Mental and physical health status among chronic hepatitis B patients

  • Yihe G. DaidaEmail author
  • Joseph A. Boscarino
  • Anne C. Moorman
  • Mei Lu
  • Loralee B. Rupp
  • Stuart C. Gordon
  • Eyasu H. Teshale
  • Mark A. Schmidt
  • Philip R. Spradling
  • for the Chronic Hepatitis Cohort Study Investigators



Little is known about health-related quality of life (HRQoL) in patients with chronic hepatitis B virus (CHB) infection in the United States. Our goal is to understand factors associated with HRQoL in this population.


We conducted a survey to assess HRQoL and behavioral risks among patients with CHB infection from four large U.S. health care systems. Primary outcomes were generated from the SF-8 scale to assess HRQoL, as measured by the mental component scores (MCS) and physical component scores (PCS). The survey also measured socio-demographic information, hepatitis-related behavioral risk factors, treatment exposure/history, stress, and social support. We supplemented survey data with electronic health records data on patient income, insurance, disease severity, and comorbidities. Multivariate analysis was used to estimate and compare adjusted least square means of MCS and PCS, and examine which risk factors were associated with lower MCS and PCS.


Nine hundred sixty-nine patients (44.6%) responded to the survey. Current life stressors and unemployment were associated with both lower MCS and PCS results in multivariate analyses. Lower MCS was also associated with White race and low social support, while lower PCS was also associated with Medicaid insurance.


Stressful life events and unemployment were related to mental and physical health status of CHB patients. Those who have social support have better mental health; White and Medicaid patients are more likely to have poorer mental and physical health, respectively. Management of CHB patients should include stress management, social support, and financial or employment assistance.


Chronic Hepatitis CHB HRQoL SF-8 



The CHeCS Investigators include the following investigators and sites: Scott D. Holmberg, Eyasu H. Teshale, Philip R. Spradling, Anne C. Moorman, Jian Xing, and Yuna Zhong, Division of Viral Hepatitis; National Centers for HIV, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), Atlanta, Georgia; Stuart C. Gordon, David R. Nerenz, Mei Lu, Lois Lamerato, Jia Li, Loralee B. Rupp, Nonna Akkerman, Nancy Oja-Tebbe, Talan Zhang, Sheri Trudeau, and Yueren Zhou, Henry Ford Health System, Detroit, Michigan; Joseph A. Boscarino, Zahra S. Daar, and Robert E. Smith, Department of Epidemiology and Health Services Research, Geisinger Clinic, Danville, Pennsylvania; Yihe G. Daida, Connie Mah Trinacty, Jonathan W. Lai, and Carmen P. Wong, Center for Integrated Health Care Research, Kaiser Permanente-Hawaii, Honolulu, Hawaii; Mark A. Schmidt and Judy L. Donald, The Center for Health Research, Kaiser Permanente-Northwest, Portland, OR.


The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


This study was funded by the Centers for Disease Control and Prevention and from Gilead Sciences. CHeCS was previously funded through May 2016 by the CDC Foundation, which received grants from AbbVie; Genentech, A Member of the Roche Group; Gilead Sciences; Janssen Pharmaceuticals, Inc. and Vertex Pharmaceuticals; past partial funders include Bristol-Myers Squibb. Granting corporations do not have access to CHeCS data and do not contribute to data analysis or writing of manuscripts.

Compliance with ethical standards

Conflict of interest

Stuart C. Gordon receives grant/research support from AbbVie Pharmaceuticals, Conatus, CymaBay, Gilead Sciences, Intercept Pharmaceuticals, and Merck. He is also a consultant/advisor for Dova Pharmaceuticals and Intercept and serves as a speaker/teacher in programs sponsored by Dova. Mei Lu, Joseph A. Boscarino, Mark A. Schmidt, Yihe G. Daida, and Loralee B. Rupp receive research grant support from Gilead Sciences and Intercept Pharmaceuticals. Eyasu H. Teshale, Anne C. Moorman, and Philip R. Spradling have no conflicts of interest to report.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study protocol was reviewed and approved by an Institutional Review Board at each participating study site.

Informed consent

The IRB has waived Informed Consent and Authorization for the use of electronic health records in this study. Passive informed consent was obtained from all individual participants who completed the study survey.


  1. 1.
    Roberts, H., Kruszon-Moran, D., Ly, K. N., Hughes, E., Iqbal, K., Jiles, R. B., et al. (2016). Prevalence of chronic hepatitis B virus (HBV) infection in U.S. households: National Health and Nutrition Examination Survey (NHANES), 1988–2012. Hepatology,63(2), 388–397.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Mayo, N. (Ed.). (2015). Dictionary of quality of life and health outcomes measurement (Mayo, N.). Milwaukee, WI: International Society for Quality of Life Research.Google Scholar
  3. 3.
    Prince, M., Patel, V., Saxena, S., Maj, M., Maselko, J., Phillips, M. R., et al. (2007). No health without mental health. The Lancet,370(9590), 859–877.CrossRefGoogle Scholar
  4. 4.
    Kendir, C., van den Akker, M., Vos, R., & Metsemakers, J. (2018). Cardiovascular disease patients have increased risk for comorbidity: A cross-sectional study in the Netherlands. European Journal of General Practice,24(1), 45–50.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Bhatti, Z., Salek, M., & Finlay, A. (2011). Chronic diseases influence major life changing decisions: A new domain in quality of life research. Journal of the Royal Society of Medicine,104(6), 241–250.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Bondini, S., Kallman, J., Dan, A., Younoszai, Z., Ramsey, L., Nader, F., et al. (2007). Health-related quality of life in patients with chronic hepatitis B. Liver International,27(8), 1119–1125.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Kim, S. J., Han, K. T., Lee, S. Y., & Park, E. C. (2015). Quality of life correlation with socioeconomic status in Korean hepatitis-B patients: A cross sectional study. Health and Quality of Life Outcomes,13(1), 55–67.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Ferreira, F. A., de Almeida-Neto, C., Teixeira, M. C., & Strauss, E. (2015). Health-related quality of life among blood donors with hepatitis B and hepatitis C: Longitudinal study before and after diagnosis. Revista Brasileira de Hematologia e Hemoterapia,37(6), 381–387.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Abedi, G., Rostami, F., & Nadi, A. (2015). Analyzing the dimensions of the quality of life in hepatitis B patients using confirmatory factor analysis. Global Journal of Health Science,7(7), 22–31.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Woo, G., Tomlinson, G., Yim, C., Lilly, L., Therapondos, G., Wong, D. K., et al. (2012). Health state utilities and quality of life in patients with hepatitis B. Canadian Journal of Gastroenterology and Hepatology,26(7), 445–451.Google Scholar
  11. 11.
    Zhuang, G., Zhang, M., Liu, Y., Guo, Y., Wu, Q., Zhou, K., et al. (2014). Significant impairment of health-related quality of life in mainland Chinese patients with chronic hepatitis B: A cross-sectional survey with pair-matched healthy controls. Health and Quality of Life Outcomes,12, 101–109.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Boscarino, J. A., Lu, M., Moorman, A. C., Gordon, S. C., Rupp, L. B., Spradling, P. R., et al. (2015). Predictors of poor mental and physical health status among patients with chronic hepatitis C infection: The Chronic Hepatitis Cohort Study (CHeCS). Hepatology,61(3), 802–811.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Moorman, A. C., Gordon, S. C., Rupp, L. B., Spradling, P. R., Teshale, E. H., Lu, M., et al. (2013). Baseline characteristics and mortality among people in care for chronic viral hepatitis: The chronic hepatitis cohort study. Clinical Infectious Diseases,56(1), 40–50.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Spradling, P. R., Rupp, L., Moorman, A. C., Lu, M., Teshale, E. H., & Gordon, S. C., et al. (2012). Hepatitis B and C virus infection among 1.2 million persons with access to care: Factors associated with testing and infection prevalence. Clinical Infectious Diseases,55(8), 1047–1055.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Center for Diseases Control (CDC). (2013). Locations and reasons for initial testing for hepatitis C infection–chronic hepatitis cohort study, United States, 2006–2010. MMWR. Morbidity and Mortality Weekly Report,62(32), 645–648.Google Scholar
  16. 16.
    Ware, J. E., Jr., Kosinski, M., Bjorner, J. B., Bayliss, M. S., Batenhorst, A., Dahlof, C. G., et al. (2003). Applications of computerized adaptive testing (CAT) to the assessment of headache impact. Quality of Life Research,12(8), 935–952.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Turner-Bowker, D. M., Bayliss, M. S., Ware, J. E., Jr., & Kosinski, M. (2003). Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Quality of Life Research,12(8), 1003–1012.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale. Journal of Psychosomatic Research,11(2), 213–218.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Boscarino, J. A., & Adams, R. E. (2009). PTSD onset and course following the World Trade Center disaster: Findings and implications for future research. Social Psychiatry and Psychiatric Epidemiology,44(10), 887–898.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Boscarino, J. A., Hoffman, S. N., Adams, R. E., Figley, C. R., & Solhkhah, R. (2014). Mental health outcomes among vulnerable residents after Hurricane Sandy: Implications for disaster research and planning. American Journal of Disaster Medicine,9(2), 107–120.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Stewart, A. L., & Ware, J. E. (Eds.). (1992). Measuring functioning and well-being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press.Google Scholar
  22. 22.
    Stewart, A. L., Greenfield, S., Hays, R. D., Wells, K., Rogers, W. H., & Berry, S. D., et al. (1989). Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. JAMA,262(7), 907–913.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    Stewart, A. L., Hays, R. D., & Ware, J. E. (1988). The MOS short-form general health survey. Reliability and validity in a patient population. Med Care,26(7), 724–735.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    McDonald, S. D., Mickens, M. N., Goldberg-Looney, L. D., Mutchler, B. J., Ellwood, M. S., & Castillo, T. A. (2018). Mental disorder prevalence among U.S. Department of Veterans Affairs outpatients with spinal cord injuries. The Journal of Spinal Cord Medicine,41(6), 1–12.CrossRefGoogle Scholar
  25. 25.
    Ware, J. E., & GlaxoSmithKline, (Eds.). (2001). How to score and interpret single-item health status measures: A manual for users of the of the SF-8 health survey : (with a supplement on the SF-6 health survey). Boston, MA: Lincoln, RI : QualityMetric, Inc.; Boston. MA: Health Assessment Lab.Google Scholar
  26. 26.
    Ware, J. E., Kosinski, M., Turner-Bowker, D. M., & Gandek, B. (Eds.). (2001). How to score the SF-8 Health Survey. Boston, MA: Health Assessment Lab.Google Scholar
  27. 27.
    Bradley, K. A., Bush, K. R., McDonell, M. B., Malone, T., & Fihn, S. D. (1998). Screening for problem drinking: Comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. J Gen Intern Med,13(6), 379–388.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine,158(16), 1789–1795.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Adams, R. E., Boscarino, J. A., & Galea, S. (2006). Social and psychological resources and health outcomes after the World Trade Center disaster. Social Science and Medicine,62(1), 176–188.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Freedy, J. R., Kilpatrick, D. G., & Resnick, H. S. (1993). Natural disasters and mental health: Theory, assessment, and intervention. Journal of Social Behavior and Personality,8(5), 49–103.Google Scholar
  31. 31.
    Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and Medicine,32(6), 705–714.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., et al. (2002). Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine,346(13), 982–987.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    National Center for Health Statistics (2003). U.S. Census 2000 population with bridged categories. (Vol. (PHS) 2003–1335). Hyattsville, MD: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.Google Scholar
  34. 34.
    Deyo, R. A., Cherkin, D. C., & Ciol, M. A. (1992). Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. Journal of Clinical Epidemiology,45(6), 613–619.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Austin, S. R., Wong, Y. N., Uzzo, R. G., Beck, J. R., & Egleston, B. L. (2013). Why summary comorbidity measures such as the charlson comorbidity index and elixhauser score work. Medical Care,53(9), e65–72.CrossRefGoogle Scholar
  36. 36.
    Scheffé, H. (1953). A method for judging all contrastsin the analysis of variance. Biometrika,40(1–2), 87–110.Google Scholar
  37. 37.
    Centers for Disease Control and Prevention. (2018). Current cigarette smoking among adults-United States, 2005–2016. Morbidity and Mortality Weekly Report,67(2), 53.CrossRefGoogle Scholar
  38. 38.
    National Institute on Alcohol Abuse and Alcoholism (2017). Alcohol Facts and Statistics. Accessed March, 2018.
  39. 39.
    National Institute on Drug Abuse (2015). Nationwide Trends. Accessed March, 2018.
  40. 40.
    Bosma, H., Peter, R., Siegrist, J., & Marmot, M. (1988). Two alternative job stress models and the risk of coronary heart disease. American Journal of Public Health,88(1), 68–74.CrossRefGoogle Scholar
  41. 41.
    Atesci, F. C., Cetin, B. C., Oguzhanoglu, N. K., Karadag, F., & Turgut, H. (2005). Psychiatric disorders and functioning in hepatitis B virus carriers. Psychosomatics,46(2), 142–147.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Adams, R. E., & Boscarino, J. A. (2011). A structural equation model of perievent panic and posttraumatic stress disorder after a community disaster. Journal of Traumatic Stress,24(1), 61–69.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Yamashita, J. (2012). A review of psychological assessments for disaster mental health studies. Psychological Trauma,4(6), 560–567.CrossRefGoogle Scholar
  44. 44.
    Slobodin, O., Caspi, Y., Klein, E., Berger, B. D., & Hobfoll, S. E. (2011). Resource loss and posttraumatic responses in Bedouin members of the Israeli Defense Forces. Journal of Traumatic Stress,24(1), 54–60.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Karacaer, Z., Cakir, B., Erdem, H., Ugurlu, K., Durmus, G., Ince, N. K., et al. (2016). Quality of life and related factors among chronic hepatitis B-infected patients: A multi-center study, Turkey. Health and Quality of Life Outcomes,14(1), 153–162.PubMedPubMedCentralCrossRefGoogle Scholar
  46. 46.
    Tutuncu, E. E., Guner, R., Gurbuz, Y., Kaya Kalem, A., Ozturk, B., Hasanoglu, I., et al. (2017). Adherence to nucleoside/nucleotide analogue treatment in patients with chronic hepatitis B. Balkan Medical Journal,34(6), 540–545.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Eisenberg, J. M., & Power, E. J. (2000). Transforming insurance coverage into quality health care: Voltage drops from potential to delivered quality. JAMA,284(16), 2100–2107.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Margaretten, M., Yelin, E., Imboden, J., Graf, J., Barton, J., Katz, P., et al. (2009). Predictors of depression in a multiethnic cohort of patients with rheumatoid arthritis. Arthritis and Rheumatism,61(11), 1586–1591.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Center for Behavioral Health Statistics and Quality (2015). 2014 National Survey on Drug Use and Health: Detailed Tables. Accessed June, 2019.
  50. 50.
    Ozkan, M., Corapcioglu, A., Balcioglu, I., Ertekin, E., Khan, S., Ozdemir, S., et al. (2006). Psychiatric morbidity and its effect on the quality of life of patients with chronic hepatitis B and hepatitis C. International Journal of Psychiatry in Medicine,36(3), 283–297.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Arnsten, J., Demas, P., Grant, R., Gourevitch, M., Farzadegan, H., Howard, A., et al. (2002). Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users. JGIM,17(5), 377–381.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Coleman, K. J., Stewart, C., Waitzfelder, B. E., Zeber, J. E., Morales, L. S., Ahmed, A. T., et al. (2016). Racial-ethnic differences in psychiatric diagnoses and treatment across 11 health care systems in the mental health research network. Psychiatric Services (Washington, D. C.),67(7), 749–757.CrossRefGoogle Scholar
  53. 53.
    Center for Diseases Control (2016). Surveillance for Viral Hepatitis – United States, 2014. Accessed May, 2017.

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Yihe G. Daida
    • 1
    Email author
  • Joseph A. Boscarino
    • 2
  • Anne C. Moorman
    • 3
  • Mei Lu
    • 4
  • Loralee B. Rupp
    • 4
  • Stuart C. Gordon
    • 4
    • 5
  • Eyasu H. Teshale
    • 6
  • Mark A. Schmidt
    • 7
  • Philip R. Spradling
    • 3
  • for the Chronic Hepatitis Cohort Study Investigators
  1. 1.Center for Integrated Health Care ResearchKaiser Permanente HawaiiHonoluluUSA
  2. 2.Department of Epidemiology & Health Services ResearchGeisinger ClinicDanvilleUSA
  3. 3.Division of Viral Hepatitis; National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and PreventionAtlantaUSA
  4. 4.Henry Ford Health System, Center for Health Policy & Health Services ResearchOne Ford PlaceDetroitUSA
  5. 5.Wayne State University School of MedicineDetroitUSA
  6. 6.Lead, Epidemiology Research Team; Epidemiology and Surveillance Branch; Division of Viral Hepatitis; National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and PreventionAtlantaUSA
  7. 7.Kaiser Permanente Northwest, Center for Health ResearchPortlandUSA

Personalised recommendations