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Jane et al.

BMC Public Health (2016) 16:146
DOI 10.1186/s12889-016-2844-0

RESEARCH ARTICLE Open Access

Early detection of unhealthy behaviors, the
prevalence and receipt of antiviral
treatment for disabled adult hepatitis B and
C carriers
Sui-Whi Jane1†, Ming-Shyan Lin2†, Wen-Nan Chiu2, Li-Ju Lai3, Po-Han Chen4 and Mei-Yen Chen5*

Abstract
Background: Evidence indicates that hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are the leading
causes of liver cirrhosis and hepatocellular carcinoma. Antiviral treatments have recently been reported as successful
cures. However, the prevalence rates of HBV or HCV infection, unhealthy behaviors and receipt of adequate treatment in
disabled adults have not been described. The aim of this study was to examine the prevalence of HBV or HCV carriers,
receipt of antiviral treatment, and early detection of unhealthy behaviors in disabled adults in Taiwan.
Methods: A population-based, cross-sectional study was conducted between July and December 2013 with 845
community-dwelling adults with disabilities aged >20 years. Statistical analyses included descriptive statistics,
Chi-squared tests, and stepwise regression analysis.
Results: The prevalence of HBV and HCV infections was 12.9 and 14.1 %, respectively. HCV carriers tended to be
older (p < 0.001) and with a lower education (p < 0.001). The majority of HBV/HCV carriers did not know the type
of hepatitis infection and did not receive adequate antiviral treatment. After adjusting for potential confounding
variables, regression analysis showed that the factors significantly associated with elevated liver function were HCV
infection (p < 0.001), HBV infection (p = 0.001), high fasting blood glucose levels (p = 0.001), overweight (p = 0.003), older
age (p = 0.027), and alcohol drinking (p = 0.028).
Conclusions: There was a high prevalence of HCV infection among adults with disabilities; few received adequate
antiviral treatment or early detection of unhealthy behaviors for the prevention of liver cancer. Clinicians can provide
health education to help the participants and caregivers better understand the relationships between specific risk
factors and liver health and can encourage HBV and HCV carriers to undergo annual physical check-ups and receive
adequate treatment, as covered by the national health insurance.
Keywords: Prevalence, Unhealthy behavior, Hepatitis B virus, Hepatitis C virus, Disability

Background of the liver, most commonly caused by a viral infection
Liver cancer is one of the most common cancers world- [1–4]. The mechanism by which hepatitis viral infection
wide, particularly in Central and East Asia [1]. The leading leads to liver cancer might involve the infection-related
causes of liver cirrhosis, liver failure, and hepatocellular chronic inflammation [3, 4].
carcinoma (HCC) are hepatitis B virus (HBV) and hepa- Globally, HBV and HCV infections and their sequelae
titis C virus (HCV) infections. Hepatitis is inflammation remain a major health problem, associated with 1.45
million deaths annually [5]. In Taiwan, liver cirrhosis
and HCC are the most common causes of death, ac-
* Correspondence: meiyen@mail.cgust.edu.tw

Equal contributors
counting for 34.9 deaths per 100,000 persons [6]. In
5
College of Nursing, Chang Gung University of Science and Technology, No. addition, HBV and HCV are endemic, with prevalence
2, Chiapu Rd. West Sec., Putz City, Chiayi County 61363, Taiwan rates of 15–20 and 2–3 %, respectively, among the
Full list of author information is available at the end of the article

© 2016 Jane et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

HCC [6. who treatment. and risk factors associated with liver participation. such as injectable drug equipment. we people are HBV carriers. disability has become a human rights issue in Taiwan. 7]. have recently been reported as successful cures vide written informed consent before study enrollment. [11. interview was conducted. B. from the first week of life [3]. 3 servings of vegetables related to adopting healthy lifestyles and habits for and 2 servings of fruit daily)... obesity [10.0 million among disabled HBV or HCV carriers. consumed alcohol but had ceased drinking alcohol advantaged areas. In this study. blood of an infected person or with unsterilized mate. or “current” if the participant the prevalence of and relationships with unhealthy be. In Taiwan. descriptive study aimed to rials. Therefore. Taiwan. or tattoo explore the prevalence of HBV/HCV carriers and receipt needles [4]. drinking plenty of water the liver [10. intellectual.g. Furthermore. obesity is an increas. was currently drinking. and disability been associated not only with HBV or HCV infection classification. education level (years of education achieved). without disabilities [14]. more than one million people were desig. A community-based health screening survey was con- nated as disabled by the government in 2012 [13]. and a information. such as abnormal serum glutamate. less education. especially disabled residents living in rural had severe chronic disease or cancer. marital pyruvate transaminase (SGPT) levels. “ceased” if the participant had previously prevention policies among HBV or HCV carriers in dis. and multiple disabilities) and confirmed before the ingly important health problem in disabled people [19]. The majority of nursing team in collaboration with a private hospital and HCV infections are transmitted via contact with the the Bureau of Health Promotion in Chiayi County. BMC Public Health (2016) 16:146 Page 2 of 7 general adult population. and nearly 90 % of HCC pa. 30 min/day.629 people with disabilities. Therefore. vaccine doses were administered to all infants starting based on government records [13].. living arrangement. intellectual disability. 12]. (2) “Do you smoke haviors. less economic healthy behaviors. An estimated 2. from these records. and 1024 dis- top five disabilities were physical disability. This study was part of a health promotion program for and mother-to-infant transmission accounts for the ma. Demographic characteristics included age. Long-term studies have participants were selected by convenience sampling. 1500 mL/day). Taiwan launched a universal of anti-viral treatment in the southwestern coastal area. [1–4]. The demonstrated that 20 years after the mass HBV vaccin. Moreover. Unhealthy behaviors and receipt of anti-virus treatment den of liver function.5–3. hearing impairment. 20] using eight questions (1) “Do you (e. and higher rates of poverty than people function among disabled HBV/HCV carriers. razors. Methods advantaged areas [8–10]. and exercising (e. Disabilities were classified according to but also with cigarette smoking. 3 regularly drink alcohol?” Drinking was classified as times per week) [20]. community-dwelling adults with disabilities led by a jority of cases with chronic infection [3]. few studies have explored for at least 6 months. However. People with disabilities have infections. and HCC have status. This cross-sectional. Fortunately. In Taiwan. there were 37. “never” if the participant had never consumed Few actions have been implemented to enhance cancer alcohol. and (3) pro- ribavirin. many people still receive inadequate Participants who were unable to answer questions.g. HCV infection is significantly associated with health disparity and older people in dis. antiviral treatments for HBV and (2) walk or transfer to the local hospital with or without HCV in adult carriers. receipt of adequate antiviral treatments. we determined the prevalence rates of viral combination of disabilities.g. In addition. unhealthy behaviors and determinants of liver function 60–90 % of carriers are at risk of liver cirrhosis and among disabled HBV/HCV carriers. the incidence of HBV questionnaire in writing or by interview in Mandarin or infection significantly declined to 0. Participants and design HBV infection occurs mainly during early childhood. Additionally. Liver dysfunction. strategies for weight loss include were assessed based on expert recommendations adopting a healthier diet (e. reductions in weight might reverse the bur. the potential health care Instruments and measurements savings due to early intervention and prevention efforts have also recently been recognized [13]. alcohol drinking. investigated the prevalence of and relationships between tients are infected with HBV or HCV.g. occupation. gender. inclusion criteria were the ability to (1) complete the ation program was implemented. health status. A.Jane et al. and the government definition (e. and receipt of adequate treatment cigarettes?” Smoking was classified as “never” . HBV vaccination program in 1984. undergoing dialysis were excluded.6 % in young adults Taiwanese with or without assistance or via a caregiver. loss of vital abled residents participated in this project. physical. The ducted between July and December 2013. in which three HBV In this area.. From this organs. un- poorer health outcomes. such as interferon combined with assistance from family or institutional staff. 15–18]. or who were areas [10].

All pants were current users of alcohol and cigarette smokers.05 cups of water each day?” The answer was classified were considered statistically significant.1 % (n = 119). 55. as calculated by weight (kg) divided by the square The prevalence of HBV and HCV infections was of height (m2). the final data analyses were conducted with 845 prescription from a physician?” participants. (6) “Do you eat 2 servings of fruit every day?” The Results answer was classified as “insufficient” if the participant Demographic characteristics answered never or sometimes and as “sufficient” if the Of the 1024 disabled community residents who were participant usually consumed at least 2 servings or eligible. A cover letter tion (χ2 = 16. this letter emphasized that Unhealthy behaviors between hepatitis B or C the responses would remain confidential. or “current” if the examination by the staff of the collaborating hospital. glucose (normal range. while the remainder lived <140/90 mmHg).001) and have a lower level of educa- medical examination would be provided. after ment. with health care assistants or alone (Table 1). Multivariate classified as “insufficient” if the participant answered linear regression was used to analyze the factors associ- never or sometimes and as “sufficient” if the ated with liver function that were chosen on the basis participant usually consumed at least 3 servings of relevant confounders after univariate analysis. (5) “Do you eat 3 markers. More than using enzyme-linked immunoassays. three times Data analysis per week. 32.9 % (n = 109) and 14.Jane et al. 77 (9.4. the HCV carriers tended to be older describing the study purpose and explaining that a free (χ2 = 24. inviting participation in the study was sent to the 18 district public health nurses.6. or 1. BMC Public Health (2016) 16:146 Page 3 of 7 if the participant never smoked. All standard references were from 12. 177 did not meet the inclusion criteria. After excluding 1 know that you have a viral infection called hepatitis?” participant who failed to complete the physical examin- If yes. Physiological biomarkers were measured for liver range 20–96). occupation status. or 150 min per week.5 bowl-sized servings of vegetables per day. C. disability classifi- Procedure and ethical considerations cation. Nearly one-third of the participants (normal range. and the remainder (n = 342. and more than two-thirds (78.001) than the non-carriers. Participants virus carriers were allowed to ask questions and seek clarification Of the total sample. each participant was exercise was classified as “irregular” if the participant accompanied by a senior nursing student and commu- responded never or sometimes or as “regular” nity volunteer during the health screenings. education level. and the majority of the participants were function. age and marital status were sig- the Institutional Review Board (Chang Gung Memorial nificantly different.9 years (SD = 18. Nearly half (50. p < 0. Written informed consent was no significant differences in gender and living arrange- obtained from all participants or their caregiver. examination and serum hepatitis B surface antigen 40. The Chi-square as “insufficient” if the participant answered never statistic for testing the equality of proportions or rates was or sometimes and as “sufficient” if the participant used to compare demographic variables. To participant was currently smoking.4. however. there were Hospital No 102-3331B). All tests were two-sided. and living This study was approved by the Ethical Committee of arrangement. respectively the Ministry of Health and Welfare [21].6 %) had a physical disability. Based on HBV infection. Armonk. <40 mU/mL) as measured by the (n = 276. if the participant usually exercised for a total or cumulative duration of >30 min per day. HCV. (7) “Do you in 847 participants for data analyses. resulting one bowl-sized serving of fruit per day.8 %) did (HBsAg) and anti-HCV antibodies as determined not have an education beyond middle school. such as an anti-viral naire.1 %) and 121 (14. fasting blood two-thirds of the participants were unemployed (n = 609). (3) Regular help build a caring environment. systolic 49 % were married. p < 0.9 %) and diastolic blood pressure (normal range. and p values <0. <110 mg/dL). and body mass index (BMI). . and SGPT men (n = 472. then the participant was asked (8) “Have you ation and 1 participant who had an incomplete question- received hepatitis treatment. including HBV. Based on HCV infection.8 %). 27 % (n = 227) collaborating hospital during the physical had an intellectual disability. and unhealthy behaviors between the individuals servings of vegetables every day?” The answer was with or without HBV or HCV infection. there were no statis- tically significant differences in gender.3 %) partici- about the study before they consented to participate. The mean age was 53. were living with their family. physiological bio- answered usually or always. (Table 1). (4) “How often do SPSS version 20 (IBM Corp.. NY) was used for you consume at least 1500 mL or eight bowl-sized data analyses. “ceased” if the participants were interviewed during a weekend in a participant had previously smoked but had ceased school auditorium after the blood collection and physical smoking for at least 6 months.4 %) had multiple disabilities. however.

overweight.4) 99 (90.5) 26 (21.8) 42 (10.8) 27 (15.7) Pearson Chi-Square: *p < 0.8) 53 (14.3) 92 (80.9) Others 94 (81.8) 321 (87.9)a Current smokers 99 (13. older age (β = −0.7) Sufficient 239 (32.001).2) 96 (15.2) 103 (14.001 Receiving antiviral treatment χ2 = 21.5) 8 (7.5) 207 (78.6) 22 (12.21 2 χ2 = 0.06 2 χ = 0.72.4) 151 (84.86 χ2 = 0.56*** a with missing data Yes 12 (1.9) 15 (12.3) 48 (6. p < 0.0) 79 (10. n = 452) reported ***p < 0.8) Regular 348 (47.1) 58 (21.8) Without job 529 (86.2) 54 (15.97*** With families 580 (87.22 2 Awareness of viral infection χ2 = 44. Despite the limitations of the present study.6) Mean ± SD Cessation 48 (6.84 χ2 = 16.2) Marital status a χ = 6.0) 48 (13.5 % (n = 570) reported insufficient vegetable intake.0) Never 625 (85.01 N (%) N (%) Female 332 (89.0) 575 (86.5) 93 (78. ***p < 0.6) 107 (89.2) No 710 (96.76** 62.9) respectively.31*** χ2 = 30.43 40 ~ 64 307 (83.9 % had high fasting blood glucose.4) 334 (46.7) 96 (80.12. **p < 0.3) 69 (16.1) 88 (80.3) 288 (84. There were no significant differences between systolic blood pressure.3) 23 (9. 81 % (n = 685) reported insufficient fruit in- take. and 18. including p < 0.56 χ2 = 0.16* Cessation 82 (11.4) 406 (86.5) 82 (68.1) ≥ Middle school 356 (86.7) Sufficient 139 (18.001).5) 88 (80.9) 348 (81.5 ± 15.3) 213 (90.8) 13 (6. respectively.6) 288 (91. received adequate anti-viral treatment (p < 0.2) 18 (15.4) 75 (68.2) 10 (1.1) 85 (78.0) Insufficient 497 (67.09* Fruit (2 servings/day) χ2 = 0.6) 75 (68.2) 27 (12.7 χ2 = 24. Considering the health status the convenience sampling that limits the generalizability of the HBV and HCV carriers.5) 22 (20.2) 92 (13.7) 65 (59.5) 21 (19.11.5) 20 (7.9) Sufficient 245 (33.6) 38 (31.9 % had abnormal four key findings regarding liver health in disabled adult .6) 392 (54.8) 481 (66.6) Married 371 (89.5) 37 (31.08.8) Insufficient 597 (81.0) 376 (90.7) Age (years) 51.9) Occupation χ2 = 0.0) 41 (11.3) Adopting regular exercisea χ2 = 1.0) 207 (91.7) 592 (81.8) 716 (98.21 χ2 = 7.88 χ2 = 0. p = 0.01.26 ≤ Primary school 378 (88.2) Education χ2 = 0.7) 29 (12.0) 58 (49.08.63*** Current user 61 (8.48* 2 χ = 13.9) 21 (19.8) Irregular 387 (52. respectively.1) Disability classification χ2 = 1.5 and 58. More than half (53.3) 134 (18. p < 0.7 χ2 = 11.0) Never 555 (75.1) 12 (11.001).7 and 44.7) 702 (96.77 With job 207 (87.2) 20 (8.2.8) 544 (74.7) 68 (9.028) were significant in the regression Physiological biomarkers and health status among analysis for elevated liver function (Table 4).8) 38 (9.7 % were of the findings to all adults with disabilities in Taiwan.05.4) 46 (14.1) 513 (84.1) 51 (11.0) 33 (12. p = 0.0) 60 (50.01 2 χ2 = 0.7*** χ2 = 49.16 χ2 = 0.6) 8 (6. HBV infection (β = 0. Regarding knowledge of hepa. p = 0.7) 45 (16. p = 0.8) Yes 26 (3.001 irregular exercise.0) 489 (67.0) 102 (85.1.4) 12 (10.003).1) No 724 (98.29.2) 62 (16. 28.001) and systolic blood pressure (χ2 = 6.7 % (n = 563) reported insufficient a with missing data water intake.2) Alcohol usea χ2 = 4.2) Insufficient 488 (66.0) 87 (13.7) 21 (18.001.4) 81 (68.3) 23 (19. the majority of HBV/HCV carriers did infection (β = 0.3) 16 (14. overweight (β = 0.8) Multiple disabilities 300 (87.0) 66 (14.6) Physical 243 (88.2) 344 (83.0) 320 (85.4) 9 (7.4) 27 (8.3) Other 156 (87.5) 36 (33. After adjusting for potential confounding variables. 49.Jane et al. BMC Public Health (2016) 16:146 Page 4 of 7 Table 1 Demographic characteristics of the samples (N = 845) Table 2 Health-related behaviors among hepatitis B or C virus Variables Hepatitis B infection Hepatitis C infection carriers Negative Positive Negative Positive Variables Hepatitis B infection Hepatitis C infection N (%) N (%) Negative Positive Negative Positive Gender χ2 = 2.0) 34 (15.7) 42 (12.3) ≥ 65 245 (92. 66.7) ~ 39 184 (87.6) 10 (9.027).41 Male 404 (85.8) 198 (93.9) 86 (72.3) 44 (40.4) 34 (31. HCV titis viral infection. hepatitis carriers HCV carriers tended to have abnormal SGPT (χ2 = Discussion 53.0) 237 (32.01 χ2 = 0.02 Single 269 (85.3 and HBV/HCV carriers and non-carriers in any of the health. 26.5) 73 (67. respectively.0) 231 (83.3) 24 (3.0) 23 (20. not know the type of hepatitis infection and had not p = 0.1) 81 (18.5 %.2) 242 (33. and current alcohol drinking (β = 0. and 67. related behaviors (Table 2).40 Intellectual 193 (85. Table 2).5 ± 14.11 χ2 = 5.36*** Water (1500 mL/day) a χ = 0.0) 58 (14.0) 608 (84.56*** 2 Vegetable (3 servings/day) χ = 0. high fasting blood glucose levels (β = 0.1) Living arrangement χ = 0.5) 68 (14.9) 80 (13.2) Cigarette smoke χ2 = 3.05) levels (Table 3).

HCV hepatitis C virus.90 <0.9 %) was lower than the nationwide prevalence N (%) N (%) (15–20 %).10 3.3) 89 (81.78 0.98 −0.2) 89 (81. especially in older people and those health insurance [4]. the prevalence of chronic HBV and HCV infections SBP (mmHg) χ2 = 1. including the western coastal areas (HBV.21 0. ticipants have unhealthy behaviors.08 2.47 0. and Western Europe and North America (1 %) ≥ 40 101 (13. Variables Hepatitis B infection Hepatitis C infection The prevalence rate of HBV in the present study Negative Positive Negative Positive (12.003 2.4) 61 (58. few people are the awareness of virus infection and motivate disabled aware of viral infections. in addition to HBV/HCV infec- C virus carriers tion and older age.89 0.8) 49 (49. most of the disabled participants and primary health care providers. HBV or HCV carriers emerged from this study.66 χ2 = 2.5) 372 (55. HCV.03 2 adults with disabilities living in rural areas (14. but higher than those of the adult popula- SGPT (mu/mL) χ2 = 1.12 3.00 ~ 9. such as interferon. high fasting blood glucose levels. HBV hepatitis B virus a CI: confidence interval Dependent variable: SGPT Model summary: F = 11. 20. with or without hepatitis reported some specific unhealthy The present study also revealed that many disabled par- behaviors.7) 43 (36.3) 148 (20.42 Age (1 > 65) −4. and ribavirin are covered by the Taiwan national with disabilities.6) 31 (28.85 1. including sub- Saharan Africa and East Asia (5–10 %).13 HCV (1 = positive) 15.9) 65 (55.59 0.68 ~ 11.001 4.4) 166 (23. Fourth.68 0.4) 86 (79.6) 87 (73. Second.22 0.98 χ2 = 6.8 %) [10].1) Based on the results of the present study (Table 2).58 ~ 23. Table 4 Factors associated with elevated liver function (SGPT) Variables Unstandardized Beta t value p 95 % CIa B SE Constant 19. lack of education. 18. DBP diastolic blood pressure. ≥ 140 260 (35.02 0. antiviral treatments.6) 43 (41.40 1.25 0.61 Smoking (1 = current smoker) 1.9) possible reasons for higher rates of HCV infection in DBP (mmHg) χ = 0.1 %) than < 90 558 (76. SBP systolic blood some antiviral drugs are effective for eradicating the en- pressure.2) 50 (50.28 2. < 140 470 (64.89 <0.04 ~ 14. the Middle East < 40 635 (86.7 %.19 ~ 20. lamivudine. poverty.03 0.72*** tion in different geographical areas.1) 53 (44. Fortunately.87 2 χ = 0.1) about virus-related hepatitis.3) the nationwide prevalence (2–3 %) include health dispar- ≥ 90 172 (23.92.027 −8.15 2. Therefore. although the number of newly acquired Body mass index (kg/m ) 2 χ = 1. strategies to enhance with a low socioeconomic status.3) 78 (10.028 0.65 (1 > 110 mg) BMI (1 = overweight/obesity) 5.8) 20 (18.001 10.51 Alcohol (1 = current drinker) 6.6) 22 (20. over. illiteracy.7) 648 (89. fruit.4) 32 (26. and lack of information < 109 575 (78. such as inadequate weight.7) 20 (18.53 Abbreviations: SGPT serum glutamic pyruvic transaminase.9) (2–5 %).26 2.87 ~ 11.6) 554 (76.66 χ2 = 53. First.3) the implementation of the national immunization pro- Overweight/Obesity 384 (56.001 .001 tire virus and reducing the incidences of hepatic cancer by 78 % and liver cirrhosis by 47 % [1–4].29 ~ −0. 10.24 0.08 −2.1) [1–4].37 HBV (1 = positive) 9.81 0.11 3. which are effective and can successfully cure antiviral treatments are important issues for clinicians the infection.30 2.7) 238 (33. Although there is currently ≥ 110 160 (21.1) 28 (23.71 1.418 −2.001 16. ***p < 0.67 11.54 2 χ = 0. and very few receive antiviral residents to receive and complete the entire course of treatment. Therefore.5) 299 (44. BMC Public Health (2016) 16:146 Page 5 of 7 Table 3 Physiological biomarkers associated with hepatitis B or preventable risk factors.38 2 HBV infections in Taiwan has declined substantially since Average/under 292 (43.4) 77 (71.9) no vaccine for HCV. evidence strongly suggests that Abbreviations: SGPT serum glutamic pyruvic transaminase.29* remains high in some rural areas [3.56 Fasting blood glucose 7.7) ity resulting from the limited resources and unqualified FBG (mg/dL) χ2 = 0. FBG fasting blood glucose * p < 0.7) 577 (79.9) 90 (76. ade- there was a high prevalence of HCV infection in adults fovir.56 medical personnel using unsterilized materials [4].3) 482 (66.001 2.Jane et al.7) gram.20 5. and alcohol consumption were important and exercise and insufficient water. 12]. p < 0. BMI body mass index. and vegetable intake.35 0. Third.91 2.3) 76 (63.05.71 ~ 6.

3Department of Ophthalmology. 2015. and alcohol drinking in the final the prevention of liver cancer. BMC Public Health (2016) 16:146 Page 6 of 7 Moreover. 4Department of Orthopedic Surgery. Author details In addition. Acknowledgments mental. healthy behaviors and referral for further diagnosis of style factors. Although these habits were not directly corre. Taiwan.int/ for community-dwelling adults with disabilities. Available from: [http://www. such as the amount and type of lated with health status.who. In Authors’ contributions addition. previous studies have reported alcohol consumed and extent of cigarette smoking. and increasing evi. the 3 vaccination doses in infancy. WNC. and editing of the final draft for publication. Prevent hepatitis. 2015. 6. Furthermore. diabetes. data analysis. Taiwan. and inadequate water. Available from: [http://www. Competing interest The authors declare that they have no competing interests. LJL. Access date of Dec 25. Chang to antiviral treatments at 6–12-month periods for HCV Gung University of Science and Technology. 1 Nursing Department. Hepatitis C. The association between obesity and non-alcoholic fatty liver disease could explain this increased risk [22–24]. Chang Gung Memorial Hospital. overweight. and selection and recall bias need to be considered because of vegetable intake were significantly associated with obesity/ the various health conditions of the participants. such as alcohol consumption. Hepatitis B. World Health Organization.mohw. of abnormal liver function [26].gov.aspx?f_list_no=312&fod_list_ study design does not allow for causality to be established. and initiating health promotion programs A meta-analysis of cohort studies reported a 17 and 90 % are important health strategies for these minority adults. . the staff of the Chiayi County Health Bureau. some unmodifiable risk factors. poor adher- ence to a Mediterranean diet was particularly detrimental Conclusions and implications for the risk of HCC in chronically infected HBV and/or There was a high prevalence of HCV infection among HCV carriers [22. overweight and HCC [20–23]. 2015. SWJ. and tions for people with disabilities living in rural areas is Public Health Nurses for providing administrative support. no=1601]. Access date of Dec 25. therapies. and MSL were involved with the conceptualization of the study. early detection of un- Similarly. References 1.. Centers for Disease Control (CDC). and HBV/HCV carriers. HCV carriers. health care providers and district governments. unhealthy behaviors. Chang Gung University of Science and Technology. pants were not randomly recruited and were from the 5.6 % of the participants reported and possible confounders might not have been measured.gov. Cause of death statistics. Second. current and previous alcohol consumption. Chiayi County. All authors read and approved the final manuscript.int/ nosis of chronic liver disease. Available from: generalizability of these findings. 23].tw/home/Hepatitis_B_Acute]. Access date of Dec 25. Buddhist-Tzu Chi Hospital. World Health Organization. HBV or HCV carriers in an Aboriginal popula.. Chang Gung Memorial whose HBV antibodies are no longer present following Hospital.who. Taiwan. increasing awareness of virus-related obesity. carriers with disabilities is an important strategy for Putz City. 2015.g. Ministry of Health and Welfare. and very few received early treatment or information on cose levels. 5College of Nursing. a previous study indicated that important life. every 3–6 months) for the early diag. the descriptive [http://www. Yunlin. in addition to HBV/HCV infection. 2.tw/home/Hepatitis_C_Acute]. respectively Third. 2015. hepatitis and its consequences. Access date of Dec 25. 3. the partici. and avoiding overuse of alcohol and smoking 2. 2Deparment of Internal Medicine. Available from: [http://www. Chiayi. 9. also contribute to HCC [20]. Taiwan. same geographic area. World Health Organization. 2015.tw/cht/DOS/Statistic. Acute hepatitis B virus infection 2015. West Sec. fruit. Limitations 4. Considering the limitations associated with physical. grams could be provided for disabled young people Taoyuan. Available from: [http://www. that insufficient exercise. Taiwan. First. adoption of appropriate mediacentre/factsheets/fs164_apr2014/en/]. Yunlin. more convenient HBV vaccine booster pro. Taiwan. Access date of Dec 25. few of the The modifiable factors significantly associated with participants possessed an awareness of their liver health.cdc. compared with those of normal weight [25]. increased risk of HCC for overweight and obese people. adults with disabilities in the present study. mediacentre/factsheets/fs204/en/]. Chiayi County 61363. and PHC participated in the conceptualization of the study and smoking also had the most elevated levels of biomarkers data collection. or multiple disabilities among this vulnerable The authors would like to thank the individuals who participated in this study for their support in making this study possible. MYC. Acute hepatitis C virus infection. elevated liver function included high fasting blood glu. Taiwan. providing accessible HBV dence is emerging that obesity is a major etiology for vaccine booster programs and antiviral treatments for abnormal liver function among the young generation [24]. Despite the presence of regression model. We would like to acknowledge population.cdc. Finally. Received: 5 September 2015 Accepted: 8 February 2016 further studies are necessary to explore and initiate poten- tial health promotion programs that encourage regular monitoring (e. self-reporting often results in underestimation of (Table 2). which limits the who. Available from: [http://www. an important strategy for primary health care providers. No.int/campaigns/hepatitis-day/2015]. respectively.gov. Furthermore. the inclusion of healthy lifestyle modifica. tion with a high incidence of alcohol consumption and study design. This study had certain limitations.1 and 6. Chiapu Rd. access Chang Gung Memorial Hospital. Moreover. Access date of Dec 25. 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