The Jade Ribbon Campaign: A Model Program for Community Outreach and Education to Prevent Liver Cancer in Asian Americans

Exploring Vaccination Challenges among Syrian Refugees in Jordan: Insights from Camps and Communities, and Perceived Parental Barriers to Childhood Vaccination Uptake

PURPOSE

To identify and understand the multifaceted barriers faced by Syrian refugees when seeking vaccination services for their children.

METHODS

A survey questionnaire was administered through structured interviews to a sample of Syrian refugees residing inside the Al-Zaatari camp and in various urban areas across Jordanian communities. This process utilized a multi-stage sampling approach, beginning with a random selection from clusters or strata, and then employing convenience sampling within each to select participants. The survey covered demographics, barriers to vaccination, and vaccine hesitancy.

RESULTS

A total of 332 participants completed the survey with a mean age of 32.7 ± 10 years ranging from 18 to 67. More than half of the sample (59%) had an education of 11th grade or less. Sociodemographic disparities regarding barrier perception were evident among participants. Middle-aged adults (older than 32), males, and those with a monthly income less than USD 200 had scored significantly higher on barrier perceptions across all categories (p < 0.05). In-camp residents were less likely to face vaccination barriers compared to those living outside the camps (p < 0.001). Psychological antecedents of vaccine assessments showed that younger individuals had significantly higher scores in complacency, calculation, and constraints (p < 0.05). Participants with lower income had lower constraints and calculation scores (p < 0.05). In-camp residents had significantly higher scores in complacency, constraints, and calculation constructs compared outside camps counterparts (p < 0.05). Participants with no formal education had higher scores in complacency and constraints, and those with less than a 12th-grade education and higher education degrees scored significantly higher on the collective responsibility construct (p < 0.05).

CONCLUSIONS

Efforts to promote vaccination among refugees should consider the specific challenges faced by this population, including financial barriers, healthcare access inequalities, and the impact of living arrangements. Public health strategies should address not only individual and psychological factors but also the physical and logistical challenges in obtaining vaccines.

Family Involvement in Asian American Health Interventions: A Scoping Review and Conceptual Model

Family members play a crucial role in the health of Asian American communities, and their involvement in health interventions can be pivotal in optimizing impact and implementation. To explore how family members can be effectively involved in Asian American health interventions and develop a conceptual framework of methods of involvement at the stages of intervention development, process, and evaluation, this scoping review documented the role of Asian American family members in interventions (across any health objective). Of the 7175 studies identified through database and manual searches, we included 48 studies in the final analysis. Many studies focused on Chinese (54%) or Vietnamese (21%) populations, were conducted in California (44%), and involved spouses (35%) or parents/children (39%). We observed involvement across 3 stages: (1) intervention development (formative research, review process, material development), (2) intervention process (recruitment, receiving the intervention together, receiving a parallel intervention, enlisting support to achieve goals, voluntary intervention support, agent of family-wide change, and participation gatekeepers), and (3) intervention evaluation (received evaluation together, indirect impact evaluation, and feedback during intervention). Impact of family member involvement was both positive (as sources of encouragement, insight, accountability, comfort, and passion) and negative (sources of hindrance, backlash, stigma, obligation, and negative influence). Suggestions for future research interventions include (1) exploring family involvement in South Asian or young adult interventions, (2) diversifying types of family members involved (eg, extended family), and (3) diversifying methods of involvement (eg, family members as implementation agents).

Gaps and Disparities in Chronic Hepatitis B Monitoring and Treatment in the United States, 2016-2019

BACKGROUND

Chronic hepatitis B (CHB) carries an increased risk of death from cirrhosis and hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends patients with CHB receive monitoring of disease activity, including ALT, hepatitis B virus (HBV) DNA, hepatitis B e-antigen (HBeAg), and liver imaging for patients who experience an increased risk for HCC. HBV antiviral therapy is recommended for patients with active hepatitis and cirrhosis.

METHODS

Monitoring and treatment of adults with new CHB diagnoses were analyzed using Optum Clinformatics Data Mart Database claims data from January 1, 2016, to December 31, 2019.

RESULTS

Among 5978 patients with new CHB diagnosis, only 56% with cirrhosis and 50% without cirrhosis had claims for≥1 ALT and either HBV DNA or HBeAg test, and among patients recommended for HCC surveillance, 82% with cirrhosis and 57% without cirrhosis had claims for≥1 liver imaging within 12 months of diagnosis. Although antiviral treatment is recommended for patients with cirrhosis, only 29% of patients with cirrhosis had≥1 claim for HBV antiviral therapy within 12 months of CHB diagnosis. Multivariable analysis showed patients who were male, Asian, privately insured, or had cirrhosis were more likely (P<0.05) to receive ALT and either HBV DNA or HBeAg tests and HBV antiviral therapy within 12 months of diagnosis.

CONCLUSION

Many patients diagnosed with CHB are not receiving the clinical assessment and treatment recommended. A comprehensive initiative is needed to address the patient, provider, and system-related barriers to improve the clinical management of CHB.

A Comparative Trial of Improving Care for Underserved Asian Americans Infected with Hepatitis B Virus

BACKGROUND

Hepatitis B virus (HBV) is the leading cause of hepatocellular carcinoma (HCC). Asian Americans have the highest incidence and mortality rates of HCC among all US racial/ethnic groups. Inadequate monitoring and treatment of chronic hepatitis B contribute to poor health outcomes and increased healthcare costs among Asian Americans.

AIMS

The goal of this study is to assess the effect of a patient-led strategy on chronic hepatitis B monitoring and treatment adherence specifically among Asian Americans with culturally tailored Patient Navigator-led Intervention.

METHODS

From 2015 to 2018, 532 eligible participants living with chronic hepatitis B in the greater Philadelphia and New York city metropolitan areas were randomly assigned to either the intervention group or the control group. Generalized linear mixed-effects models were used to estimate the odds ratio (OR) for rates of doctor visits for chronic hepatitis B and rates of alanine aminotransferase testing for evidence of liver damage.

RESULTS

Intervention group had higher rates of doctor visits than the control group at both 6-month (77.22% vs. 45.75%) and 12-month assessments (90.73% vs. 60.61%). Significantly more intervention group participants received ALT testing than control group participants at 6-month (52.90% vs. 25.10%) and 12-month (75.40% vs. 46.75%) follow-up.

CONCLUSIONS

Culturally and linguistically appropriate intervention has strong effects on adherence to follow-up care among Asian American hepatitis B patients experiencing challenges to medication adherence and follow up care. These findings further identify opportunities for practical implementation of evidence-based intervention that could lead to reductions in disparities in chronic liver disease and liver cancer among high-risk, underserved populations.

Health Within Reach-a Patient-Centered Intervention to Increase Hepatitis B Screening Among Asian Americans: a Randomized Clinical Trial

BACKGROUND

There are few studies to date of interventions to increase viral hepatitis screening among Asian Americans, who have high rates of chronic hepatitis B (HBV) infection.

OBJECTIVE

To develop, implement, and test the efficacy of a mobile application (Hepatitis App) delivered in four languages to increase HBV screening among Asian Americans.

DESIGN

Cluster-randomized clinical trial.

PARTICIPANTS

Four hundred fifty-two Asian American patients ≥ 18 years of age, who had no prior HBV testing, and received primary care within two healthcare systems in San Francisco, CA.

INTERVENTIONS

The intervention group received the Hepatitis App, delivering interactive video education on viral hepatitis in English, Cantonese, Mandarin, or Vietnamese and a provider printout (Provider Alert) and Provider Panel Notification. The comparison group received a mobile application delivering nutrition and physical activity education and Provider Panel Notification.

MAIN MEASURES

Primary outcomes were patient-provider discussion about HBV and documentation of a HBV screening test within 3 months post-intervention. Secondary outcome was documentation of an order for a HBV screening test.

KEY RESULTS

Participants had a mean age of 57 years and were 64% female, 80% foreign-born, and 44% with limited English fluency. At post-visit, over 80% of intervention participants reported they liked using the Hepatitis App. At 3-month follow-up, the intervention group was more likely than the comparison group (all P < 0.001) to have discussed HBV with their provider (70% vs.16%), have a HBV test ordered (44% vs.10%), and receive a HBV test (38% vs.8%). In multivariable analyses, the intervention odds ratio for HBV test ordering was 7.6 (95% CI: 3.9, 14.8) and test receipt was 7.5 (95% CI: 3.6, 15.5).

CONCLUSIONS

A multi-lingual educational intervention using a mobile application in primary care clinics was well received by Asian American patients, enhanced patient-provider communication about HBV, and increased HBV screening. Technology can improve healthcare quality among Asian Americans.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02139722 ( https://clinicaltrials.gov/ct2/show/NCT02139722 ).

A training for health care workers to integrate hepatitis B care and treatment into routine HIV care in a high HBV burden, poorly resourced region of Uganda: the '2for1' project

INTRODUCTION

The "2for1" project is a demonstration project to examine the feasibility and effectiveness of HBV care integrated into an HIV clinic and service. An initial phase in implementation of this project was the development of a specific training program. Our objective was to describe key features of this integrated training curriculum and evaluation of its impact in the initial cohort of health care workers (HCWs).

METHODS

A training curriculum was designed by experts through literature review and expert opinion. Key distinctive features of this training program (compared to standard HBV training provided in the Government program) were; (i) Comparison of commonalities between HIV and HBV (ii) Available clinic- and community-level infrastructure, and the need to strengthen HBV care through integration (iii) Planning and coordination of sustained service integration. The training was aided by a power-point guided presentation, question and answer session and discussion, facilitated by physicians and hepatologists with expertise in viral hepatitis. Assessment approach used a self-administered questionnaire among a cohort of HCWs from 2 health facilities to answer questions on demographic information, knowledge and attitudes related to HBV and its prevention, before and after the training. Knowledge scores were generated and compared using paired t- tests.

RESULTS

A training curriculum was developed and delivered to a cohort of 44 HCWs including medical and nursing staff from the two project sites. Of the 44 participants, 20 (45.5%) were male, average age (SD) was 34.3 (8.3) with an age range of 22-58 years. More than half (24, 54.5%) had been in service for fewer than 5 years. Mean correct knowledge scores increased across three knowledge domains (HBV epidemiology and transmission, natural history and treatment) post-intervention. However, knowledge related to diagnosis and prevention of HBV did not change.

CONCLUSION

A structured HBV education intervention conducted as part of an HIV/HBV care integration training for health care workers yielded improved knowledge on HBV and identified aspects that require further training. This approach may be replicated in other settings, as a public health strategy to heighten HBV elimination efforts.

Development of an intervention system for linkage-to-care and follow-up for hepatitis B and C virus carriers

Background

Poor connections in the cascade of viral hepatitis care have been discussed around the world. In 2011 in Japan, 500,000 to 1.25 million hepatitis B and C virus carriers needed to consult with hepatologists, so linkage-to-care (LTC) needs to be promoted. Therefore, in this study, to improve LTC and care-seeking behaviors, we attempted to establish a community-based intervention system and evaluate its effectiveness by analyzing behavior modifications.

Methods

In a model city, Okazaki (population: 387,887 as of 2019), LTC was encouraged among HBV and HCV carriers by annually mailed brochures, and their care-seeking behaviors were followed up through questionnaires for 8 years (2012–2019). Their behavior modifications and demographic characteristics were analyzed anonymously in cooperation with community health workers, hepatologists, and researchers.

Results

Through regional HBsAg and anti-HCV screening, 333 HBV and 208 HCV carriers were identified. Before the intervention, only 34.7% (25/72) of HBV- and 34.3% (24/70) of HCV-positive individuals had consulted with hepatologists. However, in 2019, after the intervention, these proportions increased to 79.8% (91/114) and 91.2% (52/57), respectively. Access to outpatient care and treatment uptake also continuously improved. However, individuals over 70 years of age were significantly less likely to engage in care-seeking behaviors (p < 0.05), and significantly fewer HCV-positive females received treatment (p = 0.03).

Conclusions

A paper-based reiterative intervention encouraging LTC and follow-up successfully improved the care-seeking behaviors of hepatitis virus-positive individuals and enabled their behavior modifications to be monitored. Further trials are required to advance the system by age- and gender-specific interventions.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10269-5.

Interventions to increase migrants' care-seeking behaviour for stigmatised conditions: a scoping review

BACKGROUND

Despite availability of effective treatments, migrants in high-income countries seek care for conditions associated with stigma to a lower extent than the rest of the population. We conducted a scoping review to map the literature on interventions to increase migrants' care-seeking behaviour in high-income countries for stigmatised conditions. Main body of the abstract: We searched 15 electronic databases and journals, hand-searched references and citations, to identify studies on interventions to increase migrants' care-seeking in high-income countries for stigmatised conditions. We applied language restrictions for English and Swedish, and searched the full time period up to 5 July 2019. Our primary outcome of interest was care utilisation.

RESULTS

5447 records were identified in the literature searches. We identified 16 eligible studies, all from North America, that reported interventions to increase migrants' care-seeking behaviour for hepatitis B (n = 1) and mental health (n = 15). Three approaches were identified: health communication (n = 10), support groups (n = 2), and primary care-based approaches (n = 4). There was a general trend towards community-based interventions tailored to individual migrant groups. Significant gaps were identified in the literature, including studies conducted in Europe and studies including men or children. Furthermore, the choice of study designs introduced significant bias that prevented accurate conclusions on intervention effectiveness.

CONCLUSION

The available evidence on interventions to increase migrants' in high-income countries care-seeking behaviour for stigmatised conditions is limited in scope and quality. Future research, using reliable study designs, is needed to fill the remaining gaps and to boost the scope and reliability of the evidence.

Effectiveness of Interventions for Hepatitis B and C: A Systematic Review of Vaccination, Screening, Health Promotion and Linkage to Care Within Higher Income Countries

Viral hepatitis is a significant global health concern, particularly within low-middle income countries. Diseases historically affecting low-middle income countries, such as viral hepatitis, have become increasingly prevalent within high-income countries due to globalisation and mass international migration. High prevalence of viral hepatitis in migrant populations is of particular concern due to the associated morbidity and mortality, as well as the increased risk of vertical and horizontal transmission in the community. This is compounded by the asymptomatic nature of hepatitis, meaning many of those affected are unaware of their infection status. Long-term effects of viral hepatitis can include liver cirrhosis, liver cancer and liver failure. Therefore, the health needs of vulnerable migrants within high-income countries due to issues associated with viral hepatitis require attention. This includes assessment of measures such as targeted health education, increased screening, linkage to appropriate treatment and follow-up care. Additionally, it is necessary to address migrant healthcare barriers, such as language, economic and social barriers. It is imperative that vulnerable migrant groups gain appropriate access to health services to prevent disease transmission and the widening of health-related disparities within high-income countries.

Interventions to reduce the burden of vaccine-preventable diseases among migrants and refugees worldwide: A scoping review of published literature, 2006-2018

BACKGROUND

Disparities in vaccine-preventable disease (VPD) burden and immunisation coverage between migrants and refugees and their host populations have been described in numerous countries worldwide. Effective strategies are required to reduce the health disparities and immunisation inequities experienced by migrants and refugees.

METHODS

Using Arksey and O'Malley's framework, we conducted a scoping review to identify available literature on interventions aimed at reducing VPD burden among migrants and refugees worldwide. We searched for relevant empirical, peer-reviewed literature published in English between 2006 and 2018 using MEDLINE, Ovid EMBASE, CINAHL, Sociological Abstracts, and Web of Science databases. Relevant information from the studies, including intervention type, details and outcomes, were charted in Microsoft Excel and results were summarised using a descriptive analytical method.

RESULTS

Seventy studies met the inclusion criteria. The number of published studies increased over the years. The majority of studies were conducted in high-income countries. More studies were conducted among migrants (not including refugees) (n = 48, 66%) than specifically among refugees (n = 25, 34%). Interventions were implemented in a variety of settings, including health care (n = 31, 42%), community (n = 29, 39%), off-shore (n = 7, 9%), national (n = 4, 5%), school (n = 2, 3%), and workplace (n = 1, 1%). Studies reported interventions focused at the individual (to facilitate uptake of health services) (n = 4, 5%), community (to raise awareness) (n = 25, 34%), provider (to offer health services) (n = 12, 16%) and/or system (to increase compliance with recommendations) (n = 33, 45%) level. To be effective, interventions were designed to overcome commonly identified barriers to accessing services related to language, culture, distance and cost. Engagement with community members and organisations was an effective way to co-design interventions that address migrants' specific needs.

CONCLUSIONS

Studies emphasised the importance of interventions that address the heterogeneity within and between migrant and refugee populations. Considerable variation in practice remains, therefore more evaluation of interventions is needed to inform policy and programme decision-making.

Cancer/health communication and breast/cervical cancer screening among Asian Americans and five Asian ethnic groups

Objectives: This paper is an examination of cancer/health communication factors (i.e. cancer/health information seeking, patient-provider communication (PPC), cancer screening information from providers) and screening for breast and cervical cancer among Asian Americans and five Asian ethnic groups (Chinese, Filipinos, Japanese, Koreans, Vietnamese) in comparison to Whites. Additionally, the relationship between cancer/health communication disparity and cancer screening gaps between Asian Americans and Whites was investigated. Design: Data comes from a nationally representative sample of 2011-2014 Health Information National Trends Surveys (HINTS). Results: Asian Americans and most Asian ethnic-groups reported significantly lower rates of cancer/health information seeking and lower evaluations for PPC as compared to Whites, though differences within Asian ethnic groups were observed (Koreans' greater cancer/health information seeking, Japanese' higher PPC evaluation). When the cancer/health communication factors were controlled, Asian Americans' odds of cancer screening were increased. Especially, Asian Americans' odds of adhering to the breast cancer screening guideline became nearly 1.4 times greater than Whites. Conclusion: This research demonstrates that health organizations, providers, and Asian American patients' collaborative efforts to increase the access to quality cancer information, to make culturally competent but straightforward screening recommendations, and to practice effective communication in medical encounters will contribute to diminishing cancer disparities among Asian Americans.

Causes and trends in liver disease and hepatocellular carcinoma among men and women who received liver transplants in the U.S., 2010-2019

Background and aims

The national Organ Procurement and Transplant Network (OPTN) reported the major indication for liver transplants in 2018 was for other/unknown causes. This study was undertaken to examine all causes and trends in liver disease and hepatocellular carcinoma (HCC) among adults who received liver transplants in the past 10 years.

Methods

A national cohort study of all adults who received liver transplants from Jan 1, 2010 to Dec 31, 2019 recorded in the OPTN STAR database analyzed by etiology of liver disease and HCC, and gender.

Results

Adult liver transplants increased from 5,731 in 2010 to 8,345 in 2019 (45.6% increase). Between 2010 and 2014, liver disease and HCC associated with hepatitis C (HCV) was the major cause for liver transplantation. Proportion of liver transplants for HCV associated liver disease and HCC has since decreased to 18.7% in 2019 compared with 44.5% in 2010 [25.8%, (95% CI 24.3% to 27.3%), p<0.001], while liver transplants for liver disease and HCC associated with alcohol-associated liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) increased from 12.7% to 28.8% [16.1%, (95% CI 14.8% to 17.4%), p<0.001], and from 9.1% to 21.5% [12.4%, (95% CI 11.2% to 13.5%), p<0.001], respectively. When all causes of liver disease were examined, only 1.7% of liver transplants had unspecified causes. The five major causes of liver disease and HCC among men receiving liver transplants in 2019 were ALD (33.1%), HCV (21.9%), NAFLD (18.5%), cholestatic liver disease (5.7%) and hepatitis B (4.9%), while the major causes among women were NAFLD (26.8%), ALD (21.1%), HCV (13.1%), cholestatic liver disease (11.1%), and autoimmune liver disease (5.6%).

Conclusions

Our study found NAFLD in 2017 in women and ALD in 2019 in men have surpassed HCV as the leading causes of liver disease and HCC among adults receiving liver transplants.

Barriers to Disease Monitoring and Liver Cancer Surveillance Among Patients with Chronic Hepatitis B in the United States

Chronic hepatitis B infection (CHB) is a condition that needs ongoing care such as monitoring for liver enzymes (ALT) and HBV DNA tests in treated and untreated patients, and annual imaging evaluation for liver cancer. Although follow-up care and treatment might seem straight forward, an estimated two-thirds of those who are aware of their infection are not seeing a health care provider, and more than half of those who are eligible for treatment do not receive it. This study aimed to compile and examine studies related to the barriers of disease monitoring, treatment, and liver cancer surveillance for CHB patients in the United States (US). A total of 4439 studies on monitoring and surveillance of CHB published between 2007 and 2018 were identified through a search of electronic databases. After critical assessment, the authors included 42 studies, divided into categories: 'patient-related barriers'; 'provider-related barriers'; and 'system-related barriers'. Among the patient-related barriers, one of the most frequent factors invoked in failing to have adequate surveillance was lack of patient's knowledge. In the provider-related barrier category, a lack of disease knowledge and adherence to guidelines was frequently reported. For the system-related barrier category, the only recurrent mention was a lack of clarity in guidelines or lack of guidelines from certain national institutions. This review summarizes and highlights the need for long-term disease management improvement of chronic hepatitis B infection for patients and healthcare providers that care for them.

Barriers to chronic Hepatitis B treatment and care in Ghana: A qualitative study with people with Hepatitis B and healthcare providers

BACKGROUND

Hepatitis B viral (HBV) infection remains an important public health concern particularly in Africa. Between 1990 and 2013, Hepatitis B mortality increased by 63%. In recent times, effective antiviral agents against HBV such as Nucleos(t)ide analogs (NAs) are available. These drugs are capable of suppressing HBV replication, preventing progression of chronic Hepatitis B to cirrhosis, and reducing the risk of hepatocellular carcinoma and liver-related death. Notwithstanding, these treatments are underused despite their effectiveness in managing Hepatitis B. This study sought to explore barriers to treatment and care for people with Hepatitis B (PWHB) in Ghana, paying particular attention to beliefs about aetiology that can act as a barrier to care for PWHB.

METHODS

We used an exploratory qualitative design with a purposive sampling technique. Face-to-face interviews were conducted for 18 persons with Hepatitis B (PWHB) and 15 healthcare providers (HCP; physicians, nurses, and midwives). In addition, four focus group discussions (FGD) with a composition of eight HCPs in each group were done. Participants were recruited from one tertiary and one regional hospital in Ghana. Data were processed using QSR Nvivo version 10.0 and analysed using the procedure of inductive thematic analysis. Participants were recruited from one tertiary and one regional hospital in Ghana.

RESULTS

Three main cultural beliefs regarding the aetiology of chronic Hepatitis B that act as barriers to care and treatment were identified. These were: (1) the belief that chronic Hepatitis B is a punishment from the gods to those who touch dead bodies without permission from their landlords, (2) the belief that bewitchment contributes to chronic Hepatitis B, and (3) the belief that chronic Hepatitis B is caused by spiritual poison. Furthermore, individual level barriers were identified. These were the absence of chronic Hepatitis B signs and symptoms, perceived efficacy of traditional herbal medicine, and PWHB's perception that formal care does not meet their expectations. Health system-related barriers included high cost of hospital-based care and inadequate Hepatitis B education for patients from HCPs.

CONCLUSION

Given that high cost of hospital based care was considered an important barrier to engagement in care for PWHB, we recommend including the required Hepatitis B laboratory investigations such as viral load, and the recommended treatment in the National Health Insurance Scheme (NHIS). Also, we recommend increasing health care providers and PWHB Hepatitis B knowledge and capacity in a culturally sensitive fashion, discuss with patients (1) myths about aetiology and the lack of efficacy of traditional herbal medicines, and (2) patients' expectations of care and the need to monitor even in the absence of symptoms.

Management of hepatitis B infected pregnant women: a cross-sectional study of obstetricians

BACKGROUND

Our study aims to describe how obstetricians manage pregnant women infected with chronic hepatitis B in a region with a large high-risk population.

METHODS

We performed a cross-sectional study among practicing obstetricians in Santa Clara County, California. All obstetricians practicing in Santa Clara County were invited to participate in the study. Obstetricians were recruited in person or by mail to complete a voluntary, multiple choice survey on hepatitis B (HBV). Survey questions assessed basic HBV knowledge and obstetricians' self-reported clinical practices of the management of HBV-infected pregnant women. Pooled descriptive analyses were calculated for the cohort, as well as, correlation coefficients to evaluate the association between reported clinical practices and hepatitis B knowledge.

RESULTS

Among 138 obstetricians who completed the survey, 94% reported routinely testing pregnant women for hepatitis B surface antigen (HBsAg) with each pregnancy. Only 60.9% routinely advised HBsAg-positive patients to seek specialist evaluation for antiviral treatment and monitoring and fewer than half (48.6%) routinely provided them with HBV information. While most respondents recognized the potential complications of chronic HBV (94.2%), only 21% were aware that chronic HBV carries a 25% risk of liver related death when left unmonitored and untreated, and only 25% were aware of the high prevalence of chronic HBV in the foreign-born Asian, Native Hawaiian and Pacific Islander population. Obstetricians aware of the high risk of perinatal HBV transmission were more likely to test pregnant women for HBV DNA or hepatitis B e-antigen in HBV-infected women (r = 0.18, p = 0.033). Obstetricians who demonstrated knowledge of the long-term consequences of untreated HBV infection were no more likely to refer HBV-infected women to specialists for care (r = 0.02, p = 0.831).

CONCLUSION

Our study identified clear gaps in the practice patterns of obstetricians that can be readily addressed to enhance the care they provide to HBV-infected pregnant women.

Cultural Appropriateness in Health Communication: A Review and A Revised Framework

A revised framework for cultural appropriateness is offered on the basis of a systematic review of operationalizations in 44 cancer screening interventions for Asian Americans. Studies commonly conveyed the epidemiological bases of the intervention (97.7%) and used the language of the population (95.5%). Less commonly reported were strategies central to health communication: cultural features of the intervention messages (77.3%) and the cultural beliefs and values that the intervention focused on (43.2%). Few used cultural tailoring (4.5%) and none aimed to address acculturation or cultural identity. The theoretical framework most frequently used was the health belief model (27.3%) which does not explain the role of culture. More studies focused on cultural barriers (20.5%) than cultural strengths (9.1%). Our revised framework comprises six cultural appropriateness strategies of cultural identity, linguistic, perceptual features, content, constituent-involving, and socioeconomic context-adaptive. It prioritizes cultural identity to recognize the dynamics within racial ethnic groups and to inform adaptive efforts for cultural appropriateness. It emphasizes examining cultural strengths that can facilitate change, as well as reducing cultural barriers. Future research and action should address the disparities in extant health disparities research in which theory and methods are underdeveloped and underutilized for Asian Americans.

Reducing Liver Cancer Risk in African-Born Immigrants Through Culturally Targeted Hepatitis B Group Education Programs

Of 900 West African-born immigrants living in New York City who were tested for hepatitis B virus (HBV), over 9% were found to have the infection (Shankar H et al. Clin Infectious Dis 62(S4):S289-s297, 2016). Community targeted group education programs (EP) have been shown to improve immigrant population's health (Bailey E et al. J Natl Med Assoc 92(3):136-42, 2000). Our aim is to enhance HBV screening in at-risk West African immigrants through the development of a group EP as a first critical step to reducing liver cancer risk. The framework for an HBV group EP was created based on our prior work to identify barriers and facilitators for HBV screening in this community (Sriphanlop, P et al. Am J Health Behav 5(10):745-754, 2014). The framework was then refined with input from community "gatekeepers" or leaders (n = 57) through four focus groups. After refining the group EP, we then pilot tested the EP with 154 participants from eight different West African communities with a pre-/post-test HBV knowledge survey assessment to determine the impact of the group EP. Results from the pre-/post-test survey assessment demonstrated a significant increase in HBV knowledge after the EP (70% pre-test vs. 88% post-test, p value <.01). Through a community-based participatory approach, a group EP could be effective in increasing knowledge about HBV infection and HBV screening as a first step to reducing liver cancer risk.

Promising practices for the prevention of liver cancer: a review of the literature and cancer plan activities in the National Comprehensive Cancer Control Program

INTRODUCTION

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are risk factors for hepatocellular carcinoma, a type of primary liver cancer, and are most prevalent in people born 1945-1965. Relatively little information is available for liver cancer prevention, compared to other cancers. In this review, we provide a summary of current promising public health practices for liver cancer prevention from the literature, as well as liver cancer-related initiatives in the National Comprehensive Cancer Control Program (NCCCP).

METHODS

Two types of source materials were analyzed for this review: published literature (2005-present), and current cancer plans from the NCCCP (2005-2022). A search strategy was developed to include a review of several scientific databases. Of the 73 articles identified as potentially eligible, 20 articles were eligible for inclusion in the review. Eligible articles were abstracted using a data abstraction tool. Three independent keyword searches on 65 NCCCP plans were conducted. Keyword searches within each of the plans to identify activities related to liver cancer were conducted. Relevant information was abstracted from the plans and saved in a data table.

RESULTS

Of the 20 eligible articles, 15 articles provided information on interventions related to liver cancer and hepatitis B or hepatitis C prevention. All 15 of the intervention articles were related to hepatitis; 13 were hepatitis B-focused, two were hepatitis C-focused, and 14 focused on Asian/Pacific Islander American populations. The independent keyword search of NCCCP plans produced 46 results for liver, 27 results for hepatitis, and 52 results for alcohol. Two plans included activities related to liver cancer. Twenty-four plans included activities related to hepatitis.

DISCUSSION

A majority of the intervention articles published focused on HBV infection in Asian/Pacific Islander American populations, and a small percentage of NCCCP plans included liver-related content. The findings from this review will inform the development of an Action Plan on liver cancer prevention for the NCCCP, which will assist programs with the adoption and uptake of promising practices for the prevention of liver cancer.

Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers

Migrant Chinese populations in Western countries have a high prevalence of chronic hepatitis B but often experience poor access to health care and late diagnosis. This systematic review aimed to identify obstacles and supports to timely and appropriate health service use among these populations. Systematic searches resulted in 48 relevant studies published between 1996 and 2015. Data extraction and synthesis were informed by models of healthcare access that highlight the interplay of patient, provider and health system factors. There was strong consistent evidence of low levels of knowledge among patients and community members; but interventions that were primarily focused on increasing knowledge had only modest positive effects on testing and/or vaccination. There was strong consistent evidence that Chinese migrants tend to misunderstand the need for health care for hepatitis B and have low satisfaction with services. Stigma was consistently associated with hepatitis B, and there was weak but consistent evidence of stigma acting as a barrier to care. However, available evidence on the effects of providing culturally appropriate services for hepatitis B on increasing uptake is limited. There was strong consistent evidence that health professionals miss opportunities for testing and vaccination. Practitioner education interventions may be important, but evidence of effectiveness is limited. A simple prompt in patient records for primary care physicians improved the uptake of testing, and a dedicated service increased targeted vaccination coverage for newborns. Further development and more rigorous evaluation of more holistic approaches that address patient, provider and system obstacles are needed.

Impact of hepatitis B on mortality and specific causes of death in adults with and without HIV co-infection in NYC, 2000-2011

High rates of immigration from endemic countries contribute to the high chronic hepatitis B (HBV) prevalence in New York City (NYC) compared to the United States overall, i.e. about 1 million individuals. We describe the impact of HBV infection on mortality and specific causes of death in NYC. We matched surveillance and vital statistics mortality data collected from 2000 to 2011 by the New York City Department of Health and Mental Hygiene (DOHMH) and analysed demographics and premature deaths (i.e. whether death occurred at <65 years) in persons with and without chronic HBV or HIV infection (excluding those with hepatitis C). From 2000 to 2011, a total of 588 346 adults died in NYC. Of all decedents, 568 753 (97%) had no report of HIV or HBV, and 4346 (0·7%) had an HBV report. Of HBV-infected decedents, 1074 (25%) were HIV co-infected. Fifty-five percent of HBV mono-infected and 95% of HBV/HIV co-infected decedents died prematurely. HBV disproportionately impacts two subgroups: Chinese immigrants and HIV-infected individuals. These two subgroups are geographically clustered in different neighbourhoods of NYC. Tailoring prevention and treatment messages to each group is necessary to reduce the overall burden of HBV in NYC.

Clinical course of hepatitis B surface antigen positive subjects following screening: A retrospective observational study from April 2008 to January 2013

AIM

Determination of the percentage of hepatitis B surface antigen (HBsAg) positive participants who undergo screening and treatment may reduce the development of hepatocellular carcinoma. This study assessed the percentages of HBsAg positive participants detected by free screening at medical institutions in Saga Prefecture who underwent detailed examinations and antiviral treatment.

METHODS

Participants were screened for HBsAg positivity at medical institutions in Saga Prefecture from April 2008 to January 2013, with some visiting physicians for detailed examinations and applying for reimbursement. Participants in the database of the Health Promotion Division of Saga Prefecture and results of detailed examinations were analyzed retrospectively.

RESULTS

Screening revealed 193 eligible participants, 105 men (54%) and 88 women (46%), of a mean age of 55.5 ± 14.9 years. Of these 193 participants, 147 (76%) visited physicians for detailed examinations, 24 (16%) were regarded as needing treatment and seven (3.6%) were reimbursed for antiviral treatments. The 46 participants who did not undergo detailed examinations were significantly younger than the 147 examined participants (50.9 ± 13.2 vs 56.9 ± 15.2 years, P = 0.018). Of the 110 participants thought to require observation, 68 (62%) were assigned to this group without determination of alanine aminotransferase or hepatitis B virus DNA concentration, and 15 (14%) had indications for antiviral treatment according to the 2014 guidelines of the Japanese Society of Hepatology.

CONCLUSION

The proportion of HBsAg positive participants receiving antiviral treatment was lower than that of participants undergoing detailed examinations.

HBV Outreach Programs Significantly Increase Knowledge and Vaccination Rates Among Asian Pacific Islanders

Hepatitis B virus (HBV) testing and vaccination rates remain low among Asian-American/Pacific Islanders (APIs) despite high rates of HBV infection. The aim of our study was to assess the effectiveness of an outreach campaign to increase HBV knowledge, testing, and vaccination among a cohort of APIs. Vietnamese Americans were invited to participate in a free HBV screening and vaccination outreach program though pubic service announcements. Attendees completed a survey to assess barriers to vaccination and HBV-related knowledge before and after a 30-min education session by a bilingual board-certified gastroenterologist. Among 98 participants, 100% (22/22) of HBV naïve patients were provided a HBV vaccination series at no cost and over 75% (14/18) of HBV-infected patients were connected to further medical care. Notable reported barriers to prior testing and/or vaccination were cost of the vaccine, concern about missing work for evaluation, and lack of provider recommendation. Knowledge levels about HBV risk factors, potential consequences, and treatment options were poor at baseline but significantly increased after the education session (49 vs. 64%, p < 0.001). Outreach campaigns linked with education can successfully address several barriers to HBV testing and offer an approach to improve HBV awareness and prevention among difficult-to-reach populations.

Simultaneous Human Immunodeficiency Virus-Hepatitis B-Hepatitis C Point-of-Care Tests Improve Outcomes in Linkage-to-Care: Results of a Randomized Control Trial in Persons Without Healthcare Coverage

In this randomized-control trial, conducted at a free clinic in France for predominately immigrant populations without healthcare, we demonstrate that simultaneous HIV/HBV/HCV point-of-care rapid testing improves screening outcomes. Increased awareness of infection status likely helped link these patients to care.

Background. In Europe and the United States, more than two thirds of individuals infected with hepatitis B virus (HBV) or hepatitis C virus (HCV) and 15%–30% of human immunodeficiency virus (HIV)-positive individuals are unaware of their infection status. Simultaneous HIV-, HBV-, and HCV-rapid tests could help improve infection awareness and linkage-to-care in particularly vulnerable populations.

Methods. The OptiScreen III study was a single-center, randomized, control trial conducted at a free clinic (“Médecins du Monde”, Paris, France). Participants were randomized 1:1 to receive 1 of 2 interventions testing for HIV, HBV, and HCV: standard serology-based testing (S-arm) or point-of-care rapid testing (RT-arm). The main study endpoints were the proportion of participants who became aware of their HIV, HBV, and HCV status and who were linked to care when testing positive.

Results. A total of 324 individuals, representing mainly African immigrants, were included. In the S-arm, 115 of 162 (71.0%) participants performed a blood draw and 104 of 162 (64.2%) retrieved their test result. In comparison, 159 of 162 (98.2%) of participants randomized to the RT-arm obtained their results (P < .001). Of the 38 (11.7%) participants testing positive (HIV, n = 7; HBV, n = 23; HCV, n = 8), 15 of 18 (83.3%) in the S-arm and 18 of 20 (90.0%) in the RT-arm were linked-to-care (P = .7). In post hoc analysis assuming the same disease prevalence in those without obtaining test results, difference in linkage-to-care was more pronounced (S-arm = 60.0% vs RT-arm = 90.0%; P = .04).

Conclusions. In a highly at-risk population for chronic viral infections, the simultaneous use of HIV, HBV, and HCV point-of-care tests clearly improves the “cascade of screening” and quite possibly linkage-to-care.

First Year Open Enrollment Findings: Health Insurance Coverage for Asian Americans and the Role of Navigators

The health insurance coverage established by the Patient Protection and Affordable Care Act has created an opportunity to reduce racial/ethnic disparities in healthcare. It is expected that of the 24 million individuals projected to join, nearly one-half will be non-white and one-fourth will speak a language other than English at home. Asian Americans are one of the fastest growing racial/ethnic groups in the USA. The majority are foreign born and experience limited English proficiency. The role of navigators has been shown to increase enrollment rates of public insurance programs. They are trusted for their shared traditions and sense of community. By conducting culturally-targeted outreach, Cambodian, Chinese, Vietnamese, Korean, and Laotian community-based organizations were able to reach individuals for whom the percentage of uninsured is disproportionately high. They enrolled eligible Asians immigrants in coverage despite language barriers and limited health knowledge. Through a collaborative network, a community-level intervention was implemented that was associated with increases in first year marketplace enrollment and greater likelihood of obtaining a primary care physician. Preventable illnesses, lost productivity, and inadequate healthcare are major hardships in immigrant communities that bear similar burdens to society. Bringing primary care to the underserved helps to contain these costs.

Hepatitis B knowledge and associated factors among people with chronic hepatitis B

OBJECTIVE

To assess hepatitis B knowledge among people with chronic hepatitis B (CHB) in Australia.

METHODS

People with CHB in three Australian jurisdictions completed a self-administered questionaire, including 24 hepatitis B knowledge questions across four domains: transmission; natural history; epidemiology and prevention; and clinical management.

RESULTS

Ninety-three people completed the survey. Mean age was 45 years, 43% were women and 93% were born overseas (75% from Asia). Mean total knowledge score was 55 out of 100 with 17 participants (18%) scoring ≥75 (defined as a high knowledge). Clinical management scored the lowest (median: 25) and natural history scored the highest (median: 80). In adjusted linear regression, tertiary education (vs. secondary and under) was associated with higher knowledge score (β: 11.95; 95%CI: 2.45, 21.44; p=0.01). In adjusted logistic regression, very good English proficiency (vs. limited/no proficiency) was associated with high knowledge (OR: 7.65; 95%CI: 1.94, 30.19; p<0.01). Participants reporting hepatitis B-related anxiety demonstrated a significantly higher knowledge score compared to those reporting no such anxiety (β: 15.11; 95%CI: 4.40, 25.81; p<0.01).

CONCLUSIONS AND IMPLICATIONS

Hepatitis B-related knowledge gaps were identified among people with CHB. Interventions to improve knowledge should focus on people with low levels of academic education and limited English proficiency.

Hepatitis B screening practice among older Chinese in the Greater Washington, DC, area

OBJECTIVES

Older Chinese Americans are at greater risk of contracting hepatitis B virus (HBV) because they were born before the implementation of universal childhood vaccination policies. This study examined the prevalence of HBV screening, test results, and predictors of HBV screening among older Chinese.

METHODS

Two hundred fifty-two Chinese immigrants (older than 50 years) recruited from Chinese-speaking physicians' offices in the Washington, DC, area participated in a cancer screening questionnaire. Descriptive statistics and hierarchical logistic regressions were conducted.

RESULTS

Among the 164 participants (65%) who underwent HBV screening, 66% reported that they were susceptible to HBV infection. Stronger self-care beliefs, longer US residency, lower HBV knowledge, and lack of physician recommendations were independently and negatively associated with HBV screening.

CONCLUSIONS

Many older Chinese did not adhere to HBV screening guidelines because of cultural views and information deficiency. Culturally appropriate interventions aimed to enhance their knowledge and communication with physicians about HBV are needed for promoting screening.

Community-based hepatitis B screening: what works?

INTRODUCTION

Chronic hepatitis B (CHB) affects over 350 million people worldwide and can lead to life-threatening complications, including liver failure and hepatocellular cancer (HCC). Modern antiviral therapies could stem the rising tide of hepatitis B-related HCC, provided that individuals and populations at risk can be reliably identified through hepatitis B screening and appropriately linked to care. Opportunistic disease screening cannot deliver population-level outcomes, given the large number of undiagnosed people, but they may be achievable through well-organized and targeted community-based screening interventions.

MATERIAL AND METHODS

This review summarizes the experience with community-based CHB screening programs published in the English-language literature over the last 30 years.

RESULTS

They include experiences from Taiwan, the USA, The Netherlands, New Zealand, and Australia. Despite great variability in program setting and design, successful programs shared common features, including effective community engagement incorporating the target population's cultural values and the ability to provide low-cost or free access to care, including antiviral treatment.

CONCLUSION

While many questions still remain about the best funding mechanisms to ensure program sustainability and what the most effective strategies are to ensure program reach, linkage to care, and access to treatment, the evidence suggests scope for cautious optimism. A number of successful, large-scale initiatives in the USA, Asia-Pacific, and Europe demonstrated the feasibility of community-based interventions in effectively screening large numbers of people with CHB. By providing an effective mechanism for community outreach, scaling up these interventions could deliver population-level outcomes in liver cancer prevention relevant for many countries with a large burden of disease.

Efficient identification of low-income Asian American women at high risk for hepatitis B

Hepatitis B disproportionately affects Asian Americans. Because outreach to promote testing and vaccination can be intensive and costly, we assessed the feasibility of an efficient strategy to identify Asian Americans at risk. Prior research with California's statewide toll-free phone service where low-income women call for free cancer screening found 50% of English-and Spanish-speaking callers were willing to participate in a study on health topics other than cancer screening. The current study ascertained whether Asian Americans could be recruited. Among 200 eligible callers, 50% agreed to take part (95% confidence interval 43%-57%), a rate comparable to our previous study. Subsequent qualitative interviews revealed that receptivity to recruitment was due to trust in the phone service and women's need for health services and information. This was a relatively low-intensity intervention in that, on average, only five minutes additional call time was required to identify women at risk and provide a brief educational message. Underserved women from diverse backgrounds may be reached in large numbers through existing communication channels.

Cancer incidence trends among Asian American populations in the United States, 1990-2008

BACKGROUND

National cancer incidence trends are presented for eight Asian American groups: Asian Indians/Pakistanis, Chinese, Filipinos, Japanese, Kampucheans, Koreans, Laotians, and Vietnamese.

METHODS

Cancer incidence data from 1990 through 2008 were obtained from 13 Surveillance, Epidemiology, End Results (SEER) registries. Incidence rates from 1990 through 2008 and average percentage change were computed using SEER*Stat and Joinpoint software. The annual percentage change (APC) in incidence rates was estimated with 95% confidence intervals (95% CIs) calculated for both the rate and APC estimates. Rates for non-Hispanic whites are presented for comparison.

RESULTS

Prostate cancer was the most common malignancy among most groups, followed by lung, colorectal, liver, and stomach cancers. Breast cancer was generally the most common cancer in women, followed by colorectal and lung cancers; liver, cervix, thyroid, and stomach cancers also ranked highly. Among men, increasing trends were observed for prostate (Asian Indians and Pakistanis: APC 1990-2003 = 2.2, 95% CI = 0.3 to 4.1; Filipinos: APC 1990-1994 = 19.0, 95% CI = 4.5 to 35.4; Koreans: APC 1990-2008 = 2.9, 95% CI = 1.8 to 4.0), colorectal (Koreans: APC 1990-2008 = 2.2, 95% CI = 0.9 to 3.5), and liver cancers (Filipinos: APC 1990-2008 = 1.6, 95% CI = 0.4 to 2.7; Koreans: APC 1990-2006 = 2.1, 95% CI = 0.4 to 3.7; Vietnamese: APC 1990-2008 = 1.6, 95% CI = 0.3 to 2.8), whereas lung and stomach cancers generally remained stable or decreased. Among women, increases were observed for uterine cancer (Asian Indians: APC 1990-2008 = 3.0, 95% CI = 0.3 to 5.8; Chinese: APC 2004-2008 = 7.0, 95% CI = 1.4 to 12.9; Filipina: APC 1990-2008 = 3.0, 95% CI = 2.4 to 3.7; Japanese: APC 1990-2008 = 1.1, 95% CI = 0.1 to 2.0), colorectal cancer (Koreans: APC 1990-2008 = 2.8, 95% CI = 1.7 to 3.9; Laotians: APC: 1990-2008 = 5.9, 95% CI = 4.0 to 7.7), lung cancer (Filipinas: APC 1990-2008 = 2.1, 95% CI = 1.4 to 2.8; Koreans: APC 1990-2008 = 2.1, 95% CI = 0.6 to 3.6), thyroid cancer (Filipinas: APC 1990-2008 = 2.5, 95% CI = 1.7 to 3.3), and breast cancer in most groups (APC 1990-2008 from 1.2 among Vietnamese and Chinese to 4.7 among Koreans). Decreases were observed for stomach (Chinese and Japanese), colorectal (Chinese), and cervical cancers (Laotians and Vietnamese).

CONCLUSIONS

These data fill a critical knowledge gap concerning the cancer experience of Asian American groups and highlight where increased preventive, screening, and surveillance efforts are needed-in particular, lung cancer among Filipina and Korean women and Asian Indian/Pakistani men, breast cancer among all women, and liver cancer among Vietnamese, Laotian, and Kampuchean women and Filipino, Kampuchean, and Vietnamese men.

Demographic and serological characteristics of Asian Americans with hepatitis B infection diagnosed at community screenings

There is limited information regarding follow-up and hepatitis B serological status of Asian Americans diagnosed with chronic hepatitis B (CHB) through community screening. The aims of this study were to evaluate the prevalence and characterize CHB among Asians living in Los Angeles, assess follow-up of individuals with CHB diagnosed at screening and compare with patients with CHB followed by community gastroenterologists. Between October 2007 and May 2010, 7387 Asians were tested for HBV. HBsAg positive individuals (CHB) underwent additional testing for ALT, HBeAg/anti-HBe and HBV DNA. Patients with CHB were contacted 6 months later to determine whether they received follow-up care. We compared serological patterns of these individuals with CHB to patients with CHB who were seen for the first time (treatment naïve) by community gastroenterologists during the study period. Prevalence of CHB was 5.2%. About 99% patients with CHB were foreign-born, and only 27% could read/write English. 297 (77%) patients with CHB could be reached 6 months after diagnosis; 43% did not receive follow-up care, mostly because of lack of medical insurance. Patients with CHB followed by gastroenterologists were more likely to have insurance (69% vs 26%, P < 0.0001). 90% patients with CHB at screening were HBeAg negative/anti-HBe positive with 62% having inactive disease compared to only 30% of patients seen by gastroenterologists (P < 0.0001). Among CHB participants, 13% met criteria for treatment compared to 51% of patients with CHB (P < 0.0001). Only a small number of CHB screening participants require antiviral therapy. Lack of medical insurance is the main reason for most patients with CHB not seeking follow-up care after screening.

Hepatitis Outreach Network: a practical strategy for hepatitis screening with linkage to care in foreign-born communities

BACKGROUND & AIMS

Many foreign-born persons in the US are at high risk of chronic hepatitis B (HBV) and C (HCV) infections, yet are not aware of their infection, and lack healthcare coverage or linkage to care.

METHODS

A unique partnership, the Hepatitis Outreach Network, combines the expertise and resources of the Mount Sinai School of Medicine, the NYC Department of Health and Mental Hygiene, and community-based organizations, to provide education, screening and link to care in communities with high prevalence of chronic viral hepatitis. Comprehensive HBV and HCV screening identifies infected patients, who then receive further evaluation from either local or Mount Sinai physicians, combined with patient-navigators who organize follow-up visits.

RESULTS

Of 1603 persons screened, 76 had HBV and 75 had HCV. Importantly, screening for HCV based on traditional risk factors would have missed 67% of those who tested positive. Of the 76 persons with HCV infection, 49 (64%) received a medical evaluation (26 with local providers and 23 at Mount Sinai). Of the 49 HCV-infected persons evaluated, treatment was recommended in 11 and begun in 8 (73%). Of the 76 persons with HBV infection, 43 (57%) received a medical evaluation (31 with local providers and 12 at Mount Sinai). Of the 43 HBV-infected persons evaluated, treatment was recommended and begun in 5 (100%).

CONCLUSIONS

Hepatitis Outreach Network has successfully established novel proof of concept for identifying HBV and HCV infections in foreign-born persons through use of several unique elements that effectively link them to care.

Electronic messages increase hepatitis B screening in at-risk Asian American patients: a randomized, controlled trial

BACKGROUND

Hepatitis B (HBV) induced hepatocellular carcinoma is the greatest cancer health disparity affecting Asian Americans, but the prevalence of screening to detect HBV is suboptimal.

AIMS

Our aims were to determine the effectiveness of electronic health record (EHR) prompts to increase ordering of HBV tests among primary care providers (PCPs) within an academic health system.

METHODS

We conducted a randomized, controlled trial between April and June 2011 among 76 PCPs caring for 175 outpatient adults with Chinese or Vietnamese surnames, with appointments with providers and no history of HBV testing. Providers were randomized to either receive an EHR prompt for HBV testing prior to patients' appointments or usual care. Primary outcomes were the proportion of patients (1) whose physician ordered a HBsAg test and (2) who completed testing. Secondary outcomes were (A) test results and (B) whether the physicians followed-up on the results.

RESULTS

HBsAg tests were ordered for 36/88 (40.9 %) of the intervention patients and 1/87 (1.1 %) of the control patients [χ (2) (df = 1) = 41.48, p < 0.001]. Thirty intervention patients (34.1 %) and no control patients completed the HBsAg test [χ (2) (df = 1) = 35.80, p < 0.001]. Four (13.3 %) of the completed tests were HBsAg-positive, 14 (46.7 %) were immune, and 12 (40 %) were unprotected from HBV. Two HBsAg-positive patients were referred to specialists, and 3 unprotected patients were vaccinated for HBV.

CONCLUSIONS

EHR-based provider prompts significantly increased HBV testing in Chinese and Vietnamese patients when compared to "usual care." EHR prompts are a promising intervention that could significantly increase screening for HBV.

Electronic messages increase hepatitis B screening in at-risk Asian American patients: a randomized, controlled trial

BACKGROUND

Hepatitis B (HBV) induced hepatocellular carcinoma is the greatest cancer health disparity affecting Asian Americans, but the prevalence of screening to detect HBV is suboptimal.

AIMS

Our aims were to determine the effectiveness of electronic health record (EHR) prompts to increase ordering of HBV tests among primary care providers (PCPs) within an academic health system.

METHODS

We conducted a randomized, controlled trial between April and June 2011 among 76 PCPs caring for 175 outpatient adults with Chinese or Vietnamese surnames, with appointments with providers and no history of HBV testing. Providers were randomized to either receive an EHR prompt for HBV testing prior to patients' appointments or usual care. Primary outcomes were the proportion of patients (1) whose physician ordered a HBsAg test and (2) who completed testing. Secondary outcomes were (A) test results and (B) whether the physicians followed-up on the results.

RESULTS

HBsAg tests were ordered for 36/88 (40.9 %) of the intervention patients and 1/87 (1.1 %) of the control patients [χ (2) (df = 1) = 41.48, p < 0.001]. Thirty intervention patients (34.1 %) and no control patients completed the HBsAg test [χ (2) (df = 1) = 35.80, p < 0.001]. Four (13.3 %) of the completed tests were HBsAg-positive, 14 (46.7 %) were immune, and 12 (40 %) were unprotected from HBV. Two HBsAg-positive patients were referred to specialists, and 3 unprotected patients were vaccinated for HBV.

CONCLUSIONS

EHR-based provider prompts significantly increased HBV testing in Chinese and Vietnamese patients when compared to "usual care." EHR prompts are a promising intervention that could significantly increase screening for HBV.

Culturally appropriate photonovel development and process evaluation for hepatitis B prevention in Chinese, Korean, and Vietnamese American communities

Asian Americans have disproportionately high prevalence of chronic hepatitis B virus infection in the United States and yet have low hepatitis B screening and vaccination rates. We developed three photonovels specifically designed for Chinese, Korean, and Vietnamese Americans and evaluated their cultural relevance and effectiveness in increasing self-efficacy and intention to have a hepatitis B screening. Photonovels' storylines were drawn from focus group themes, and lay people from each community played actors/actresses in community settings. Photonovels were pilot tested, revised, and distributed in a hepatitis B intervention. A two-page process evaluation questionnaire was mailed to 441 participants after one month. Descriptive analysis and multiple logistic regressions were conducted to assess the overall evaluation of the photonovel and to assess factors associated with self-efficacy and intention to have hepatitis B screening. Eighty-four percent of participants responded to the process evaluation. The majority of participants either strongly agreed or agreed that the cancer information in the photonovel was helpful, the story was written by someone who knows the community, and the information was easy to understand. Overall, more than 80% of them thought this photonovel was a good teaching tool. Favorable evaluation of the photonovel was associated with both having intention and self-efficacy to have a hepatitis B screening in the next 5 months. When stratified by level of education and income, the associations were stronger among the lower income and education groups. Culturally appropriate photonovels are useful tools to promote hepatitis B screening among Asian Americans, especially among those of lower socioeconomic status.

Attitudes toward hepatitis B virus among Vietnamese, Chinese and Korean Americans in the Houston area, Texas

We explored attitudes about prevention, screening and treatment of hepatitis B virus (HBV) infection in Chinese, Korean and Vietnamese communities. We use qualitative methods in 12 focus groups (n = 113) of adults who self-reported their ethnicity to be Chinese, Korean, or Vietnamese. We use grounded theory (i.e., consensus-building between co-coders about recurring, emerging themes) for analysis. Diet, nutrition, fatigue and stress were misidentified as HBV causes. Improving hygiene, diet, exercise, and holistic methods were misidentified as viable HBV prevention methods. Common screening problems included not affording test and not understanding test results. Participants shared reasons for using complementary and alternative medicine--when Western medicine fails or becomes unaffordable. Participants sought information from medical providers and fellow community members, but also from the internet. Many of the attitudes and opinions that emerged may deter participation in HBV screening, prevention and treatment, insofar as community members may factor them into healthcare decision-making, choose alternative but ineffective methods of prevention and treatment, and undervalue the benefits of screening. More patient education in both traditional and new media is necessary for clarifying transmission, screening and treatment misunderstandings.

Effectiveness of a culturally integrated liver cancer education in improving HBV knowledge among Asian Americans

OBJECTIVE

The aim of this study was to assess the effectiveness of a hepatitis B virus (HBV) educational program in increasing HBV knowledge.

METHODS

Using a cluster randomized control trial to recruit participants from the community-based organization in the Baltimore-Washington Metropolitan Area; a total of 877 Asian American participants completed a self-administered pretest. HBV knowledge was the outcome measure. The intervention group received a 30-minute educational program. After the educational program, the intervention group completed a post-education survey. Six months after the education, all participants were followed by phone.

RESULTS

The intervention group showed significantly higher knowledge scores than the control group at the 6-month follow-up (between-group difference was 1.44 for knowledge of transmission modes and 0.59 for sequelae, p < 0.01). For the intervention group, the increase in knowledge of HBV transmission modes in post-education was much higher than that at the 6-month follow-up (4.18 vs. 2.07), p < 0.01) compared to baseline. Age was also an important factor on the educational effect: Those older than 60 years reported the lowest scores in all three points.

CONCLUSIONS

Findings suggest that this culturally integrated liver cancer educational program increased HBV knowledge. Differential strategies are needed to target age groups, separately educating those younger and those older.

Identification and treatment of chronic hepatitis B in Chinese migrants: results of a project offering on-site testing in Rotterdam, The Netherlands

BACKGROUND & AIMS

Migrants born in countries where hepatitis B is endemic are a risk group for chronic hepatitis B virus (HBV) infection. Treatment options have improved, but due to the asymptomatic nature of chronic HBV infection, the majority of patients remain unidentified.

METHODS

In 2009, a campaign targeting the Chinese community was held in the city of Rotterdam, The Netherlands. The campaign combined disease awareness activities with free HBV testing at outreach locations. Chronically HBV infected patients were referred to specialist care based on a referral guideline. Before and after the campaign, knowledge of chronic hepatitis B was measured through questionnaires in a convenience sample of the target population (n=285 and n=277).

RESULTS

In a period of 3 months, 13 outreach activities took place and 1090 Chinese migrants were tested for HBV. Forty-nine percent had serological signs of a past or recent HBV infection and 8.5% (n=92) were chronically infected. Thirty-eight percent (n=35) of chronically infected patients were referred for evaluation by a specialist and of these, 15 started antiviral treatment within 1 year of follow-up. Before the campaign, 55% answered correctly to 6 or more out of 10 knowledge items. Knowledge was positively associated with educational level. After the campaign, an increase in knowledge was observed in participants with low levels of education.

CONCLUSIONS

Chinese migrants could be reached with an outreach campaign, and on-site testing was well accepted. A high prevalence of chronic HBV infection was found and referral to specialist care and initiation of treatment was successful.

Using survey results regarding hepatitis B knowledge, community awareness and testing behavior among Asians to improve the San Francisco Hep B Free campaign

Asians are disproportionately affected by chronic hepatitis B (HBV) infection and its fatal consequences. The Hep B Free campaign was launched to eliminate HBV in San Francisco by increasing awareness, testing, vaccination and linkage to care. The campaign conducted 306 street intercept and telephone interviews of San Francisco Asians to assess current levels of HBV knowledge, testing behaviors and effectiveness of existing campaign media materials. One-third of respondents ranked HBV as a key health issue in the Asian community, second to diabetes. General HBV awareness is high (85%); however, a majority could not name an effective prevention method. Sixty percent reported having been tested for HBV; provider recommendation was the most often cited reason for testing. Respondents reported a high level of trust in their providers to correctly assess which health issues they may be at risk for developing and test accordingly, confirming that efforts to increase HBV testing among Asians must simultaneously mobilize the public to request testing and compel providers to test high-risk patients. Regarding community awareness, more than half reported hearing more about HBV recently; younger respondents were more likely to have encountered campaign materials and recall correct HBV facts. Assessment of specific campaign materials found that while upbeat images and taglines captured attention and destigmatized HBV, messages that emphasize the pervasiveness and deadly consequence of infection were more likely to drive respondents to seek education and testing. The campaign used survey results to focus efforts on more intensive provider outreach and to create messages for a new public outreach media campaign.

Knowledge of hepatitis B risk factors and prevention practices among individuals chronically infected with hepatitis B in San Francisco, California

Asian/Pacific Islanders (A/PIs) in the United States are disproportionately affected by the hepatitis B virus (HBV), which can cause a lifelong liver infection that may result in cirrhosis, liver failure, liver cancer, or death. Although previous studies have measured knowledge of hepatitis B transmission and prevention practices in A/PI communities, we present results from the first population-based study of this type, which specifically focuses on A/PIs who are chronically infected with HBV. Through telephone interviews, we assessed the HBV risk factor knowledge and prevention practices of a population-based, random sample of persons with chronic HBV who were reported to the San Francisco Department of Public Health between October 2007 and July 2009. Among 829 respondents, 67% were foreign born A/PIs of Chinese ethnicity who did not speak English as their primary language. Among all respondents, 75% were unable to identify how they acquired HBV, and 41% said that they do nothing to prevent transmission of HBV to their close contacts. Knowledge of HBV risk factors and recommended prevention practices was poor among A/PIs who are chronically infected with HBV and who may transmit the infection to others.

Effectiveness of hepatitis B treatment in clinical practice

It is important to examine the effectiveness of current therapies for chronic hepatitis B in clinical practice, given the therapeutic advances over the past 15 years. A 2010 Institute of Medicine report on hepatitis and liver cancer stated that the public and health care providers have a lack of knowledge and awareness about viral hepatitis, and that there is a gap between medical innovation and community care. We review the efficacy of hepatitis B treatment, based on results from clinical trials, and discuss the effectiveness of these treatments in clinical practice. We also discuss why having efficacious treatments alone would have a small impact on the global health burden of hepatitis B, and highlight the importance of educating the public and the medical community and coordination of care.

Barriers to screening for hepatitis B virus infection in Asian Americans

BACKGROUND

Routine screening for hepatitis B virus (HBV) infection can identify individuals who need vaccination or treatment, as vaccination can prevent HBV infection. Although the overall prevalence of HBV infection in the United States is low (<1%), it is high (~10%) in Asian Americans. However, HBV screening rates in this population have been reported to be low.

AIMS

This article systemically reviews the reported prevalence of HBV infection, the rate of HBV screening and access to HBV care, barriers for HBV screening and care, and a possible approach for improving HBV screening in Asian Americans.

METHODS

Articles published from 1999 to 2011 on HBV screening and disparity in Asian Americans were identified by searching electronic databases (PubMed and Cochrane Library), and reviewed.

RESULTS

Published studies, including a recent report from the Institute of Medicine of the National Academies, revealed HBV screening rates are low in Asian Americans. This review addresses the need for HBV screening in Asian Americans. Barriers to HBV screening are related to patients, providers, and/or the healthcare system. Screening programs that incorporate culturally sensitive interventions and include educational outreach, vaccination, and a link to healthcare services improve rates of HBV screening and vaccination in this at-risk community.

CONCLUSIONS

A strategy that integrates efforts from the healthcare profession, federal agencies, and the community will be needed to improve HBV screening and access to HBV care for Asian Americans.

Is chronic hepatitis B being undertreated in the United States?

Chronic infection with the hepatitis B virus (HBV) is a major risk factor for development of end-stage liver disease, including cirrhosis, liver failure and primary liver cancer. There are now seven antiviral agents approved by the United States Food and Drug Administration (FDA) for the management of chronic HBV infection. Despite the fact that there are between 1.4 and 2 million chronic HBV infections in the United States, fewer than 50,000 people per year receive prescriptions for HBV antiviral medications. This report discusses possible explanations for the disparity between the number of people who are chronically infected and the number of people who receive treatment. Explanations for this incongruence include the potentially large number of infected persons who are unscreened and thus remain undiagnosed, and lack of access, including insurance, education and referral to appropriate medical care, particularly for disproportionately infected populations.

Disparities in liver cancer incidence by nativity, acculturation, and socioeconomic status in California Hispanics and Asians

BACKGROUND

Asians and Hispanics have the highest incidence rates of liver cancer in the United States, but little is known about how incidence patterns in these largely immigrant populations vary by nativity, acculturation, and socioeconomic status (SES). Such variations can identify high-priority subgroups for prevention and monitoring.

METHODS

Incidence rates and rate ratios (IRR) by nativity among 5,400 Hispanics and 5,809 Asians diagnosed with liver cancer in 1988-2004 were calculated in the California Cancer Registry. Neighborhood ethnic enclave status and SES were classified using 2000 U.S. Census data for cases diagnosed in 1998-2002.

RESULTS

Foreign-born Hispanic males had significantly lower liver cancer incidence rates than U.S.-born Hispanic males in 1988-2004 (e.g., IRR = 0.54, 95% confidence interval [CI] = 0.50-0.59 in 1997-2004), whereas foreign-born Hispanic females had significantly higher rates in 1988-1996 (IRR = 1.42, 95% CI = 1.18-1.71), but not 1997-2004. Foreign-born Asian males and females had up to 5-fold higher rates than the U.S.-born. Among Hispanic females, incidence rates were elevated by 21% in higher-enclave versus lower-enclave neighborhoods, and by 24% in lower- versus higher-SES neighborhoods. Among Asian males, incidence rates were elevated by 23% in higher-enclave neighborhoods and by 21% in lower-SES neighborhoods. In both racial/ethnic populations, males and females in higher-enclave, lower-SES neighborhoods had higher incidence rates.

CONCLUSIONS

Nativity, residential enclave status, and neighborhood SES characterize Hispanics and Asians with significantly unequal incidence rates of liver cancer, implicating behavioral or environmental risk factors and revealing opportunities for prevention.

IMPACT

Liver cancer control efforts should especially target foreign-born Asians, U.S.-born Hispanic men, and residents of lower-SES ethnic enclaves.