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Health Education Research Advance Access originally published online on August 31, 2006
Health Education Research 2006 21(5):654-661; doi:10.1093/her/cyl047
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© The Author 2006. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org

Risk perceptions and behavioral intentions for Hepatitis B: how do young adults fare?

RM Gonzales1,*, DC Glik1, M Prelip1, L Bourque1, J Yuen2, A Ang3 and MC Jones2

1 School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095, USA
2 Immunization Branch, California Department of Health Services, Berkeley, CA 94704, USA
3 School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA

*Correspondence to: R. M. Gonzales. E-mail: rachelmg{at}ucla.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflict of interest statement
 Acknowledgements
 References
 
Young adults are at risk for Hepatitis B infection. Little is known about their attitudes and beliefs concerning Hepatitis B, which are determinants of getting immunized. This investigation examined risk perceptions and behavioral intentions concerning Hepatitis B among a convenience sample of 1070 young adults, 18–24 years old who participated in a Hepatitis B campaign that aired a prevention-based advertisement in movies. The campaign did not produce any significant effects. Therefore, analyses presented in this paper explored whether risk perceptions and intentions vary by sociodemographic characteristics. Most young adults do not perceive themselves to be at risk for Hepatitis B, but perceive other people to be at risk. Gender and ethnic differences in behavioral intentions to seek out Hepatitis B information were also observed. This study offers insight about important factors to consider when designing Hepatitis B prevention interventions for young adults and suggests that increasing health-promotion efforts for this group, while accounting for differences in age, culture and gender, are warranted.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflict of interest statement
 Acknowledgements
 References
 
Hepatitis B mainly affects 20- to 50-year olds, many of them young adults. In the United States, >1 million people are chronic carriers of Hepatitis B. Roughly 100 000–150 000 persons become acutely infected with the virus and 5000 die from its effects each year [1, 2]. Chronic Hepatitis B is associated with significant morbidity, including cirrhosis, liver cancer and liver failure [3]. Hepatitis B virus transmission is linked to infected bodily fluids [4, 5], associated with sexual behaviors, injection drug use [5], tattooing and body piercing [6, 7]. Since young adults often engage in these activities, rarely seek health care [8], are sexually active and perceive themselves to be at low risk for infectious disease [9], they are at heightened risk for Hepatitis B.

Efforts to reduce the incidence of Hepatitis B among young adults are limited, despite an effective vaccine. Immunization coverage for children and adolescents has increased since 1991 due to universal immunizations for newborns [10] and state laws (1997–2000) requiring immunizations for children entering day care, grade/middle school and state college [8, 11]. Children born before 1992, now young adults, have low Hepatitis B immunization rates since they were not covered by these mandates. Adult immunization recommendations also overlook young adults by focusing on older adults identified at risk [4]. It is estimated that only 10–15% of 18- to 24-year old Californians have received Hepatitis B vaccinations, which means many young adults are unprotected against Hepatitis B [10, 11, 17].

Few investigations have examined health beliefs associated with Hepatitis B among young adults. Concepts of risk perception indicate that young persons often misperceive true risks for disease [12] and have difficulty in understanding the effects of cumulative risk or the consequences of repeated exposures to risks overtime [13, 14]. Young persons often rate their risk for disease lower than that of others, an optimistic bias tendency [13].

The Health Belief Model [15] posits that preventive behaviors are associated with health beliefs. How campaigns frame messages [16] also shape risk perceptions or health decisions. Prevention-focused framing relies on individual differences for promoting effective behavior change [13, 16]. The Hepatitis B campaign described emphasized preventive messages (i.e. Hepatitis B is preventable). These frameworks guided this investigation, which examined how Hepatitis B perceptions and intentions varied by individual factors.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflict of interest statement
 Acknowledgements
 References
 
Evaluation of the Hepatitis B campaign initiated by the California Department of Health Services determined data collection. The 6-week campaign was implemented in movie theaters throughout 11 California counties in 2003. A repeated cross-sectional design was used for evaluation in two southern California counties, with an intervention (airing slide) and control (not airing slide) theater. The slide was shown for 15 s, 16 min before the start of each movie. Message of the slide included: ‘Anyone can get Hepatitis B’, ‘Hepatitis B can be prevented’ and ‘get immunization information’ (see Figure 1).


Figure 1
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  		Fig. 1 Hepatitis B campaign slide.

 
Procedures
The sample included 1203 18- to 24-year olds attending movie theaters in Los Angeles (n = 601) and Orange (n = 602) counties in April 2003 and June 2003. Inclusion criteria included voluntary willingness, 18–24 years old and movie attendance. Recruitment occurred outside the theater as individuals approached the ticket booth for pre-test and as they exited the theater for post-test. Individuals were screened for eligibility with introductory questions. Separate samples of the 18- to 24-year population were sought in order to assess the impact of the communication message on the population as a whole. Each pre-test/post-test condition had ~75 respondents at each theater, totaling 150 per intervention and control (see Table I).


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  		Table I Demographic characteristics of sample by county, site and time of administration

 
Data collection occurred twice: at the start and end of the campaign (April 23–26 and May 30–June 1, 2003). Theater participation was based on the willingness of corporations to comply with evaluation activities. Obtaining corporate approval was challenging as they are against solicitation of their patrons. Because the study was voluntary and incentives (movie passes) were provided, some chains approved. Institutional Review Board approval was provided from the University of California, Los Angeles.

Measures
Items on the self-administered questionnaire measured the impact of the campaign's Hepatitis B slide, including awareness, risk perceptions, behavioral intentions and recall of and exposure to the slide.

Since findings from the campaign evaluation revealed minimal effects of the slide, this investigation only included age, ethnicity and gender as independent variables. Age was recoded into three categories: 18, 19–22 and 23–24 years. Similarly, ethnicity originally collected in five categories: White (n = 524), African–American (n = 52), Latino (n = 322), Asian (n = 207) and other (n = 96), with two respondents who did not report their ethnic background, was recoded to White/Asian/other, Latino and African–American. The White, Asian and other ethnic groups were combined as no differences in mean scores across the independent variables were found. Hepatitis B awareness was measured by a dichotomous item ‘Have you ever heard about Hepatitis B?’. Respondents who answered ‘no’ (11.1%) were dropped from analyses, reducing the sample to 1070.

General population risk perceptions, personal risk perceptions and behavioral intentions associated with Hepatitis B were included as dependent measures and are based on health beliefs [15], optimistic bias [13] and message framing [16]. Factor analysis yielded three groupings for items that assessed risk perceptions and behavioral intentions.

General population risk perceptions
Five items measured risk perceptions for the general population ({alpha} = 0.77): (i) teens and young adults are at risk for Hepatitis B; (ii) Hepatitis B affects people of all ages; (iii) anyone is at risk for Hepatitis B; (iv) Hepatitis B is a very serious disease and (v) Hepatitis B affects people of all racial/ethnic groups. A scale of 1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, 5 = strongly agree recorded responses. High means indicate that respondents perceive people in the general population to be at risk for Hepatitis B, while low scores indicate they do not perceive them to be at risk.

Personal risk perceptions
Two items measured personal risk perceptions ({alpha} = 0.51): (i) I am at risk for Hepatitis B and (ii) My friends are at risk for Hepatitis B. Responses were based on the same scale described above.

Behavioral intentions
Three items measured behavioral intentions ({alpha} = 0.56): (i) How likely are you to call your doctor to get more information about Hepatitis B immunizations; (ii) How likely are you to seek more information about Hepatitis B and (iii) I already know enough information about Hepatitis B. The first two items were recorded by 1 = not at all likely, 2 = somewhat likely, 3 = neither likely nor unlikely, 4 = likely, 5 = very likely and the last item used 1 = strongly disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, 5 = strongly agree. The alpha yielded for two groupings are lower than the generally accepted boundary (0.70) indicating that response patterns for the items were not consistent. In other words, the items may not represent the subscale being measured. Because the study questionnaire had limited items available, concepts of personal risk perceptions and behavioral intentions may not be fully represented by the items. Nevertheless, the response pattern was similar to that found in previous research; hence, responses were retained in analyses.

Data analyses
The Statistical Package for Social Sciences (12.0) was used for analyses. Since few participants saw the Hepatitis B slide (10.5%), further analyses explored the extent to which the study groups, defined by county, condition, test and campaign period could be combined. No significant differences were found between the study groups and dependent variables with the exception of an effect by county on general population risk perceptions, although because the means were fairly similar (meanLA = 3.8 versus meanOC = 4.0), the data were pooled for this investigation (see Table III).


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  		Table III Analysis of variance testing for mean differences between independent variables (general population risk perceptions, personal risk perceptions and behavioral intentions for Hepatitis B) and study variables (campaign period, county, site and time of administration)a

 
Analysis of variance testing was performed to assess for associations, main effects and interactions between Hepatitis B risk perceptions and behavioral intentions by sociodemographic factors (see Table IV). P values < 0.05 indicated statistical significance.


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  		Table IV Analysis of variance testing for mean differences between independent variables (general population risk perceptions, personal risk perceptions and behavioral intentions for Hepatitis B) and age, ethnicity, and gender

 

   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflict of interest statement
 Acknowledgements
 References
 
Sample characteristics
The average age of the sample was 20 years, ranging from 18, 19- to 22- and 23- to 24-year olds (29, 54 and 17%, respectively). Ethnic backgrounds included: White (44%), Latino (27%), Asian (17%), African–American (4%) and other (8%). Gender was 53% males and 47% females. There were no differences between the 133 who had ‘never heard’ of Hepatitis B, who were dropped from analyses, and the 1070 who had ‘heard’ of it (see Table II).


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  		Table II Chi-square analyses testing the association between Hepatitis B awareness and participant characteristics

 
Perceptions of risk for the general population
Participants generally perceived people in the general population at risk for Hepatitis B (mean = 3.98), significantly differing by age and ethnicity (P < 0.05). Eighteen-year olds (mean = 3.83) were least likely to think the general population was at risk for Hepatitis B compared with 19- to 22- (mean = 4.01) and 23- to 24- (mean = 4.06) year olds. African–American (mean = 3.84) and Latino (mean = 3.92) groups were also less likely than White/Asian/other group (mean = 3.99) to think people in the general population were at high risk for Hepatitis B. A significant interaction between age and ethnicity (P < 0.05) was observed, where African–American 18-year olds were least likely to think the general population was at risk (mean = 3.09) compared with White/Asian/other (mean = 3.91) or Latino 18-year olds (mean = 3.76). No differences in risk perceptions for the general population existed by gender, as females and males reported similar risk (means 3.99 versus 3.94, respectively).

Perceptions of personal risk
Participants perceived their Hepatitis B risk to be low (mean = 2.44). Significantly differing by age (P < 0.05), older respondents were more likely to perceive greater risk for themselves (meanages 19–22 years = 2.47 and meanages 23–24 years = 2.58) than younger respondents (meanage 18 years = 2.30). A significant interaction between age and ethnicity (P < 0.05) showed that African–American 18-year olds (mean = 1.84) were least likely to think they were at risk for Hepatitis B than 18-year-old Latino (mean = 2.37) and White/Asian/other groups (mean = 2.30). Gender and age also significantly interacted (P < 0.05) by personal risks as 18-year-old males had lower personal risk perceptions for Hepatitis B (mean = 2.20) than their female age counterparts (mean = 2.40).

Behavioral intentions
Information-seeking behavioral intentions for Hepatitis B were fairly low, averaging 2.62. Significantly more females (mean = 2.73) reported higher intentions to seek out information (P < 0.05) than males (mean = 2.52). Results also showed that the White/Asian/other group reported significantly lower tendencies to seek out information (P < 0.05) than African–Americans and Latinos (means = 2.57, 2.92, 2.68, respectively).


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflict of interest statement
 Acknowledgements
 References
 
The past decade has witnessed widespread efforts promoting Hepatitis B immunizations for infants and children. Unfortunately, efforts targeting young adults, whose risk is high, are limited. Not only are young adults not getting immunized but also there is a lack of knowledge regarding what is known about their attitudes of risk and behaviors related to Hepatitis B. Hepatitis B infections are highest in younger, ethnic minority populations because they typically view themselves not at risk for disease and engage in risky behaviors [8, 9].

Study results confirm past research on risk perceptions. In comparing the risk for oneself versus others, young persons attributed lower risk to themselves, while risk perception ratings for others in the general population were moderate to high, revealing the optimistic bias displayed by younger persons. The age–ethnicity interaction suggests that the tendency for youngsters to underestimate personal risk may be developmentally related to age. Thus, while personal risk perceptions for 18-year olds remained relatively low, with increasing age, perceptions increased. We found females more willing than males to seek out Hepatitis B information, which may explain females having higher rates of immunization [8].

The association between ethnicity and behavioral intentions suggests that cultural health beliefs may play a role in immunization participation. Health care barriers exist for both young and ethnic minority populations [8, 9]; therefore, health education initiatives promoting immunization are critical for increasing Hepatitis B-related risk perceptions and information-seeking intentions among young adult populations.

Overall, findings emphasize the importance of developing age and gender appropriate and culturally relevant educational strategies tailored toward meeting the needs of hard-to-reach young adults. Although, in order to tailor future health communication campaigns focused on increasing Hepatitis B immunizations among young adults, future studies should examine the knowledge base of young adults, especially younger aged groups between 18 and 21 years and ethnic minorities with respect to how they view Hepatitis B (i.e. as a dangerous epidemic or as a sexually transmitted infection) and its transmission; where health-related information about Hepatitis B is typically obtained; their Hepatitis B immunization status and the extent to which they have access to health care to receive immunizations. The last piece of information is critical information especially since certain young adult groups may work under employers who do not provide health insurance or coverage.

Study limitations
Data are based on self-reports which may be subject to over- or underreporting, potentially distorting results. As the effects of only certain demographic variables were assessed, other unmeasured factors may also be influencing risk perceptions and intentions. Because of time and space constraints in data collection, the number of questionnaire items was limited, which resulted in lowered reliability for some of the measures. The study also did not assess the vaccination status for Hepatitis B among respondents. As only 10–15% of this population are fully immunized, this may only have marginal impact on outcomes. Finally, qualitative data could enrich the findings.

Strengths of this study include the description of Hepatitis B-related attitudes and behavioral intentions among young adults that can inform future research and interventions. The age group studied is underrepresented in population surveys as many are not in school, yet are at high risk for many health issues. Finally, this effort involved an innovative means (using advertisements in movie theaters) to reach a high-risk group. As in many health-promotion efforts, this approach has potential, but the strength of the intervention may not have been sufficient. Further research is needed to confirm this assumption.

Implications for public health policy and practice
Efforts to educate and immunize young adults at risk for Hepatitis B are critical to reduce infection, and to address existing immunization disparity in California and throughout the United States. Increasing risk perceptions and Hepatitis B immunization coverage among this age group is needed. Future research should consider other information that may be related to attitudes and behaviors regarding Hepatitis B, in particular ‘what they know about Hepatitis B’ including risk factors, and the availability of vaccinations. Information about young adults' awareness of Hepatitis B compared with similar infectious agents (i.e. human immunodeficiency virus or Hepatitis C) would also be useful.

Hepatitis B is a silent killer and costs associated with its treatment are high. Currently there are no policies mandating universal immunization coverage among young adults; prevention of this disease is thus dependent on persuading individuals to get immunized and take precautions. Integration of this issue with larger campaigns that address liver diseases in general, including Hepatitis A, B and C, cirrhosis from excess alcohol consumption and exposure to toxins, may be more efficient at improving population health than single issue campaigns.


   Conflict of interest statement
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflict of interest statement
Acknowledgements
 References
 
None declared.


   Acknowledgements
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflict of interest statement
 Acknowledgements
References
 
Funding was provided by the California Department of Health Services, Immunization Branch. We thank all staff for project assistance with data collection.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflict of interest statement
 Acknowledgements
 References
 
1. Seid M, Simmes DR, Linton LS, et al. Correlates of vaccination for Hepatitis B among adolescents. Arch Pediatr Adolesc Med 2001 155:921–6.[Abstract/Free Full Text]

2. Blosten J and Clark PA. Cost-effectiveness of preimmunization Hepatitis B screening in high-risk adolescents. Public Health Rep 2001 116:165–8.[Web of Science][Medline]

3. Beasley RP. Hepatitis B virus as the etiologic agent in hepatocellular carcinoma-epidemiological considerations. Hepatology 1981 2:S21–6.[Web of Science]

4. Hadler SC and Margolis HS. Hepatitis B immunization: vaccine types, efficacy, and indications for immunization. In Remington JS and Swartz MN (Eds.). Current Clinical Topics in Infectious Diseases.Boston, MA: Blackwell Scientific Publications 1992 pp. 283–308.

5. Mahoney FJ. Update on diagnosis, management, and prevention of Hepatitis B virus infection. Clin Microbiol Rev 1999 12:351–66.[Abstract/Free Full Text]

6. Mast EE, Williams IT, Atler MJ, et al. Hepatitis B vaccination of adolescent and adult high-risk groups in the United States. Vaccine 1998 16:S27–9.

7. Meheus A. Teenagers' lifestyle and the risk of exposure to Hepatitis B virus. Vaccine 2000 18:S26–9.

8. Middleman AB. Race/ethnicity and gender disparities in the utilization of a school-based Hepatitis B immunization initiative. J Adolesc Health 2004 34:414–9.[Web of Science][Medline]

9. Wiecha JM. Differences in knowledge of Hepatitis B among Vietnamese, African-American, Hispanic, and White adolescents in Worchester, Massachusetts. Pediatrics 1999 104:1212–6.[Abstract/Free Full Text]

10. Centers for Disease Control and Prevention. Update: recommendations to prevent Hepatitis B virus transmission—United States. Morb Mortal Wkly Rep 1999 48:33–5.[Medline]

11. California Department of Health Services, Immunization Branch. Educational and child care facility immunization requirements. California Health and Safety Code, Division 105. Available at: www.dhs.ca.gov/ps/dcdc/izgroup/pdf/SchoolLaws0204.pdf. Berkeley, CA, 2004, Accessed: 13 November 2004.

12. Slovic P, Fischhoff B, Lichtenstein S. Rating the risk. In Glickman TS and Gough M (Eds.). Readings in Risk.Washington, DC: Resources for the Future 1990 pp. 61–75.

13. Weinstein ND. Optimistic biases about personal risks. In Lofstedt R and Frewer L (Eds.). Risk and Modern Society.London: Earthscan Publications 1998 pp. 239–41.

14. Holtgrave DR, Tinsley BJ, Kay LS. Encouraging risk reduction: a decision-making approach to message design. In Maibach E and Parrott RL (Eds.). Designing Health Messages.Thousand Oaks, CA: Sage Publications 1995.

15. Rosenstock IM. The historical origins of the health belief model. Health Educ Monogr 1974 2:354–95.

16. Rothman AJ and Salovey P. Shaping perceptions to motivate healthy behavior: the role of message framing. Psychol Bull 1997 121:3–19.[CrossRef][Web of Science][Medline]

17. California Department of Health Services, Immunization Branch. California Health and Safety Code Division 105. Communicable Disease Prevention and Control Part 2. Immunizations. Reports from a Serologic Survey.Berkeley, CA: Department of California 1991.

Received on January 27, 2005; accepted on March 2, 2006


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This Article
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