Results of the baseline study for the hepatitis C prevention and treatment campaign are published here:Hepatitis C Knowledge, Attitudes, and Practices in Egypt. A list of priority communication messages was extracted from the study findings, as shown just below.
Priority Messages for the First Wave of HCV TV Spots in Egypt
Based on Findings of the General Public Survey
By: Farag Elkamel, PhD. WHO Communication Expert
25/10/2015
This document summarizes the key results of the telephone poll that was conducted on a randomly drawn sample of the general public consisting of 1,027 respondents, 18 years of age and above. The sample was randomly drawn from all governorates, and weighted to represent gender and population distribution across all provinces in Egypt. The survey was conducted through cell phone numbers from May 20th to 22nd 2015. Furthermore, the current document concludes priority messages from these results for the first wave of TV spots targeting the general public
Prevalence
The study results show that 4.0% of respondents know that they have hepatitis C, and an additional 46.0 % know of someone else who has the virus.
When we look at age distribution, none of the 4% who knew that they have HCV is under 30 years old, while the percentage increases to 4.8% among respondents 30-50, and to 6.3% of those who are over 50 years old. It is interesting that these results are supported in large part by the findings of another KAP survey conducted on a sample of 1,000 persons who are infected with HCV. That survey revealed that only 7% were under 30, while 40% were 30-50 years old, and 53% were older than 50 years old. It is interesting that almost all of those who know that they have the virus found out this fact accidentally, either because they did blood tests because they got sick, or as a requirement for travel, or while attempting to donate blood.
Message Implications-1: HCV is widespread. Early diagnosis can lead to a better response to medication. If you have had a surgery, blood transfusion, or injections to treat bilharzias, asks your doctor’s advice for blood testing.
Knowledge:
Despite the very high prevalence of hepatitis C in Egypt, which is estimated by the EDHS 2014 to be 7% of the adult population, the KAP survey of the general public reveals that knowledge of different aspects of infection and prevention is severely lacking.
On the other hand, there are 13.1% who never heard of HCV, and of the rest who did, 38.5% never heard of the new treatment.
Message Implications-2: Good news for those who have HCV. There is a new medicine which is highly effective. If you have HCV, consult your doctor or register your name at the NCCVH website immediately.
Respondents were asked the following important open question: “How is virus C transmitted?” The following are percentages of total respondents who mentioned various ways of transmission:
| Through the blood | 52.7 |
| Through items that are infected with the blood of an HCV patient | 23.2 |
| Through injection | 8.9 |
| I don’t know | 19.6 |
In response to a question regarding different ways a person can protect themselves from contracting the virus from an infected person, modest percentages of the total sample mentioned the following ways (without being prompted):
| Don’t use an infected person’s tools | 17.8 |
| Don’t use an infected person’s shaving tools | 5.3 |
| Don’t do anything | 20.2 |
| I don’t know | 13.8 |
Respondents who had heard of virus C were asked the following question: “If a person had HCV and was treated, can he/she still get it again or does he/she have immunity against getting re-infected? ” It is quite alarming that only 35.5% gave the correct answer that the person can get re-infected, while 20.3% said that the person would have immunity, and 44.2% said that they didn’t know.
Message Implications-3: You can protect yourself. HCV is transmitted only through blood or items that are contaminated with it. No one should ever share needles, razors, nail scissors, clippers, or nail files with anyone else.
The study also investigated the presence of misinformation about how virus C may be transmitted. Respondents were asked to agree or disagree with a number of statements that represent misinformation regarding possibilities of transmission through casual daily contact with a person infected with HCV. Following are the percentages of the total sample who agreed with those false statements:
| Sharing toilets | 26.8 |
| Drinking glasses | 34.1 |
| Eating utensils | 36.8 |
| Hugging, kissing or touching | 46.4 |
| Sexual intercourse | 29.2 |
As will be discussed below, 90% of respondents believe that an infected person is not to blame for having the disease. However, 10% either blame the sick person or state that they aren’t sure whether to blame them or not. Part of this negative attitude or confusion can be attributed to the spread of the above mentioned misinformation, which leads the public to fear and avoid safe daily contact with infected persons, which contributes to the creation of an unnecessary stigma. There is another risk in not responding to these rumors, which is drawing attention away from the important behaviors that do matter in prevention.
Message Implications-4: Normal daily contact with a person who is infected with HCV is safe, including kissing, hugging, and the use of same drinking glasses and eating utensils or using same bathroom.
Given the fact that almost half the households in Egypt either have someone who has HCV or know of someone who does, the essential knowledge necessary to cope with this disease becomes necessary to spread to the public. The current situation certainly requires an intervention given the following modest percentages of respondents who mentioned different practices that infected persons should engage in once they are diagnosed with HCV:
| Go to a specialized doctor and follow his/her advice and get regular medical checkups | 53.0 |
| Eat a healthy and balanced diet that includes a lot of vegetables and fruit | 12.1 |
| Stay away from too much sugar and fat | 6.3 |
| Exercise regularly; and avoid smoking | 1.1 |
| Get the new treatment | 28.4 |
It is recommended that the part of the campaign which targets healthcare providers includes messages to them regarding the need to give proper advice to HCV patients about lifestyle.
Attitudes:
Results show a mild indication of a stigma, as only 5.0% of those who ever heard of HCV say that infected persons only have themselves to blame, while 90.0% said that infected persons are victims and we should therefore support and stand by them. However, most of the remaining 5.0 stated that they didn’t know whether to blame or support the infected persons.
Injection is preferred over oral pills or tablets by 41.6% of respondents, compared with 36.5% who prefer the latter. The remaining 21.4% either didn’t have a clear preference or gave different answers that were mostly in favor of injection. When asked why they preferred injection, 87.7% of the respondents who made that choice said that injection has a faster and stronger effect, and 12% said that pills cause them stomach problems. On the other hand, 44% of respondents who preferred pills and capsules over injections said that pills and capsules were easier, better and quicker, and 42.6% said that they didn’t like the pain associated with injections. Only 4.8 percent reject injection because it has the potential to transmit diseases.
It has been reported elsewhere that Egypt has one of the highest rates of injecting medicines in the world, and that “more recent studies in China and Egypt found unnecessary health facility injection rates of 57% and 95%, respectively[1].
Message Implications-5: Whenever possible, ask your doctor if you can take an oral medicine instead of injection. Oral medicine has the same treatment effect, but is pain-free and avoids the risk of infection.
Reduction of injection in favor of oral medicine continues to be a target for Egypt, despite what seems to be a comforting piece of evidence that an overwhelming 97.4% said that a syringe should only be used once. When we asked a follow up question on how to identify a new syringe, 98% of them said that a new syringe should be in a new and well-sealed wrapping.
Practices:
The study has also identified certain risky practices among the general public. Following are percentages of respondents who said that they shared specific items with other members of their families:
| Shaving device (men only) | 6.3 |
| Nail clipper | 49.2 |
| Nail file | 32.5 |
| Nail Scissors | 38.5 |
| Toothbrush | 2.4 |
| Tools used for pedicure or ear piercing at a coiffeur (women only) | 5.4 |
These results give additional confirmation to the urgent need for the content outlined in message implications-3 above.
Another aspect of risky practices that was investigated was what people do if blood is spelled over their clothes or other surfaces. The following percentages reflect the responses made by respondents regarding substances they use:
| Water only | 38.5 |
| An antiseptic/Dettol | 47.2 |
| Chlorine | 13.5 |
| Washing powder or soap | 18.8 |
| Alcohol | 1.1 |
| A dry cloth or handkerchief | 2.5 |
Finally, we asked those who said that they use chlorine a follow up question to investigate how they actually use it. Unfortunately, a small minority of them mentioned correct ways of using the substance. While the prototype message on this subject is to mix a cup of chlorine with four cups of water, only 7.2% of those who mentioned chlorine (1.0% of the total sample) gave this answer. Others either gave different answers or simply answered that they didn’t know. On the other hand, the healthcare providers’ survey showed that most of those who mentioned chlorine said that they mix one cup with nine cups of water, which may indicate a previous message or instructions to this effect. While the message on chlorine use as a disinfectant remains important, this issue of proper chlorine mixing needs to be sorted out in order to avoid confusion or negative feedback.
Communication Messages
There are plenty of messages that need to be communicated to the general public, HCV patients, and healthcare providers. Messages for all of these three segments of the audience have been presented here: Combating hepatitis-c in Egypt. Messages for the general public campaign were extracted from the baseline survey described above, and were organized according to Elkamel’s Knowledge & Social Change Model described elsewhere in this site.
Awareness Knowledge: (WHAT)
The objective of Awareness Knowledge is to make target audiences aware of hepatitis C and of the possibilities for its prevention and treatment. Awareness knowledge should thus include the following:
- There is a serious disease called hepatitis C
- There is a new and effective medicine to treat hepatitis C
- Hepatitis B is a serious disease (for HCV patients and healthcare providers)
- There is a vaccine for hepatitis B (for HCV patients and healthcare providers)
How-to-Knowledge: (HOW)
Individual need to know how they can protect themselves from getting infected, or get the treatment if they are hepatitis c patients. This facet of knowledge includes:
- Hepatitis C can be transmitted through sharing or reusing personal items of infected individuals such as razors, scissors, nail clippers, nail files, toothbrushes, as well as tattoo, pedicure and ear piercing tools.
- Hepatitis C is not transmitted through casual daily contact including sharing toilets, drinking glasses or eating utensils, hugging, kissing or touching
- Hepatitis C patients should not donate their blood.
- Cured hepatitis C patients don’t have immunity. They can be re-infected just like anyone else if they are not careful.
- Safe Injection: use a new syringe that was never used by anyone else before and dispose of it safely.
- If the same medicine is available in the form of injections or oral tablets, choose the tablets because they are safer.
- Disinfect and cover open cuts on your skin with bandage until they heal.
- Wash your hands thoroughly with soap and water if you come in contact with blood.
- Promptly clean and disinfect surfaces or items contaminated with blood or other potentially infectious materials with chlorine solution (Clorox, Bleach) using 1 part bleach for every 9 parts water.
- Hepatitis B can be prevented by getting its vaccine (for HCV patients and healthcare providers).
Principles Knowledge: (WHY)
This aspect of knowledge is meant to provide the rational for the actions that are promoted in the “how-to” messages, including:
- Hepatitis C is preventable
- Virus C is transmitted only if the blood of an infected person enters the blood stream of another individual through transfusion or infected instruments.
- If left untreated, Virus C may lead to Liver failure and Liver Cancer.
Priority Messages for the first wave TV Spots:
What is listed below, however is a list of only five key and priority messages for the first wave of TV and radio spots targeting the general public. Other messages for the general public as well as other target groups should be the subject for subsequent communication initiatives.
The Media Campaign
The World Health Organization has never developed or produced a media campaign in Egypt. They aren’t structured to do this kind of activity, and they don’t generally have it in their budget.
Given the urgency of the hepatitis c problem in Egypt, I persuaded them that I could develop and produce an urgent campaign consisting of 5 television commercials for only 10 thousand dollars! This was the cost for renting a studio to record the voice-over and the fees for a free lancer to do pencilmation! The cost for the strategy, concept development and script was nil, as I did that myself as the WHO’s senior communication adviser. In addition, I developed the campaign slogan, designed a poster and a pamphlet which were printed with minor support from regular funding by the ministry of health and population, and secured free broadcasting of the spots on a number of public and private TV channels.
I should mention here that the 10 thousand dollars which were spent to produce the five TV spots constitute only a small fraction of the market rate for producing TV spots in 2016, where the average cost to produce only ONE spot through commercial production houses or advertising agencies was about ten times that amount!
The concept of the campaign is based on the idea of solidarity between the three segments of society: (1) the infected individuals (2) the healthcare providers, and (3) the families of infected persons and other members of the general public, under the slogan “It’s Either US or Virus C.”
I also decided to use the pencilmation (two-dimensional cartoons) technique to convey simplicity and to avoid pinpointing specific characteristics of infected or susceptible individuals and to confirm the notion that everyone is vulnerable regardless of their age, gender or socio-economic status.
The popular movie and TV star Mohamed Henedi did the voice over totally free as a contribution to the campaign. In fact I’m grateful to his personal doctor whom I asked for help to persuade Henedi to this great service for the country.
Pretesting Campaign Materials
All materials mentioned above were pretested among experts, health officials, and the target audience. Below are sample shots of the script and story board for one of the TV spots. The storyboard received official approval by both WHO and MOHP before going into the final phase of producing the spots.
Dissemination
The campaign was disseminated in July-September 2016. Following is a review of the campaign elements.
TV Spot 1
HCV is widespread. Early diagnosis can lead to a better response to medication. If you have had a surgery, blood transfusion, or injections to treat bilharzia, asks your doctor’s advice for blood testing.
فيروس “سى” منتشر فى مصر. كل ما نكتشف المرض بدرى كل ما الاستجابة للعلاج تبقى أحسن. لو عملت عملية جراحية قبل كده أو اتنقل لك دم أو خدت حقن لعلاج البلهارسيا زمان، اسأل دكتور متخصص عن نوع تحليل الدم اللى مفروض تعمله عشان تتطمن على نفسك.
TV Spot 2
Good news for those who have HCV. There is a new medicine which is highly effective. If you have HCV, consult your doctor or register your name at the NCCVH website immediately.
فيه أخبار هايلة للى عندهم فيروس “سى”. دلوقتى فيه علاج جديد وممتاز للمرض. أستشير دكتور متخصص وسجل اسمك فى موقع الانترنت بتاع اللجنة القومية لمكافحة الفيروسات الكبدية اللى تبع وزارة الصحة.
TV Spot 3
You can protect yourself. HCV is transmitted only through blood or items that are contaminated with it. No one should ever share needles, razors, nail scissors, clippers, or nail files with anyone else.
انت تقدر تحمى نفسك من فيروس “سى”. الفيروس ده بيتقل عن طريق الدم أو الحاجات الملوثة بدم شخص يكون مصاب بيه. عشان كده أوعى تستعمل سرنجة أو دبوس حجاب أو موس أو قصافة أو مقص أو مبرد ضوافر بتوع حد تانى.
TV Spot 4
Normal daily contact with a person who is infected with HCV is safe, including kissing, hugging, and the use of same drinking glasses and eating utensils or using same bathroom.
الاختلاط العادى مع أى حد مصاب بفيروس “سى” ما بينقلش العدوى. ممكن قوى نسلم عليه ونبوسه ونحضنه وياكل ويشرب معانا فى نفس الاطباق والكوبايات ونستعمل نفس الحمام اللى بيستعمله… ومن غير ما نقلق خالص.
TV Spot 5
Whenever possible, ask your doctor if you can take an oral medicine instead of injection. Oral medicine has the same treatment effect, but is pain-free and avoids the risk of infection.
ياريت دايما نطلب رأى الدكتور لو ينفع ناخد كبسولات أو أقراص بدل الحقن. الكبسولات والاقراص ليها نفس المفعول بس ما بتوجعش، وكمان مفيش احتمال خالص انها تنقل فيروس سى.
Poster
Pamphlet
just like the poster shown above, the pamphlet was also designed to integrate with the TV and radio spots. in addition to conveying the same five messages, in the same order, the pamphlet also used visuals from the relevant spots.
[1] C. Gore1, J. V. Lazarus, R. J. J. Peck, I. Sperle and K. Safreed-Harmon, Unnecessary Injecting Of Medicines Is Still a Major Public Health Challenge Globally. Tropical Medicine and International Health, volume 18 no 9 pp 1157–1159 September 2013
The Cairo University Campaign
During the Fall semester of 2016, Cairo University used the poster and pamphlet mentioned above, in addition to the radio and TV spots when it launched a campus-wide campaign for a “university free of virus c”. It’s worth mentioning that Cairo University has more than 250,000 B.A level students, 8,500 M.A students, 1,000 PhD students and more than 12,000 teaching staff.
The poster and pamphlet were only modified to feature the university logo alongside those of the ministry of health and WHO, as shown below.
Farag Elkamel 