Literature search
The literature search resulted in 3815 results (Fig. 1). After title screening, 113 citations were identified as potentially relevant and requiring abstract screening. Following abstract screening, 50 articles required a full text review with 18 articles included.
Flow chart showing details of published literature search
Study characteristics
The articles were published between 2010 and 2021 (Table 3). Of 18 included campaigns, each from a different campaign, 9 (50%) were from Europe and 5 (27.8%) targeted minority ethnicities and migrant populations in Europe. The most common aim was to increase HCV testing (50%). The scale of campaigns varied, with four (22.2%) studies reporting on nationwide campaigns, six (33.3%) on regional campaigns, two (11.1%) on multiple cities or sites, and six (33.3%) conducted in one city. Campaigns utilised traditional media (such as radio, broadcast television, and newsprint), social media, targeted internet adverts, and geosocial mobile apps particularly when targeting men who have sex with men (MSM). Two campaigns used art exhibits as a vehicle for education (Fig. 2).
United Kingdom
Of four campaigns from the United Kingdom, 3 (75%) were from Scotland [17, 24, 29]. Two campaigns targeted migrant populations of south Asian ethnicity aiming to improve awareness and encourage testing for both HCV and HBV [16, 17]. Both campaigns recruited community leaders and representatives as collaborators. Campaigns used internal adverts at mosques and community centres. Additionally, educational talks were held during public meetings. Both studies offered on-site testing (results delivered by mail) and had high uptake of screening. Uddin et al. tested 4833 participants with 57 (1.2%) anti-HCV positive (55 HCV RNA positive) and 75 (1.6%) HBsAg positive [16]. Jafferbhoy et al. tested 170 individuals with 7 (4%) anti-HCV positive (5 HCV RNA positive), and 1 (0.6%) HBsAg positive [17]. One study targeted people who had received blood products before 1991 and built on a recent national enquiry in Scotland [29]. The campaign aimed to encourage testing in this population and used information leaflets and posters distributed to GPs, pharmacies, dentists, and care homes. Materials signposted individuals to an NHS website, support helpline, and their GP for further advice and testing. Impact was assessed by analysing trends in HCV testing in the year when the enquiry report was released (2015), and when the campaign was run (2016), finding a significantly higher number of tests in the week following the release of the report and the number mentioning blood transfusion for three weeks. These increases were not sustained following the awareness campaign. The final study described an art exhibit targeted to the general population in Glasgow which was aimed at reducing stigma [24]. HCV-affected individuals expressed their views on stigma and other facets of living with HCV using visual media under the guidance of experienced artists. Themes included, the rollercoaster of despair and hope, and the positive impacts of advancement in treatment through DAAs.
United States
Two (50%) campaigns from the US targeted baby boomers and aimed to increase awareness and testing [21, 30]. One of these studies used targeted Facebook advertisements that linked directly to a testing website [30]. Additionally, a Facebook page was created where HCV information was posted. The page accumulated 49 followers between October 2015 and January 2017. Facebook advertisements reached 204,657 individuals with 8,547 (4.2%) clicks. Of 6919 unique testing website users, 2020 (29.2%) used the testing site locator, 48 (0.7%) accessed free testing. Of these 48, 1 (2.1%) was anti-HCV positive (RNA results were not reported). The second campaign used print, news, social and digital media nationwide relying on donated time [21]. These were supplemented by targeted paid advertisements using YouTube and Google directing participants to a website. Additionally, the CDC used Facebook and Twitter. Between 2012 and 2016, the campaign was shown in search results and other sites on the Google network 1.2 billion times. Google advertisements achieved a 0.4% click rate, YouTube advertisements were viewed 1.6 million times and the website was visited 200,000 times.
One study targeted African Americans in Memphis and surrounding areas aiming to encourage testing using advertisements on local radio, television, print, and social media [19]. This study was not evaluated and we could not find any further information on outcomes. The final study targeted MSM in California using social media with the aim of encouraging testing and linking participants to care [22]. The study reported that MSM from ethnic minorities were more likely to remain engaged with outreach staff.
The Netherlands
In the Netherlands one study targeted immigrants of Turkish descent [18]. Study materials were developed by repurposing existing materials. Materials were disseminated through traditional media i.e., Turkish and Dutch newspapers, radio. Brochures were also distributed through Turkish shops and educational meetings were held at mosques and community centres. Testing was offered through a mobile laboratory. Screening uptake was high with 2 (0.3%) of 647 participants testing positive for anti-HCV and 18 (3.0%) for active HBV (HBsAg positive). Additionally, 25 (4%) participants were anti-HBc positive (no active HBV) with older participants, and first-generation migrants having higher anti-HBc prevalence. A review of hospital records revealed a prevalence of 0.7% for active HBV (higher in men) and 0.1% for active HCV (higher in women) among first generation migrants older than 24 years living in Arnhem. The most frequent risk factor mentioned was circumcision (method i.e., medical, or non-medical not specified).
A second campaign was run nationwide and targeted several risk groups (primarily PWID) [23]. It aimed to increase awareness, encourage testing, and increase the number of those infected with HCV identified. There were 299 additional positive anti-HCV tests resulting from the PWID intervention (257 had chronic HCV) compared to the control regions. For the public intervention, there was a 6.8% (95% CI: 6.2–7.4%) net increase in anti-HCV tests comparing the intervention and control regions during the intervention period. There was also a 5.9% (95% CI: 0.4–11.5%) net increase in the number of anti-HCV positive tests comparing intervention and control regions.
The final campaign used a similar strategy to the national campaign but was only run in one intervention region [15]. Number of tests requested increased from 57 to 172 in the intervention region compared to 86 to 118 in the control region (2.2 (95% CI: 1.5–3.3) times higher in the intervention region). There was a 2.6% (95% CI: − 0.7–5.8%) increase in anti-HCV cases identified in the intervention region compared to the control region. Positive tests were confirmed HCV RNA testing.
Australia
Campaigns from Australia targeted PWID, [20] younger people, [27] and the general public [31]. The PWID campaign aimed to reduce higher risk behaviour around injecting including needle reuse with posters displayed at a needle and syringe program (NSP) site. The other two campaigns aimed to raise awareness and reduce stigma. The campaign targeted at younger people encouraged participants to develop video or photographic concepts which were exhibited on a dedicated website and in public galleries and shared on social media with a public vote for winning entries. The public campaign used targeted Facebook advertisements which signposted participants to educational materials and a survey.
Parameters of the campaigns identified in published literature
Canada
One campaign targeted MSM using location advertisements in print or video displayed in gay venues or events, advertisements on a queer news website, and advertisements on geosocial websites and apps [28]. The campaign aimed to evaluate the impact of advertisements on the use of a new internet-based testing service. During the study, 177 individuals created an account, with 83 (46.9%) being directed from advertisements from apps, 52 (29.4%) from the campaign website, 21 (11.9%) from location advertisements, and 20 (11.3%) from the news website.
The second campaign targeted HCV patients and care providers and aimed to reduce knowledge gaps [26]. The intervention utilised an online course promoted through a website, a nurse newsletter, and a national network of partners.
Italy
The Italian campaign targeted people of Pakistani descent living in northern Italy [32]. The intervention consisted of an educational video on a dedicated website and aimed to improve knowledge about HCV. The website was promoted on Facebook and through a mailing list. Participants were administered pre- and post-video questionnaires to assess impact. Of 600 people contacted, 339 (56.5%) took part. Pre-video knowledge was low with 32% of participants unaware of HCV, 42% unaware of the potential for long-term HCV infection, and 14% aware of access to DAAs through health services. Only 67 participants answered the post-video interview with HCV awareness improving to 97%, awareness of long-term HCV infection to 99% and awareness of DAA access to 93%.
Spain
The Spanish campaign was targeted at MSM and aimed to encourage testing for blood-borne viruses and sexually transmitted infections and to evaluate acceptability and effectiveness of testing promotion through geosocial mobile applications [25]. In total, 2656 individual messages were sent with 1019 responses (38.3%) (34 blocked or rejected the message and 139 gave indifferent responses). Of the 846 who responded favourably, 108 (12.8%) were interested in testing or vaccination, 258 (30.5%) stated that they planned to test elsewhere or had already tested, and 480 (56.7%) provided no information. Among 108 who were interested in attending a facility, 79 (73.2%) attended. Respondents were more likely to be older, to have been online when the message was sent or been online in the previous hour and using Grindr. None of 76 Hepatitis C tests performed was reactive.
Stakeholder discussions
Discussions with Gilead involved the ‘Hep C Ki?’ campaign which targeted the British South Asian community and aimed to raise awareness and drive testing for HCV [33]. The campaign included a dedicated website, posters, leaflets, digital content, media and bus stop advertisements, and a partnership with social media influencers and community comedians. Additionally, five Operational Delivery Networks (ODNs) with community outreach were interviewed. Media advertisements reached over 700,000 people. However, testing uptake is not well understood as the campaign was not designed to measure this.
Discussions with Hepatitis Scotland involved two campaigns, Hep See, the art exhibit previous described [24] and #BeHepCFree [34]. The #BeHepCFree campaign aimed to raise awareness about DAAs and consisted of two strategies, two-minute animations based on recordings from interviews with people successfully treated using DAAs and a digital media campaign launched on World Hepatitis Day in 2020. Animations were posted on YouTube, Facebook and a dedicated website. The campaign was not officially evaluated.
Grey literature
We identified a document comparing the ‘FaCe It’ campaign, a previous UK campaign to similar campaigns run in France around the same period [35]. The campaign utilised several resources including patient leaflets in multiple languages to provide basic information and answer the most important questions. Campaign posters highlighted and raised awareness about Hepatitis C. Essential information documents were distributed to assist healthcare professionals in offering testing to patients who may have been at risk of infection, a campaign booklet encouraged people to assess their individual risk, and other leaflets identified campaign media ambassadors (people living with Hepatitis C to share their experiences about living with HCV and speak to the media). Finally, a quick reference guide was developed for healthcare professionals to improve knowledge on the diagnosis and treatment of Hepatitis C. The authors identified several problems with the UK campaign including limited funding, lack of targeting, and stigmatising, accusatory messaging.
We also found a document published by Public Health England (PHE) that collated all resources developed by PHE to support an ongoing campaign to eliminate viral hepatitis [9]. This repository included posters, videos and banners for social media in multiple languages.
Additionally, we identified a review of screening campaigns for chronic viral hepatitis in migrant communities in Europe, [36] a study protocol for a community-based campaign focussed on assessing and improving HCV screening and treatment in Arizona, [37] and two documents summarising several campaigns undertaken in Australia [38, 39].
A Google search also identified web pages, news articles, social media pages, videos, and documents relating to several Hepatitis C media campaigns in multiple countries. These included campaigns reported earlier (e.g., Hep C Ki?, #BeHepCFree). Similarly, campaigns focused on raising awareness, stigma reduction, increasing testing demand, encouraging treatment seeking, and emphasising the ease of new Hepatitis C treatment. Target populations were diverse and similar to those identified through the published literature search and discussions with stakeholders including people living with Hepatitis C, south Asian populations in the UK, and baby boomers in the US. In the US, we also identified several media campaigns targeted at baby boomers run by pharmaceutical companies with the aim of boosting drug sales.
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