health Behavior Theory for Public Health: Principles,
Foundations and Applications. Jones & Bartlett Publishers.
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Figures
Figure 1. The HCV genome
Source: Cann, A. (2007, May 21). Hepatitis C Virus: a mountain to climb. MicrobiologyBytes.
Blog. Retrieved October 19, 2013, from
http://www.microbiologybytes.com/blog/2007/05/21/hepatitis-c-virus-a-mountain-to-climb/
HEPATITIS C VIRUS AND THE PUBLIC HEALTH APPROACH
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Figure 2. The HCV virion
Source: www.med-ars.it. (2003). HCV ~ hepatitis C human virus. Retrieved October 11, 2013,
from http://www.med-ars.it/galleries/virus_4.htm