All the data were acquired from the “China Sanitation Statistics Yearbook” which was published in 2016 [10] . In this study, we used the data of the incidence rate of hepatitis B and C, the outpatient and admission expenditure data per person, region GDP, urban and rural population, per capita expenditure in rural and urban areas, per capita income in rural and urban areas, rate of hospital delivery in urban and rural area, prenatal examination rate, the number of staff of disease management center and health workers nationwide, the frequency of counseling and group education by government every year in each region in China.

In the beginning, we divided 31 provinces into two regions according to the median incidence rate of hepatitis B and C of the provinces since normalcy was confirmed. The areas which incidence higher than median incidence were set as high incidence area (high area), and the area’s incidence lower than the median incidence rate were set as low incidence area (low area). The median of hepatitis B is Shanxi, and the median of hepatitis C is Guizhou, and they were categorized as high incidence area. For comparing the differences in the incidence rate of hepatitis B and C, the socio-economic factors between the high incidence areas and low incidence areas the t-test analysis was conducted. To detect the correlation between hepatitis B/C and socioeconomic factors, Pearson correlation analysis was performed. Data were analyzed using SPSS ver. 20.0, and the significance level was set at the level of p < 5%. This study was conducted between April and July 2018.

The data we used in this study were taken from the “China Statistical Yearbook”, which was published in 2016. The “China Statistical Yearbook” was publicly available at the Chinese government website; therefore, there was no special ethical committee of the institutional approval required.

The highest incidence rate of hepatitis B was Xinjiang (164.31 per thousand people), and the lowest was Beijing (7.82 per thousand people). The highest incidence rate of hepatitis C was also Xinjiang (47.66 per thousand people), and the lowest was Xizang (0.98 per thousand people).

The mean incidence rates of hepatitis B and hepatitis C in 31 provinces of China in 2015 were 70.03 and 16.51 per 100 thousand people, respectively. The mean incidence rates of hepatitis B in high and low incidence areas were 101.12 and 36.88 per 100 thousand people, respectively. The incidence rates of hepatitis C in high and low incidence areas were 24.57 and 7.91 per 100 thousand people, respectively. Among them, both hepatitis B and hepatitis C, there were 16 (51.6%) areas in the high incidence area (high area), 15 (48.4%) areas were in the low incidence area (low area). According to the results, the high incidence area of hepatitis B was also a high incidence area of hepatitis C, except the region of Xizang. Xizang was in a high incidence area of hepatitis B, but it was a low incidence area of hepatitis C (Table 1).

The differences of socioeconomic factors between high incidence and low incidence area of hepatitis B, the statistically significant difference of the incidence of hepatitis B (p < 0.01) and hepatitis C (p = 0.02), outpatient expenditure per capita (p = 0.03) were found between the two groups. There was no significant difference in other items (Table 2).

Results of comparison with high incidence area and low incidence area according to the median incidence rate of hepatitis C, there were significant differences on the incidence rate of hepatitis B (p = 0.01), the incidence rate of hepatitis C (p < 0.01), urban income (p = 0.04), rural income (p = 0.01), rural spending (p = 0.02) between two areas (Table 3).

The incidence of hepatitis B was positively correlated with the incidence of hepatitis C (r = 0.526, p < 0.01), had negative correlation with the outpatient expenses (r = −0.46, p < 0.01), prenatal examination rate (r = −0.547, p < 0.01) and the rate of hospital delivery in rural area (r = −0.422, p < 0.01). The incidence rate of hepatitis C had negative correlation with the urban income (r = −0.450, p < 0.05), rural income (r = −0.499, p < 0.05), rural spending (r = −0.443, p < 0.05), and rate of hospital delivery in rural area (r = −0.379, p < 0.05) (Table 4).

NOTE. ▲Shanxi = 山西, ▲▲Shanxi = 陕西.

Note. CDC = Center for Disease Control and Prevention. CNY = China Yuan. Group education = Public health education activities.

Note. CDC = Center for Disease Control and Prevention. CNY = China Yuan. Group education = Public health education activities.

* p < 0.05; **p < 0.01.

This study showed a positive correlation between the high incidence rate of hepatitis B and C. As previously reported [13] [14] , this statistic showed wide differences of incidence of hepatitis B and C. Hepatitis B and C have a similar pathogenesis and route of infection; therefore, we need to pay attention similarly on preventive measures of both at the same time with high incidence areas in the future.

Beijing is the capital of China and the most developed region in policies and economy, bringing young generations towards the city, which is the lowest incidence area of hepatitis. Young people are much sensitized and received the hepatitis B vaccine in comparison to other areas. They have the higher awareness of their own health, the intention to accept disease-related knowledge than other areas because of relatively higher income and knowledge. However, the incidence of hepatitis B occurs mostly among young people from 15 to 30 years [15] [16] , and sexually transmitted infection is one of the main routes of hepatitis B circulation [17] . On the other side, Beijing also has a large number of floating populations, which is a high-risk group of hepatitis [18] [19] [20] . The high HBsAg (Hepatitis B surface antigen) prevalence among floating population is attributed to poor understanding of HBV vaccination, low awareness of HBV infection control and prevention measures, and low educational levels [21] . Therefore, special strategies need to focus more on the prevention and control of sexually transmitted hepatitis for younger gathering areas. For the floating population, we need to focus on improving their knowledge of hepatitis and health awareness according to their education level.

Xinjiang is the western part of China where ethnic minorities migrate and economically developed areas, which is the highest incidence areas for both hepatitis B and C. Economic retardation, inconvenient transportation, and language disunity are the main causes of high incidence of hepatitis, high rate of home delivery, and low hepatitis screening [22] [23] . There are still a large number of ethnic minority areas in China and use various languages. The disunity of language is a barrier to medical treatment, poor acceptance of disease-related knowledge and information among local residents [24] . To reduce these obstacles of the languages, it is required to set up the health personnel who are familiar with local languages and customs to communicate properly and write a handbook of disease knowledge. Strong motivation and promotion to access to the screening of adult people, community education, and primary to tertiary prevention are needed to work together. With the existing government programs, community education and school health programs are also the key measures to improve the awareness and sensitize the people to ensure hepatitis screening and early treatment.

In this study, there is no statistical difference between the two groups on per capita GDP; however, still it is observed that per capita GDP in low-incidence areas is higher than that in high-incidence areas. The same economic disparity is also observed in the cost of health care and the daily cost of living in rural and urban areas. The economies have a potential impact on the incidence of hepatitis B and C. For example, people in economically developed areas have a relatively high level of health literacy, more responsive to regular physical examination and the compliance rates are as well higher than economically underdeveloped areas [14] . As a result, the people in higher regional GDP per capita have more opportunities for early diagnosis and treatment to prevent disease-related complications.

Population density determines the rate of transmission of infectious diseases [25] . For example, the higher the population density, the faster the disease spreads. However, our study observed that the incidence of hepatitis is not related to the density of the population. This might be due to their routes of transmission perceiving that hepatitis B and C are mainly transmitted through blood and body fluids.

The government’s participation in public facilities can reflect the importance of public health. The more investment in public facilities can ensure the better capacity to prevent and control diseases. If there are a large number of health officers and staffs in the center for disease control and prevention, more frequencies of public health education activities and consultations will be organized; the infectious disease prevention and management will also be better. However, our comparison showed that there was no significant difference between the two groups. Even for high incidence areas, the government’s emphasis on disease prevention is higher than that of low incidence areas. It shows that the government also attaches great importance to diseases in high incidence areas and expects to raise awareness of disease prevention through increased staffing and public health education activities.

The prenatal examination can detect the liver function of the mother, whether it is normal or infected with viral hepatitis [26] . The choice of delivery at hospitals ensures that newborns can be injected with hepatitis B vaccine and prevent the transmission of hepatitis from mother to infants. In our analysis, there was a negative correlation between the rate of hospital delivery in the rural area with hepatitis B and hepatitis C, and between prenatal examination rate and hepatitis B. The higher prenatal screening rate is related to the family’s emphasis on mothers and infants. Therefore, it is a good way to avoid mother-to-child transmission for mothers who choose to delivery in hospitals and receive the prenatal examination. Moreover, we need special attention to reduce the risk of transmission from mother to child for women in economically and communicatively developed areas who are unable to receive adequate prenatal care and choose institutional delivery.

In this study, we used publicly available data, and we were able to conduct the limited analysis. Therefore, we could not conduct an analysis of the causal relationship about the regional socio-economic factors, which could relate to the incidence rates of hepatitis B and C.