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

A Health Belief Model Examination of Factors Related to Hepatitis B Screening Among African Immigrants in Philadelphia

Chronic hepatitis B infection is a leading cause of liver cancer worldwide. In the USA, African immigrants (AI) have high hepatitis B virus (HBV) infection rates but low HBV knowledge and screening rates. Research about HBV among AI living in Philadelphia is particularly limited. This study aims to assess barriers to and factors influencing HBV screening in the Philadelphia AI population. African and Caribbean-born adults in Greater Philadelphia were recruited for phone interviews at community health fairs hosted by the African Cultural Alliance of North America (ACANA) and the African Family Health Organization (AFAHO) in partnership with the Hepatitis B Foundation. Seventeen interviews were recorded, transcribed, and coded independently by two members of the research team using NVivo software. Themes and subthemes were created by analysis of the codes and arranged under Health Belief Model (HBM) concepts. Major perceived barriers included lack of HBV knowledge and awareness and cultural challenges related to health care access, preventive care, fear, and stigma. Participants recommended using community organizations and programs to spread awareness about HBV and serve as cues to action. In-person education was emphasized due to lack of access to and knowledge of technology such as Zoom. While HBV educational sessions have been implemented in this population, they have not been consistent or far-reaching. The results of this study can contribute to the implementation of a comprehensive AI-specific HBV education and screening program through partnerships with community organizations to ensure that all high-risk individuals in the Philadelphia area are screened.

The role of culturally appropriate interpersonal communication strategies to reduce hepatitis B and liver cancer disparities

Introduction

Asian and Pacific Islander (API), African, and Caribbean immigrant groups in the U.S. are disproportionately impacted by chronic hepatitis B and hepatocellular carcinoma (primary liver cancer). Creating educational communication campaigns about hepatitis B and liver cancer for these communities is necessary to increase disease-related awareness and prompt health-promoting behaviors. Identifying interpersonal communication (IPC) preferences within diverse communities for integration into an educational campaign that emphasizes the link between hepatitis B and liver cancer can ultimately promote uptake of screening, vaccination and linkage to appropriate care.

Methods

Fifteen focus groups and two key informant interviews were conducted with participants from Micronesian, Chinese, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, and Francophone West African communities. Data were analyzed using thematic coding and analysis.

Results

Findings demonstrate that all communities preferred that materials be offered in both English and native languages and emphasized that campaigns highlight the connection between hepatitis B and liver cancer. Educational sessions should take place in settings where communities feel safe, including community-based organizations, religious establishments, and healthcare offices, and should be facilitated by trusted messengers, including patient navigators, doctors and faith leaders. Presenting accurate information and dispelling myths and misconceptions around hepatitis B, liver cancer, and their connection were the biggest needs identified across all focus groups.

Discussion

This study provides insight into community-specific preferences for learning about hepatitis B and liver cancer through IPC methods. The findings from this study can be used to design multi-platform, culturally and linguistically appropriate health education campaigns to facilitate improved diagnosis, prevention, and management of hepatitis B and liver cancer among heavily impacted communities in the U.S.

The Role of Culturally Appropriate Mediated Communication Strategies to Reduce Hepatitis B and Liver Cancer Disparities

Asian, Pacific Islander, African, and Caribbean communities in the U.S. are heavily impacted by chronic hepatitis B (HBV) and hepatocellular carcinoma (HCC). Educating these groups about the link between the two diseases is imperative to improve screening rates and health outcomes. This study aims to identify and incorporate preferred mediated communication methods into community-specific educational campaigns which emphasize the connection between the conditions, to promote uptake of prevention and management behaviors for HBV and HCC. Fifteen focus groups and two key informant interviews were conducted with Micronesian, Chinese, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, and Francophone West African communities. Data were analyzed using thematic coding and analysis. Findings demonstrate that all communities preferred materials be offered in both English and native languages and requested that materials highlight the connection between HBV and HCC. Delivery channel preferences and messaging themes varied by group. This study provides insight into community-specific preferences for learning about HBV and HCC. The findings can be used to design culturally and linguistically tailored, multi-platform, health education campaigns to facilitate improved HBV screening and vaccination rates and increase knowledge about HCC risk among highly impacted communities in the U.S.

Existing knowledge, myths, and perceptions about hepatitis B and liver cancer within highly impacted immigrant communities

Background

Immigrant groups from Southeast Asia, the Pacific Islands, sub-Saharan Africa, and the Caribbean bear the heaviest burden of chronic hepatitis B and primary liver cancer in the United States. Educational campaigns to increase knowledge about these diseases and their connection are necessary to promote protective health behaviors within these communities, to ultimately reduce the burden of disease, lessen stigma, and eliminate health disparities.

Objectives

This project sought to engage groups within highly impacted communities to identify existing gaps in hepatitis B- and liver cancer-related knowledge, in order to inform future health education programming that will aim to reduce stigma and promote liver cancer prevention and early detection behaviors within and across groups.

Methods

Fifteen focus groups and two key informant interviews were conducted virtually with participants from Micronesian, Chinese, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, and Francophone West African communities. Qualitative data were analyzed using thematic coding.

Results

There are large gaps in knowledge and awareness of hepatitis B and liver cancer, and the link between these two diseases among Asian, Pacific Islander, African and Haitian immigrant communities. This limited knowledge and misinformation, exacerbated by stigma, hinder these groups' utilization of hepatitis B and liver cancer diagnostic and preventative healthcare services.

Conclusion

To reduce hepatitis B and liver cancer health disparities within heavily burdened groups, health education needs to be community-informed, culturally sensitive, and actionable. Study results can guide the development of culturally and linguistically appropriate education programs that focus on the link between hepatitis B and liver cancer and the need for vaccination and routine screening, and that are responsive to the knowledge gaps and misperceptions of diverse communities. The results also provide valuable insights for healthcare providers to improve the knowledge gaps of the diverse patient populations that they serve.

Characterising the effectiveness of social determinants of health-focused hepatitis B interventions: a systematic review

Social determinants of health are important in designing effective interventions for hepatitis B virus (HBV) infection. This systematic review characterises equity-oriented, social determinants of health-focused HBV interventions, and describes their effectiveness in terms of the prevention, care, or treatment of HBV in high-income countries. We searched electronic databases for central concepts of 'HBV', 'equity', 'social determinants of health', 'intervention', and 'Organization for Economic Co-operation and Development (OECD) countries'. Screening and data abstraction were conducted independently by two reviewers. Data were abstracted from 66 studies; articles with a comparative study design (n=36) were included in the narrative synthesis, highlighting social determinants of health domains of interventions, HBV-relevant health outcomes, and extra-health social determinants of health effects (ie, those effects that extend beyond health outcomes). Synthesis aligned with six emergent themes corresponding to HBV prevention and care: knowledge and education, diagnosis and screening, immunisation, care initiation, engagement with clinical care and treatment, and upstream prevention. Studies presented a heterogeneous array of HBV-relevant health outcomes. Most interventions were tailored for social determinants of health domains of race, ethnicity, culture, and language; drug use; and socioeconomic status. Across the themes, at least two-thirds of interventions showed comparative effectiveness for addressing HBV. Extra-health social determinants of health outcomes were observed for two studies. Considerable diversity in population-level approaches was observed regarding intervention goals and effectiveness; most interventions were effective at enhancing the prevention, care, or treatment of HBV.

Acceptability and Feasibility of Home-Based Hepatitis B Screening Among Haitian Immigrants

Hepatitis B (HBV) is endemic in Haiti, therefore Haitian immigrants should be screened to identify and link affected individuals to care. Current screening approaches are ineffective. We assessed the acceptability and feasibility of home-based screening among Haitian immigrants using community health workers (CHWs). We recruited participants exiting a pragmatic trial evaluating strategies to improve care delivery (NCT02970136). Participants completed an acceptability questionnaire. Blood drawn by CHWs at participants' homes or community sites was tested for hepatitis B surface antigen, hepatitis B surface antibody and hepatitis B core antibody. Of 60 participants, 59 found screening acceptable; 53 had blood drawn. Of those, 45.3% had HBV previously, 49.1% remained susceptible and 5.7% were vaccinated. Respondents cited various reasons community members might find screening unacceptable. The high prior HBV rate highlights the need for effective outreach programs. Home-based HBV screening was both acceptable and feasible among Haitian immigrants.

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.

Knowledge, Attitudes, and Behaviors of Viral Hepatitis Among Recent African Immigrants in the United States: A Community Based Participatory Research Qualitative Study

Background: In the United States, hepatocellular carcinoma is the ninth leading cause of cancer mortality. Hepatocellular carcinoma disproportionately affects individuals of African ancestry with the rates being higher amongst individuals of foreign-born African ancestry. This study explored knowledge, attitudes, and behaviors toward viral hepatitis transmission, screening, and vaccination among recent African immigrants in Minnesota and identify ways to improve early detection and screening methods. Methods: A community based participatory research (CBPR) team with minority researchers and community members sought to gain insight on persons of African Ancestry knowledge, attitudes, and behaviors related to viral hepatitis by conducting a qualitative research study. The CBPR team developed a focus group moderator's guide with semi-structured questions related to transmission, screening, and vaccination of viral hepatitis. We conducted seven focus groups using bilingual, bicultural moderators with participants from local Ethiopian, Liberian and Kenyan communities from August 10th, 2014 to October 11th, 2014. Focus groups were audio recorded and transcribed. The CBPR team categorized the data into themes and subthemes with consensus using traditional content analysis. Results: Community partners recruited 63 participants with a majority identifying as male (51%). Participants lacked knowledge of viral hepatitis screening, vaccination, and treatment. Participants were aware of some behaviors that increased risk of acquisition of hepatitis. Participants endorsed a strategy of developing and delivering educational materials for African immigrants. Moreover, access to care and cultural awareness were mentioned as pivotal for prevention and treatment of viral hepatitis. Conclusions: Findings from this pilot study provide insight on areas of research focus. Having a research team consisting of members from the community helped to increase trust and foster an understanding of shared community values. Information from this study provides evidence to support the development culturally appropriate strategies to address disparities in viral hepatitis in these communities.