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

Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Interventions to increase vaccination in vulnerable groups: rapid overview of reviews

OBJECTIVE

Groups which are marginalised, disadvantaged or otherwise vulnerable have lower uptake of vaccinations. This differential has been amplified in COVID-19 vaccination compared to (e.g.) influenza vaccination. This overview assessed the effectiveness of interventions to increase vaccination in underserved, minority or vulnerable groups.

METHODS

In November 2022 we searched four databases for systematic reviews that included RCTs evaluating any intervention to increase vaccination in underserved, minority or vulnerable groups; our primary outcome was vaccination. We used rapid review methods to screen, extract data and assess risk of bias in identified reviews. We undertook narrative synthesis using an approach modified from SWiM guidance. We categorised interventions as being high, medium or low intensity, and as targeting vaccine demand, access, or providers.

RESULTS

We included 23 systematic reviews, including studies in high and low or middle income countries, focused on children, adolescents and adults. Groups were vulnerable based on socioeconomic status, minority ethnicity, migrant/refugee status, age, location or LGBTQ identity. Pregnancy/maternity sometimes intersected with vulnerabilities. Evidence supported interventions including: home visits to communicate/educate and to vaccinate, and facilitator visits to practices (high intensity); telephone calls to communicate/educate, remind/book appointments (medium intensity); letters, postcards or text messages to communicate/educate, remind/book appointments and reminder/recall interventions for practices (low intensity). Many studies used multiple interventions or components.

CONCLUSION

There was considerable evidence supporting the effectiveness of communication in person, by phone or in writing to increase vaccination. Both high and low intensity interventions targeting providers showed effectiveness. Limited evidence assessed additional clinics or targeted services for increasing access; only home visits had higher confidence evidence showing effectiveness. There was no evidence for interventions for some communities, such as religious minorities which may intersect with gaps in evidence for additional services. None of the evidence related to COVID-19 vaccination where inequalities of outcome are exacerbated.

PROSPERO REGISTRATION

CRD42021293355.

Factors associated with hepatitis B knowledge among people of Vietnamese ethnicity in Australia

Despite high hepatitis B (HBV) prevalence among people of Vietnamese ethnicity in Australia and elsewhere, there is limited research on levels of HBV knowledge and factors associated with such knowledge. The aim of this study was to examine HBV knowledge and associated demographic and attitudinal factors among people of Vietnamese ethnicity in Australia. People of Vietnamese ethnicity (n = 966) were recruited through community events and social media groups to complete online surveys measuring HBV knowledge, attitudes towards HBV, levels of mistrust in Western medicine, and demographic characteristics. Findings of this study indicate that levels of knowledge are mixed, with gaps in knowledge related to transmission and treatment of the virus. Those with greater knowledge of HBV tended to be older, have higher levels of formal education, have been tested for HBV, and know someone living with HBV. Those with lower levels of knowledge tended to have more negative attitudes towards the virus and greater levels of mistrust in Western medicine. Given that health literacy is connected to effective communication from health providers, we suggest that there is a need for the development of health promotion and education resources targeted at people of Vietnamese ethnicity and translated into Vietnamese. We propose that such resources be developed in consultation with Vietnamese communities and health providers to ensure that they are culturally appropriate and sensitive to people of Vietnamese ethnicity living in Australia.

Characteristics of women presenting with hepatitis B at antenatal care services in London, 2008-2018

BACKGROUND

To support interventions to prevent mother-to-child transmission of hepatitis B and fill gaps in surveillance, the Enhanced Surveillance of Antenatal Hepatitis B (ESAHB) programme was implemented in London from 2008 to 2018 to collect demographic information on women who tested positive for hepatitis B during antenatal screening. We describe the epidemiology of hepatitis B in pregnancy, as reported to ESAHB.

METHODS

The characteristics of pregnant women living with hepatitis B were described and rates were calculated by year, local authority and residence deprivation decile (1 being most deprived). Poisson regression tested the association between pregnant women living with hepatitis B and deprivation decile.

RESULTS

Between 2008 and 2018, 8879 women living with hepatitis B in London (0.35 per 1000 women) reported 11 193 pregnancies. Annual hepatitis B rates remained stable, but there was strong evidence for an inverse association between rate and deprivation decile (P < 0.001). The majority of women in the cohort presented late to antenatal care, were born outside the UK in a hepatitis B endemic area or required an interpreter for consultations.

CONCLUSIONS

ESAHB provided important data to inform service quality improvements for women living with hepatitis B. This analysis highlights the link between deprivation and hepatitis B.

Epidemiology of hepatitis B virus infection among preconception couples in South China: a cross-sectional study

OBJECTIVES

Hepatitis B virus (HBV) infection is a global public health threat, and couples of reproductive age comprise a key population in aiming to reduce both the vertical and horizontal transmission of HBV. We aimed to update knowledge on the seroepidemiology status of HBV in Guangdong, China among a large number of couples planning conception, and to identify high-risk subgroups.

DESIGN

A cross-sectional study was performed in Guangdong, China from 2014 to 2017.

SETTING

The data were collected from 641 642 couples (1 283 284 individuals) participating in the National Free Preconception Health Examination Project in Guangdong, China from 1 January 2014 to 31 December 2017. For each participant, sociodemographic data were obtained and a serum sample was tested for HBV infection status.

RESULTS

161 204 individuals (12.56%) were positive for hepatitis B surface antigen (HBsAg+), and 47 318 (3.69%) were positive for both HBsAg and hepatitis B e antigen (HBsAg+ and HBeAg+). There was a higher prevalence of HBsAg+ (12.77% vs 9.42%, p<0.05) and HBsAg+ and HBeAg+ (3.77% vs 2.45%, p<0.05) among the participants with a Guangdong household registration than a non-Guangdong household registration. Similarly, the prevalence of HBsAg (13.26% vs 11.72%, p<0.05) and HBsAg+ and HBeAg+ (4.31% vs 2.94%, p<0.05) was higher among participants not living in the Pearl River Delta than those living in the Pearl River Delta. At the couple level, 12 446 couples (1.94%) were both positive; in 51 849 (8.08%), only the wife was positive; in 84 463 (13.16%), only the husband was positive. Moreover, HBsAg+ prevalence was lowest in couples where both individuals were vaccinated (18.63%) and highest in couples where neither the wife or husband was vaccinated (24.46%).

CONCLUSION

There was a relatively high HBsAg+ prevalence in married couples in this high-epidemic region and urgent prevention strategies are required, such as ensuring access to health services for those not living in the Pearl River Delta, and expanding vaccine programmes to high-risk adults.

Barriers to and Facilitators of Hepatitis B Vaccination among the Adult Population in Indonesia: A Mixed Methods Study

To reach the goals of the Global Hepatitis Elimination 2030 program, Indonesia is now preparing a new regulation for hepatitis B vaccinations for adult population. This study aimed to determine the factors influencing vaccine uptake for hepatitis B in the adult population, and identify barriers to, and facilitators of, hepatitis B vaccination programmes. An explanatory sequential mixed methods design was implemented in this study. We conducted a survey involving 893 participants in the general population followed by 14 in-depth interviews with health providers. The survey found that only 15% (95% confidence interval 13-18%) of participants received at least one dose of the hepatitis B vaccine. Factors associated with vaccine uptake were, living in Yogyakarta compared to living in Aceh, having secondary and higher education compared to primary education, working as a health worker compared to working in other sectors, and having health insurance that covered hepatitis B vaccination compared to not having such health insurance. Our qualitative study also identified several barriers to the adult hepatitis B vaccination programme in Indonesia such as the high cost of vaccination, lack of vaccine availability in certain areas, limited human resources to implement the hepatitis B vaccination programme, and the ineffective dissemination of hepatitis B vaccination. This study highlights that accessibility and affordability of vaccinations are important determinants of vaccination uptake that should be taken into account when planning vaccination campaigns.

A psychometric evaluation of Chinese chronic hepatitis B virus infection-related stigma scale using classical test theory and item response theory

Purpose

To validate the hepatitis B virus infection-related stigma scale (HBVISS) using Classical Test Theory and Item Response Theory in a sample of Chinese chronic HBV carriers.

Methods

Feasibility, internal consistency reliability, split-half reliability and construct validity were evaluated using a cross-sectional validation study (n = 1,058) in Classical Test Theory. Content validity was assessed by COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. The Item Response Theory (IRT) model parameters were estimated using Samejima's graded response model, after which item response category characteristic curves were drawn. Item information, test information, and IRT-based marginal reliability were calculated. Measurement invariance was assessed using differential item functioning (DIF). SPSS and R software were used for the analysis.

Results

The response rate reached 96.4% and the scale was completed in an average time of 5 min. Content validity of HBVISS was sufficient (+) and the quality of the evidence was high according to COSMIN criteria. Confirmatory factor analysis showed acceptable goodness-of-fit (χ ²/df = 5.40, standardized root mean square residual = 0.057, root mean square error of approximation = 0.064, goodness-of-fit index = 0.902, comparative fit index = 0.925, incremental fit index = 0.926, and Tucker-Lewis index = 0.912). Cronbach's α fell in the range of 0.79-0.89 for each dimension and 0.93 for the total scale. Split-half reliability was 0.96. IRT discrimination parameters were estimated to range between 0.959 and 2.333, and the threshold parameters were in the range-3.767 to 3.894. The average score for test information was 12.75 (information >10) when the theta level reached between-4 and + 4. The IRT-based marginal reliability was 0.95 for the total scale and fell in the range of 0.83-0.91 for each dimension. No measurement invariance was detected (d-R ² < 0.02).

Conclusion

HBVISS exhibited good feasibility, reliability, validity, and item quality, making it suitable for assessing chronic Hepatitis B virus infection-related stigma.

Trust in healthcare providers among Chinese immigrants living with hepatitis B virus in Australia: A qualitative study

Despite the importance of trust in healthcare settings, there remains a paucity of evidence on the role it plays in patient-provider relationships and healthcare outcomes among people living with hepatitis B virus (HBV). International evidence suggests that Chinese immigrants living with HBV experience inequitable access, outcomes and treatment quality in chronic hepatitis B (CHB) health care. This study explores individual trust in healthcare providers and its impact on health-seeking behaviours and health outcomes among Chinese people living with HBV in Australia. A total of 16 participants were recruited from the Chinese community in Sydney and Melbourne and participated in semi-structured interviews. The data were analysed within a conceptual model of trust that contains five dimensions: fidelity, competence, honesty, confidentiality and global trust. The data shows how trust in physicians was formed and influenced by factors including patient-provider interactions, historically relevant experiences, health and illness beliefs and systemic barriers. While the research confirms prior findings on the impact of trust and mistrust, showing an association between low trust and treatment nonadherence, it also generates fresh insights by examining what leads to mistrust and the role of trust in shaping participants' healthcare outcomes. Findings suggest that by treating patients with respect and dignity, improving interpersonal skills and cultural competency, having open discussion on complementary and alternative medicine (CAM) treatment and protecting private information, physicians can increase patients' trust. The findings will contribute to efforts to address HBV as a health priority and increase patients' trust in healthcare providers among Chinese immigrants living with HBV.

Hepatitis B-related stigma among Chinese immigrants living with hepatitis B virus in Australia: A qualitative study

Chinese immigrants in Australia are overrepresented among people with chronic hepatitis B virus (PWCHB) but experience poor access to healthcare. Given the historical discriminatory policies against PWCHB in mainland China, this study aimed to explore the lived experiences of stigma and discrimination surrounding hepatitis B virus (HBV) among Chinese immigrants originally from mainland China. Semi-structured in-depth interviews were conducted by a researcher with a Chinese background in 2019-2020. Sixteen Chinese immigrants living with HBV were recruited across Sydney and Melbourne through advocacy and support groups. This study is positioned in social constructionism. Data analysis was informed by the Health Stigma and Discrimination Framework that highlights the interaction between layered stigmas. This study revealed the historical, social and cultural construction of HBV-related stigma among PWCHB and demonstrated how this stigma was manifested across socioecological levels in China and Australia. Findings show that HBV-related stigma has mostly been driven by knowledge deficits about HBV and fear of HBV infection. HBV-related stigma was mostly demonstrated around social isolation including isolation imposed by family and the community and employment restrictions in the Chinese workplace. In the Australian context, HBV-related stigma was related to the ethnic and cultural background of PWCHB, and primarily occurred as anticipated stigma in the community and in employment. The findings provide significant insights for crosscutting research and policy endeavours to develop and test cross-disciplinary initiatives that more broadly address the complex lived realities of Chinese immigrants living with hepatitis B virus.

Gender disparity and stigma experience of patients with chronic hepatitis B virus infection: A prospective cross-sectional study from a hospital in Nigeria

Backgound

Hepatitis B virus (HBV) infected persons often suffer stigma. Stigma can come from the society or be self-induced. This study assessed the gender differences and stigma experience of patients with HBV.

Methods

Prospective cross-sectional design with a qualitative element using a pretested interviewer administered questionnaire and an in-depth oral interview of HBV infected patients. Quantitative data obtained were entered into SPSS version 20 and analyzed using simple descriptive and inferential statistics, while content analysis was used for the qualitative data.

Results

Total of 242 respondents answered the quantitative questionnaire. There were 142(58.7%) males and 100 (41.3%) females; age range was 18-72 years with mean (SD) of 35.4(10.7) years. Overall stigma rate was 23.1%. Stigma resulted from a positive HBsAg test, and the experience was unaffected by other markers of HBV infection. Stigma was higher in the domain of disease transmission for both single and married respondents and was particularly higher among males than females. Stigma among females affected pre-marital engagements and also caused marital disharmony among married respondents. In-depth oral interview of 23 HBV infected respondents revealed that many exhibited self-stigma, had wrong knowledge of HBV infection modes, complications, and interpretation of HBV internet information which aggravated stigma reactions.

Conclusions

Stigma of HBV is high and majorly in the domain of disease transmission. It is higher in males than females. Enlightenment campaign targeting singles and married couples and HBV infection modes is advocated.

Epidemiological trends of gastrointestinal and liver diseases in Malaysia: A single-center observational study

BACKGROUND AND AIM

The spectrum of gastrointestinal (GI) and liver diseases is recognized to have a geographical variation, which may be due to environmental or genetic differences. We aimed to explore this further in a specialist clinic serving a multi-ethnic Asian urban population.

METHODS

A retrospective analysis of outpatient data from this institution's electronic medical records was conducted between January and June 2019. Clinical diagnoses of GI and liver diseases and associated demographic information were collected.

RESULTS

Data from 3676 adult patients (median age 62 years, female 51.1%) were available for analysis. The frequency of luminal GI, liver and pancreato-biliary diseases were 34.2%, 63.2%, and 2.6%, respectively. Among luminal GI diseases, 38.6% were functional gastrointestinal disorders and 61.4% had an organic cause. A higher proportion of patients of Indian ethnicity were diagnosed with IBD compared with other ethnic groups (India 21.9%, Malay 16.5%, Chinese 12.2%, P = 0.001). Among liver diseases, the most common etiologies were HBV (44.4%) and NAFLD (39.3%). Cirrhosis and/or hepatocellular carcinoma were present in 18% of liver diseases, with NAFLD as the most frequent etiology. Among patients with NAFLD, a higher proportion of ethnic Malays and Indians were evident (Malay 53.8% vs Chinese 28.7% vs Indian 61.1%, P < 0.001). In contrast, a greater proportion of ethnic Chinese were diagnosed with HBV compared with other ethnic groups (Malay 30.9% vs Chinese 57.5% vs Indian 8.4%, P < 0.001).

CONCLUSION

The spectrum of GI and liver diseases has a peculiar epidemiology, particularly with reference to the ethnic predilection of certain diseases.

What facilitates hepatitis B and hepatitis C testing and the role of stigma among primary care patients in China?

Approximately 80% of primary healthcare facilities in China were ready to deliver hepatitis care services by 2021. This study aimed to assess hepatitis B and C test uptake, identify the factors associated with testing and determine the predictors of hepatitis stigma among primary care patients. We conducted a cross-sectional survey among patients seeking care in the family medicine and primary care unit of the University of Hong Kong-Shenzhen Hospital, China. Participants were 30 years or older and had not tested for HBV and HCV in the preceding 12 months. Test uptake was defined as self-reported previous HBV and HCV testing. Descriptive statistics, Chi-square test, forward multivariable logistic regression and stepwise multiple linear regression were conducted, and a p-value <.05 was deemed statistically significant. A total of 750 eligible patients completed the survey, and 54.5% (404 ± 0.9) were between 30 and 40 years old. Most participants were heterosexuals 98.0% (n = 735), female 57.5% (n = 431), married 78.3% (587) and earned ≤1500 USD per month 54.4% (n = 408). A 66.1% (n = 496) and 13.7% (n = 103) self-reported previous HBV and HCV testing, respectively, and 62% (n = 468) were vaccinated. HCV testing was associated with HBV testing (aOR = 13.7, 95% CI:2.1-91.5); and HBV testing was associated with family history of HBV (aOR = 2.4, 95%CI:1.1-5.5). Overall hepatitis stigma was about average and decreased with family history of HBV (p = .017). In conclusion, HCV testing uptake among primary care patients was low and needs to be further promoted. Integrating HBV and HCV testing interventions and fostering family-based support for disclosure could effectively improve testing uptake.

A randomized controlled trial enhancing viral hepatitis testing in primary care via digital crowdsourced intervention

Despite the availability of hepatitis B virus (HBV) and hepatitis C virus (HCV) testing in primary care, testing rates in China remain low. Social media is an inexpensive means of disseminating information and could facilitate hepatitis testing promotion. We evaluated the capacity of digitally crowdsourced materials to promote HBV/HCV testing uptake via a randomized controlled trial (identifier: ChiCTR1900025771), which enrolled 750 Chinese primary care patients. We randomized patients (1:1) to receive crowdsourced HBV/HCV promotion materials through social media or facility-based care without promotional materials for four weeks. Exposure to all intervention materials was associated with increased odds of HBV (aOR = 1.79, 95% CI: 1.09–3.00) and HCV (aOR = 1.95, 95% CI: 1.29–2.99) testing compared to facility-based care. There was a significant reduction in hepatitis stigma among intervention group participants (HBV slope: −0.15, p < 0.05; and HCV slope: −0.13, p < 0.05). Digitally crowdsourced promotion messages could enhance hepatitis testing uptake and should be considered in hepatitis reduction strategies.

Trial registration: Chinese Clinical Trial Registry (ChiCTR1900025771) on September 9, 2019. Available from: http://www.chictr.org.cn/showproj.aspx?proj=42788

Reproductive health practices and use of health services among immigrant Indonesian women working in Malaysia

OBJECTIVE

To describe the reproductive health practices of immigrant Indonesian women working in Malaysia and their accessibility to health services.

METHODS

A cross-sectional study using a validated self-administered questionnaire was conducted with 593 immigrant Indonesian workers who stayed in Malaysia for at least six months and within the reproductive age group.

RESULTS

About 13.5% of the respondents have used health facilities for reproductive health-related problems. Less than half of the respondents preferred to use public health facilities. Only 15% used treatment available in health facilities related to irregular menstrual cycles (34.6%), severe dysmenorrhea (58.7%) and nonspecific symptoms related to menstruation (31.7%). Family planning services were the most required health service. However, only 31.5% met the needs for family planning services. One-third of the respondents had sexual reproductive health problems and required treatment, but only 9.9% sought reproductive health services when needed.

CONCLUSIONS

Strategies to improve the accessibility to sexual reproductive health services requires a collaboration between the Indonesian government representatives in Malaysia and non-governmental organizations to address the reproductive health issues among immigrant Indonesian women in Malaysia. Health policy related to immigrant workers is needed in order to enhance the accessibility to women's health needs for universal health coverage.

Impact of National Volume-Based Procurement on the Procurement Volumes and Spending for Antiviral Medications of Hepatitis B Virus

Introduction: Although persistent inhibition of HBV replication by antiviral therapy has shown to slow disease progression, cost-related access barriers to these essential medicines are becoming salient. The national volume-based procurement (NVBP) was piloted in China and led to substantial reduction in the list price of prescription drugs. To examine the impact of NVBP on selected antiviral medication costs per defined daily dose (DDD), procurement volumes, and spending.

Methods: We employed an interrupted time series design to examine changes in cost per defined daily dose (DDD), procurement volumes, and spending for NVBP bid-winning antiviral medications (tenofovir disoproxil fumarate and entecavir) in 11 pilot cities from 2017 to 2020. Procurement transaction data were obtained from 9,454 hospitals in the Chinese Hospital Pharmaceutical Audit (CHPA) database. In the secondary analysis, the control group comprised two non-NVBP drugs (adefovir and lamivudine) procured in 11 cities not exposed to the NVBP.

Results: Cost per DDD of the two hepatitis B virus (HBV) antiviral medications reduced by CNY1.598 (p = 0.002) immediately following the implementation of NVBP, dropping from an average cost of CNY16.483 per DDD at baseline to CNY6.420 at the end of the observation period. NVBP implementation resulted in a substantial reduction in daily costs of antivirals and an increase in monthly procurement volumes by 6.674 million DDDs (p = 0.017), while monthly spending was reduced by CNY138.26 million (p = 0.002). In the secondary ITS analysis with a control group, the average cost per DDD of the NVBP bid-winning antivirals declined by CNY4.537 (p < 0.001), monthly procurement volumes increased by 7.209 million DDDs (p = 0.002), and monthly spending dropped by CNY138.83 million (p < 0.001).

Conclusion: Volume-based procurement piloted in China may be effective for reducing price and total expenditures and improving drug utilization, which is especially important for HBV patients who need constant access to antiviral therapies.

A Rapid Review of Interventions to Increase Hepatitis B Testing, Treatment, and Monitoring among Migrants Living in Australia

Chronic hepatitis B (CHB) disproportionately affects migrants with low health literacy and help-seeking behaviour living in high-income countries. Evidence of effective interventions is required to increase hepatitis B (HBV) testing, treatment, and monitoring. Available evidence from Medline, Embase, Scopus, Google, and Google Scholar was identified, collated, and synthesised. Inclusion criteria included grey and peer-reviewed literature published in English between January 2012 and December 2021. Systematic reviews and meta-analyses were excluded. Seventeen peer-reviewed articles met the inclusion criteria. Most interventions were conducted at the individual level and were typically outreach testing initiatives. One study was conducted at a structural level. All studies were successful in encouraging HBV screening uptake, and 10 studies demonstrated effective linkage to care. Two studies showed evidence of monitoring participants post-intervention. Most interventions had more female than male participants. Interventions conducted across community and clinical-based settings had more participants engage in screening and/or linkage to care in community settings. Effective interventions to prevent HBV transmission and CHB-related morbidity and mortality were approaches that utilised linguistic-specific and culturally appropriate resources to successfully engage migrants. Community outreach programmes that educate participants about HBV transmission, screening, and treatment can promote community dialogue and understanding to reduce stigma and discrimination.

Knowledge and beliefs about hepatitis B virus infection and associated factors among Chinese migrants in Australia: The result of a quantitative study

Chinese immigrants to Australia have an increased prevalence of hepatitis B virus (HBV) infection compared to the general population. Despite this, engagement with HBV screening and healthcare for chronic hepatitis B (CHB) among immigrants of Chinese background is relatively low. This study investigated knowledge about HBV among this high-risk community and explored sociodemographic factors that might influence this knowledge. During February to September 2019, first generation Chinese immigrants from mainland China and their immediate descents residing in Sydney and Melbourne were recruited via convenience and snowball sampling and completed a survey in either English or Chinese. Survey items included HBV knowledge, attitudes towards people living with CHB and demographic information. Three hundred and ninety-six participants completed the survey. The median HBV knowledge score was 53% correct, indicating that knowledge about HBV was low to middle range among participants. While participants had the most knowledge in the domain of perceptions and understandings of HBV, this was still low. Participants also had limited knowledge about HBV prevention, transmission and treatment. Those with higher English proficiency, post-secondary education, lower levels of HBV-related stigma and those who had contact with people living with CHB appeared to have greater HBV knowledge. This study showed that HBV knowledge among Chinese people originally from mainland China living in Australia is limited and even deficient in some key areas. Additionally, the relationships between HBV knowledge and particular sociodemographic variables, knowing someone living with HBV and stigma associated with HBV provides key information to assist in the development of targeted health promotion to increase HBV knowledge and change stigmatising attitudes towards HBV among the Chinese community in Australia.

Hepatitis B and pregnancy: understanding the experiences of care among pregnant women and recent mothers in metropolitan Melbourne

Background

Pregnant women are a priority group for hepatitis B testing. Guideline-based care during antenatal and post-partum periods aims to prevent mother-to-child transmission of hepatitis B virus and lower the risk of liver complications in mothers. This qualitative study explored knowledge of hepatitis B and experiences of hepatitis B related care among pregnant women and mothers.

Methods

Semi-structured interviews were conducted with thirteen women with hepatitis B who were attending antenatal or post-partum hepatitis B care. The interviews were thematically analysed to assess knowledge and understanding of hepatitis B. Participants were recruited from specialist clinics in metropolitan Melbourne between August 2019 and May 2020.

Results

Four major themes were identified from interviews: (1) knowledge and understanding of hepatitis B, (2) treatment pathways, (3) accessing hepatitis B related care, and (4) disclosing status to friends. Most participants displayed an understanding of hepatitis B transmission, including mother to child transmission. The main motivator of post-partum attendance was reassurance gained concerning their child’s health. Sources of hepatitis B information included doctors, online information and family. Participants identified parents and siblings as sources of support and reported an unwillingness to disclose hepatitis B status to friends.

Conclusions

Women attending antenatal or post-partum care reported having overall positive experiences, particularly regarding reassurance of their child’s health, but displayed misconceptions around horizontal transmission. Knowledge gained from these results can contribute to the development of targeted models of care for pregnant women and mothers with young children to ensure their successful linkage to care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13112-0.

Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) infections among undocumented migrants and uninsured legal residents in the Netherlands: A cross-sectional study, 2018-2019

BACKGROUND

Migrants are not routinely screened for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in the Netherlands. We estimated the prevalence and determined factors associated with HBV, HCV and/or HIV infections among undocumented migrants and uninsured legal residents.

METHODS

In this cross-sectional study, undocumented migrants and uninsured legal residents were recruited at a non governmental organization (NGO), healthcare facility in the Netherlands and were invited to be tested for hepatitis B surface antigen (HBsAg), anti-hepatitis B core antibodies (anti-HBcAb), HCV-RNA, and anti-HIV antibodies or HIV antigen at a local laboratory.

RESULTS

Of the 1376 patients invited, 784 (57%) participated. Participants originated from Africa (35%), Asia (30%) and North/South America (30%). 451/784 (58%) participants went to the laboratory for testing. Of participants 30% were HBV exposed (anti-HBcAb-positive), with 27% (n = 119/438, 95% CI 23.1% to 31.6%) having resolved HBV infection (HBsAg-negative) and 2.5% (n = 11/438, 95%CI 1.3% to 4.5%, 64% new infection) having chronic HBV infection (HBsAg-positive). Compared to HBV non-exposed, HBV exposed individuals were older (p = 0.034) and more often originated from Africa (p<0.001). Prevalence of chronic HCV infection (HCV-RNA-positive) was 0.7% (n = 3/435, 95%CI 0.1% to 2.0%, all new infections) and HIV infection 1.1% (n = 5/439, 95%CI 0.04% to 2.6%, 40% new infection).

CONCLUSION

Prevalence of chronic HBV, chronic HCV and HIV infections in our study population is higher compared to the Dutch population, thus emphasizing the importance of case finding for these infections through primary care and public health in this specific group of migrants. Screening uptake could be improved by on-site testing.

Assessing the feasibility, acceptability and impacts of an education program on hepatitis B testing uptake among ethnic Chinese in Australia: results of a randomised controlled pilot study

Background

In Australia, Chinese migrants are among the populations most affected by hepatitis B virus (HBV) infection but often experience late diagnosis or access to clinical care. This study aims to explore approaches to increase HBV testing in Australia’s Chinese community and inform evaluation planning, specifically to i) assess the feasibility and acceptability of HBV educational programs, and ii) compare HBV testing uptake in people receiving a tailored education resource focussing on liver cancer prevention compared with a standard HBV education package.

Methods

This is a pre-post mixed-methods pilot and feasibility study. People of Chinese ethnicity and unsure of their HBV infection or immunity status were recruited from ten community sites in Melbourne, Australia in 2019–2020. Participants were randomised to receive an education package (comprised of a leaflet and in-person one-on-one educational session) with a focus on either 1) standard HBV-related information, or 2) liver cancer prevention. Participants completed a baseline questionnaire prior to receiving the intervention and were followed up at 6 months’ time for a questionnaire and an opt-in semi-structured interview. Primary study outcomes included feasibility of study procedures, measured by recruitment, participation, and retention rates; acceptability of the education program assessed by acceptability scores; and HBV testing uptake rate in each arm. Secondary outcomes include HBV-related knowledge change, assessed by pre-post comparison; and factors affecting participants’ testing behaviour analysed using qualitative data.

Results

Fifty-four participants received an education package; baseline and follow-up data from 33 (61%) were available. The study procedures of recruitment and retention were feasible; the acceptability of the education program was moderate with improved HBV-related knowledge observed. Four participants self-reported being tested: one (1/15, 7%) in the standard HBV information group and three (3/18, 17%) in the liver cancer prevention information group. Factors identified as affecting testing included perceived relevance and seriousness of HBV, healthcare access and costs of testing, and perceptions of the role of primary care providers in HBV-related care.

Conclusion

A tailored education program targeting ethnic Chinese in Australia was feasible with moderate acceptability. A larger study is required to determine if a liver cancer prevention message would improve HBV testing uptake in Chinese community than standard HBV education message. Supports from healthcare providers, community-based testing programs, and public health education programs are likely needed to motivate diagnostic testing among Chinese people at risk of HBV infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11916-0.

What factors affect patients' ability to access healthcare? An overview of systematic reviews

OBJECTIVES

This overview aims to synthesise global evidence on factors affecting healthcare access, and variations across low- and middle-income countries (LMICs) vs. high-income countries (HICs); to develop understanding of where barriers to healthcare access lie, and in what context, to inform tailored policies aimed at improving access to healthcare for all who need it.

METHODS

An overview of systematic reviews guided by a published protocol was conducted. Medline, Embase, Global Health and Cochrane Systematic Reviews databases were searched for published articles. Additional searches were conducted on the Gates Foundation, WHO and World Bank websites. Study characteristics and findings (barriers and facilitators to healthcare access) were documented and summarised. The methodological quality of included studies was assessed using an adapted version of the AMSTAR 2 tool.

RESULTS

Fifty-eight articles were included, 23 presenting findings from LMICs and 35 presenting findings from HICs. While many barriers to healthcare access occur in HICs as well as LMICs, the way they are experienced is quite different. In HICs, there is a much greater emphasis on patient experience; as compared to the physical absence of care in LMICs.

CONCLUSIONS

As countries move towards universal healthcare access, evaluation methods that account for health system and wider cultural factors that impact capacity to provide care, healthcare finance systems and the socio-cultural environment of the setting are required. Consequently, methods employed in HICs may not be appropriate in LMICs due to the stark differences in these areas.

Hepatitis B virus related stigma among Chinese living in mainland China: a scoping review

Stigma related to hepatitis B virus (HBV) has a detrimental impact on health outcomes of people living with HBV. A scoping review of published peer-reviewed articles focused on the Chinese population in mainland China published between 2010 and 2019 was undertaken. This review consists of five stages: identifying the research question, identifying relevant literature, study selection, charting the data, and collating, summarizing and reporting the results. Articles in Chinese were identified from the collection of Core Journals in the database of CNKI (China Academic Journals Full-text Database). Publications in English were identified in Global Health, Scopus, PsycINFO, Proquest and Web of Science. Forty-five peer-reviewed articles were selected for inclusion. Most studies under review focused on negative individual attitude and discrimination against people living with HBV (PLHBV) in employment, education, community and healthcare settings. There is limited information on lived experiences of those living with HBV and how they manage this stigma. The reviewed studies provide evidence for the existence of different forms of HBV-related stigma in a variety of settings. Knowledge about HBV and the level of education of research participants were the most frequently identified factors related to this stigma. These findings are useful to support HBV responses in China and countries with migration from China.

Diagnosis of Chronic Hepatitis B Pericomplication: Risk factors and Trends Over Time

BACKGROUND AND AIMS

Hepatitis B virus (HBV) is a major cause of chronic liver disease, which can progress to cirrhosis, hepatocellular carcinoma, and death. A timely diagnosis allows for antiviral treatment, which can prevent liver-related complications. Conversely, a late diagnosis signals a missed opportunity for earlier care and treatment. Our objective was to measure the proportion of chronic HBV diagnoses that are made within 6 months of presentation with a liver disease-related complication and examine associated factors and trends over time.

APPROACH AND RESULTS

We used provincial laboratory data to identify patients with chronic HBV diagnosed from 2003 to 2014. We measured the proportion who experienced a liver disease complication (decompensated cirrhosis, hepatocellular carcinoma, or liver transplant) within ±6 months of their HBV diagnosis date. A multivariable logistic regression model was used to identify factors associated with HBV diagnosis pericomplication. Of 18,434 patients with chronic HBV, 1,279 (6.9%) developed an HBV-related complication during the follow-up period. Among these, 570 (44.6%) had a first diagnosis pericomplication. HBV diagnosis pericomplication did not decrease over time and was independently associated with older age at HBV diagnosis, rural residence, alcohol use, and moderate to high levels of comorbidity. Female patients, immigrants, and those with more outpatient physician visits were less likely to have an HBV diagnosis pericomplication.

CONCLUSIONS

A high proportion of patients with HBV-related complications are first diagnosed with HBV pericomplication. These signal missed opportunities for earlier detection and treatment. Our findings support expansion of HBV screening.

A qualitative exploration of enablers for hepatitis B clinical management among ethnic Chinese in Australia

An estimated 18% of people living with chronic hepatitis B (CHB) in Australia were born in China. While guideline-based care, including regular clinical monitoring and timely treatment, prevent CHB-related cirrhosis, cancer and deaths, over three-quarters of people with CHB do not receive guideline-based care in Australia. This qualitative study aimed to identify enablers to engagement in CHB clinical management among ethnic Chinese people attending specialist care. Participants self-identified as of Chinese ethnicity and who attended specialist care for CHB clinical management were interviewed in Melbourne in 2019 (n = 30). Semi-structured interviews covered experiences of diagnosis and engagement in clinical management services, and advice for people living with CHB. Interviews were recorded with consent; data were transcribed verbatim and thematically analysed. Receiving clear information about the availability of treatment and/or the necessity of long-term clinical management were the main enablers for participants to engage in CHB clinical management. Additional enablers identified to maintain regular clinical monitoring included understanding CHB increases risks of cirrhosis and liver cancer, using viral load indicators to visualize disease status in patient-doctor communication; expectations from family, peer group and medical professionals; use of a patient recall system; availability of interpreters or multilingual doctors; and largely subsidized healthcare services. In conclusion, to support people attending clinical management for CHB, a holistic response from community, healthcare providers and the public health sector is required. There are needs for public health programmes directed to communicate (i) CHB-related complications; (ii) availability of effective and cheap treatment; and that (iii) long-term engagement with clinical management and its benefits.

The Associations Between Sociodemographic Characteristics and Trust in Physician With Immunization Service Use in U.S. Chinese Older Adults

This study investigated sociodemographic factors for immunization care use and the relationship between trust in physician (TIP) and immunization service use in older Chinese Americans. Data were collected through the Population Study of Chinese Elderly, including survey information of 3,157 older adults in the Greater Chicago area. Regression results showed that the odds of getting vaccinated were higher for those who were older, female, and had higher education and income. After adjusting for the covariates, higher TIP was associated with greater immunization service use. The highest tertile of TIP was associated with higher odds of using immunization service (OR 2.19, 95% CI [1.76, 2.72]), especially for flu and pneumonia vaccines. Findings suggests that immunization service use may be increased by improving TIP and promoting targeted health care management plans for racial/ethnic minorities, which is highly relevant to increase the vaccination rate and contain the pandemic as the COVID-19 vaccine is available.

Differences in risk factors for hepatitis B, hepatitis C, and human immunodeficiency virus infection by ethnicity: A large population-based cohort study in British Columbia, Canada

OBJECTIVES

Addressing the needs of ethnic minorities will be key to finding undiagnosed individuals living with hepatitis B (HBV), hepatitis C (HCV), or human immunodeficiency virus (HIV). To inform screening initiatives in British Columbia (BC), Canada, the factors associated with HBV and/or HCV and/or HIV infection among different ethnic groups within a large population-based cohort were assessed.

METHODS

Persons diagnosed with HBV, HCV, or HIV in BC between 1990 and 2015 were grouped as East Asian, South Asian, Other Visible Minority (African, Central Asian, Latin American, Pacific Islander, West Asian, unknown ethnicity), and Not a Visible Minority, using a validated name-recognition software. Factors associated with infection within each ethnic group were assessed with multivariable multinomial logistic regression models.

RESULTS

Participants included 202 521 East Asians, 126 070 South Asians, 65 210 Other Visible Minorities, and 1 291 561 people who were Not a Visible Minority, 14.4%, 3.3%, 4.5%, and 6.3% of whom had HBV and/or HCV and/or HIV infections, respectively. Injection drug use was most prevalent among infection-positive people who were Not a Visible Minority (22.1%), and was strongly associated with HCV monoinfection, HBV/HCV coinfection, and HCV/HIV coinfection, but not with HBV monoinfection among visible ethnic minorities. Extreme material deprivation and social deprivation were more prevalent than injection drug use or problematic alcohol use among visible ethnic minorities.

CONCLUSIONS

Risk factor distributions varied among persons diagnosed with HBV and/or HCV and/or HIV of differing ethnic backgrounds, with lower substance use prevalence among visible minority populations. This highlights the need for tailored approaches to infection screening among different ethnic groups.

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.

The association between protection motivation and hepatitis b vaccination intention among migrant workers in Tianjin, China: a cross-sectional study

BACKGROUND

Migrant workers are a susceptible population to the hepatitis b virus (HBV) and a vulnerable spot in China's immunization procedures. There is no free HBV immunization program for migrant workers in China, so understanding migrant workers' motivation to receive the HBV vaccine is the first step in designing effective immunization policies.

METHODS

A fully specified protection motivation theory (PMT) model of HBV vaccination intention among migrant workers was specified. Data were collected through a cross-sectional survey of 406 migrant workers in three migrant-dense industries in Tianjin, China. Principal component factor analysis was used to produce PMT factors and nested binary logistic regression modeling was applied to assess the associations between protection motivation and HBV vaccination intention of migrant workers.

RESULTS

The nested binary logistic regression model suggested that the severity factor and self-efficacy factor were positively related to HBV vaccination intention (OR = 2.15, 95% CI: 1.25-3.71; OR = 2.75, 95% CI: 1.62-4.66) while the response costs was negatively related to the HBV vaccination motivation (OR = 0.50, 95% CI: 0.29-0.83). The socio-demographic variables showed that younger, married and good self-rated health status participants were statistically associated with the intention of taking the HBV vaccine. Sex, education level and income group were not significantly associated with vaccination intention. The migrant-industry variables showed that migrant location had a strong effect on migrant workers' vaccination intention.

CONCLUSION

Socio-demographic, migrant-industry variables and PMT factors (severity, self-efficacy and response costs) were statistically associated with migrant workers' intention to vaccinate. Our results suggest that health policy makers should provide more information to migrants on HBV severity; inform migrant workers on where, when and how to get the HBV vaccine; tap into work organizations as a location for vaccinations; and identify migrant worker subgroups for targeted interventions.

Social Support and Health Services Use in People Aged over 65 Years Migrating within China: A Cross-Sectional Study

Background: Due to the household registration system, Chinese elderly migrants have insufficient access to health services and social support. Thus, this study examined the use of health services, the access to social support, and the interaction among the elderly migrating within China. Methods: Data were obtained from the China Migrant Dynamic Monitoring Survey in 2015, adopting probability proportionate to size as the sampling strategy. Structural equation modeling and mediating effect tests were employed to explore the associations. Results: Approximately 45.9% of elderly migrants did not seek health services when needed. The use of outpatient and inpatient services was more common than free essential public health services. The use of health services was negatively associated with migrating duration and migrating for offspring, while it was positively associated with outer social support. The mediating effects of outer social support were discovered on the relationships between the use of health services and independent variables such as migrating duration and migrating for offspring, respectively. Conclusion: Elderly migrants with a longer migrating duration or migrated for offspring seem to obtain less outer social support, resulting in a decreased use of health services. Outer social support was suggested as a key effort to improve the equalization of health services in Chinese elderly migrants.

The Lived Experience of Chronic Hepatitis B: A Broader View of Its Impacts and Why We Need a Cure

Chronic hepatitis B (CHB) is one of the most widespread liver diseases in the world. It is currently incurable and can lead to liver cirrhosis and cancer. The considerable impacts on society caused by CHB through patient mortality, morbidity, and economic loss are well-recognised in the field. This is, however, a narrow view of the harms, given that people living with CHB can be asymptomatic for the majority of their life-long infection. Of less-appreciated importance are the psychosocial harms, which can continue throughout an affected person's lifetime. Here we review the broad range of these impacts, which include fear and anxiety; financial loss and instability; stigma and discrimination; and rejection by society. Importantly, these directly affect patient diagnosis, management, and treatment. Further, we highlight the roles that the research community can play in taking these factors into account and mitigating them. In particular, the development of a cure for hepatitis B virus infection would alleviate many of the psychosocial impacts of CHB. We conclude that there should be a greater recognition of the full impacts associated with CHB to bring meaningful, effective, and deliverable results to the global community living with hepatitis B.

Improving Hepatitis B Care in the US: A Case for a New "Ryan White" Program

Chronic hepatitis B infection is common in the United States, yet only a minority of eligible people are screened, vaccinated, and receive treatment. The Ryan White HIV/AIDS program has been a key tool for ensuring that socioeconomically disadvantaged HIV-infected patients have access to care. Many of the same disease and patient attributes that make the Ryan White program necessary and effective for HIV exist in chronic hepatitis B. Thus, we believe that the current Ryan White program should be expanded to care for people with hepatitis B under similar regulations. Considering recent changes proposed to the health insurance marketplace, policymakers should strongly consider inclusion of chronic hepatitis B in the safety-net Ryan White Program.

Hepatitis B and C testing strategies in healthcare and community settings in the EU/EEA: A systematic review

An estimated 9 million individuals are chronically infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) across the European Union/European Economic Area (EU/EEA), many of which are yet to be diagnosed. We performed a systematic review to identify interventions effective at improving testing offer and uptake in the EU/EEA. Original research articles published between 1 January 2008 and 1 September 2017 were retrieved from PubMed and EMBASE. Search strings combined terms for HBV/HCV, intervention, testing and geographic terms (EU/EEA). Out of 8331 records retrieved, 93 studies were selected. Included studies reported on testing initiatives in primary health care (9), hospital (12), other healthcare settings (31) and community settings (41). Testing initiatives targeted population groups such as migrants, drug users, prisoners, pregnant women and the general population. Testing targeted to populations at higher risk yielded high coverage rates in many settings. Implementation of novel testing approaches, including dried blood spot (DBS) testing, was associated with increased coverage in several settings including drug services, pharmacies and STI clinics. Community-based testing services were effective in reaching populations at higher risk for infection, vulnerable and hard-to-reach populations. In conclusion, our review identified several successful testing approaches implemented in healthcare and community settings, including testing approaches targeting groups at higher risk, community-based testing services and DBS testing. Combining a diverse set of testing opportunities within national testing strategies may lead to higher impact both in terms of testing coverage and in terms of reduction, on the undiagnosed fraction.

Chronic hepatitis B virus case-finding in UK populations born abroad in intermediate or high endemicity countries: an economic evaluation

OBJECTIVES

The majority (>90%) of new or undiagnosed cases of hepatitis B virus (HBV) in the UK are among individuals born in countries with intermediate or high prevalence levels (≥2%). We evaluate the cost-effectiveness of increased HBV case-finding among UK migrant populations, based on a one-time opt out case-finding approach in a primary care setting.

DESIGN

Cost-effectiveness evaluation. A decision model based on a Markov approach was built to assess the progression of HBV infection with and without treatment as a result of case-finding. The model parameters, including the cost and effects of case-finding and treatment, were estimated from the literature. All costs were expressed in 2017/2018 British Pounds (GBPs) and health outcomes as quality-adjusted life-years (QALYs).

INTERVENTION

Hepatitis B virus case-finding among UK migrant populations born in countries with intermediate or high prevalence levels (≥2%) in a primary care setting compared with no intervention (background testing).

RESULTS

At a 2% hepatitis B surface antigen (HBsAg) prevalence, the case-finding intervention led to a mean incremental cost-effectiveness ratio of £13 625 per QALY gained which was 87% and 98% likely of being cost-effective at willingness to pay (WTP) thresholds of £20 000 and £30 000 per additional QALY, respectively. Sensitivity analyses indicated that the intervention would remain cost-effective under a £20 000 WTP threshold as long as HBsAg prevalence among the migrant population is at least 1%. However, the results were sensitive to a number of parameters, especially the time horizon and probability of treatment uptake.

CONCLUSIONS

HBV case-finding using a one-time opt out approach in primary care settings is very likely to be cost-effective among UK migrant populations with HBsAg prevalence ≥1% if the WTP for an additional QALY is around £20 000.

"It's just in that sea of things that I never cared about": perception of hepatitis B amongst university students in Aberdeen, North-East Scotland

Background

A significant proportion of international students at UK universities are from regions with medium to high hepatitis B prevalence rates. Understanding the perception of students regarding hepatitis B infection is crucial for the development of appropriate information and services for this population group.

Methods

Twenty semi-structured interviews were conducted with students from the University of Aberdeen. The following key areas were covered: knowledge, awareness, practices including testing, cultural and social aspects and general attitudes to health information and services. Interviews were transcribed verbatim and coded using a framework analysis approach.

Results

The participants acknowledged hepatitis B to be a serious disease yet did not consider themselves to be at risk. They felt able to go to their General Practitioner if concerned about hepatitis B but emphasised that there was no indication that this was required. There was a general lack of knowledge about the disease including confusion over other types of hepatitis. This was linked to the perceived lack of attention given to hepatitis B in, for example, sexual health education and disease awareness raising campaigns. The participants expressed a desire for information on hepatitis B to be relevant to the student population, easy to understand, socially acceptable and easily accessible on student portals and social media platforms.

Conclusions

Our study suggests that students in Aberdeen, North East Scotland lack knowledge and awareness of hepatitis B and do not perceive themselves as being at risk of hepatitis B infection. There is a need for more tailored hepatitis B messages to be incorporated into a range of contexts with clearer risk communication for the student population.

Social Determinants of Stigma and Discrimination in Vietnamese Patients with Chronic Hepatitis B

Vietnam is among the countries with the highest prevalence of chronic hepatitis B (CHB) and individuals who suffer from CHB oftentimes perceive high levels of stigma and discrimination. Our study aimed to provide evidence on the prevalence of stigma against hepatitis B virus (HBV), HBV infection, and social determinants of stigma and discrimination in patients. A cross-sectional study was conducted at Viet-Tiep Hospital, Hai Phong, Vietnam. Stigma and discrimination against CHB in the last month were measured via four dimensions: (1) Blame/Judgment; (2) Shame; (3) Discrimination in different settings; (4) Disclosure of CHB status. Multivariate Logistic and Tobit regressions were used to identify factors associated with CHB-related stigma and discrimination. Among 298 enrolled patients, 4.8% experienced blame/judgement, 10.2% perceived shame, 48.5% felt discriminated in healthcare facilities, and 90.6% disclosed their health status with spouses/partners. Factors associated with lower odds of CHB-related stigma/discrimination included living with spouses/partners, old age, being employed, and the existence of comorbidities was linked with higher odds of stigma. Anti-stigma programs should target those who are younger and have comorbidities. This could be done by community-based interventions which focus on inaccurate beliefs about viral hepatitis. Furthermore, families, healthcare providers, and society should play a crucial role in supporting CHB patients.

The Role of Primary Health Care in Hepatitis B Testing and Management: A Case Study

Hepatitis B is a complex disease requiring lifelong management. Infection is linked to birth in high prevalence regions including Africa and Asia. Best practice guidelines identify who to test for hepatitis B, however, a significant proportion of Australians with hepatitis B have not been diagnosed, and are subsequently at risk of serious morbidity and mortality. This study sought to address the gap between current and optimal hepatitis B testing in a primary care clinic with a likely high population of undiagnosed hepatitis B. Between September 2015 and December 2016, four interventions aimed at enhancing general practitioner testing practices were implemented: staff education, quality improvement and patient-triggered activities. Compared to the baseline (2014) the following parameters all increased in 2016: the number of patients tested (15 tests per month in 2014, 24 tests per months in 2016), the correct ordering of the recommended tests (17% in 2014, 61% in 2016) and hepatitis B vaccine dose ordering (n = 35 in 2014, n = 110 in 2016). However, the proportion of patients born in Africa or Asia tested for hepatitis B did not increase. Distribution of a patient held-reminder led to the greatest number of tests being ordered (n = 54 tests ordered in 1 month). Within a single primary care clinic situated in a high hepatitis B prevalence area, an intervention designed to improve adherence to hepatitis B testing guidelines, increased testing levels. A systematic approach can assist general practitioners to improve their understanding of hepatitis B testing and prioritise people most at risk.

Cost-effectiveness of screening for chronic hepatitis B and C among migrant populations in a low endemic country

BACKGROUND

Chronic infection with hepatitis B or C virus (HBV/HCV) can progress to cirrhosis, liver cancer, and even death. In a low endemic country as the Netherlands, migrants are a key risk group and could benefit from early diagnosis and antiviral treatment. We assessed the cost-effectiveness of screening foreign-born migrants for chronic HBV and/or HCV using a societal perspective.

METHODS

The cost-effectiveness was evaluated using a Markov model. Estimates on prevalence, screening programme costs, participation and treatment uptake, transition probabilities, healthcare costs, productivity losses and utilities were derived from the literature. The cost per Quality Adjusted Life Year (QALY) gained was estimated and sensitivity analyses were performed.

RESULTS

For most migrant groups with an expected high number of chronically infected cases in the Netherlands combined screening is cost-effective, with incremental cost-effectiveness ratios (ICERs) ranging from €4,962/QALY gained for migrants originating from the Former Soviet Union and Vietnam to €9,375/QALY gained for Polish migrants. HBV and HCV screening proved to be cost-effective for migrants from countries with chronic HBV or HCV prevalence of ≥0.41% and ≥0.22%, with ICERs below the Dutch cost-effectiveness reference value of €20,000/QALY gained. Sensitivity analysis showed that treatment costs influenced the ICER for both infections.

CONCLUSIONS

For most migrant populations in a low-endemic country offering combined HBV and HCV screening is cost-effective. Implementation of targeted HBV and HCV screening programmes to increase early diagnosis and treatment is important to reduce the burden of chronic hepatitis B and C among migrants.

A blind spot? Confronting the stigma of hepatitis B virus (HBV) infection - A systematic review

Background: Stigma, poverty, and lack of knowledge present barriers to the diagnosis and treatment of chronic infection, especially in resource-limited settings. Chronic Hepatitis B virus (HBV) infection is frequently asymptomatic, but accounts for a substantial long-term burden of morbidity and mortality. In order to improve the success of diagnostic, treatment and preventive strategies, it is important to recognise, investigate and tackle stigma. We set out to assimilate evidence for the nature and impact of stigma associated with HBV infection, and to suggest ways to tackle this challenge.

Methods: We carried out a literature search in PubMed using the search terms ‘hepatitis B’, ‘stigma’ to identify relevant papers published between 2007 and 2017 (inclusive), with a particular focus on Africa.

Results: We identified a total of 32 articles, of which only two studies were conducted in Africa. Lack of knowledge of HBV was consistently identified, and in some settings there was no local word to describe HBV infection. There were misconceptions about HBV infection, transmission and treatment. Healthcare workers provided inaccurate information to individuals diagnosed with HBV, and poor understanding resulted in lack of preventive measures. Stigma negatively impacted on help-seeking, screening, disclosure, prevention of transmission, and adherence to treatment, and had potential negative impacts on mental health, wellbeing, employment and relationships.

Conclusion: Stigma is a potentially major barrier to the successful implementation of preventive, diagnostic and treatment strategies for HBV infection, and yet we highlight a ‘blind spot’, representing a lack of data and limited recognition of this challenge. There is a need for more research in this area, to identify and evaluate interventions that can be used effectively to tackle stigma, and to inform collaborative efforts between patients, clinical services, policy makers, traditional healers, religious leaders, charity organisations and support groups.

A blind spot? Confronting the stigma of hepatitis B virus (HBV) infection - A systematic review

Background: Stigma, poverty, and lack of knowledge present barriers to the diagnosis and treatment of chronic infection, especially in resource-limited settings. Chronic Hepatitis B virus (HBV) infection is frequently asymptomatic, but accounts for a substantial long-term burden of morbidity and mortality. In order to improve the success of diagnostic, treatment and preventive strategies, it is important to recognise, investigate and tackle stigma. We set out to assimilate evidence for the nature and impact of stigma associated with HBV infection, and to suggest ways to tackle this challenge. Methods: We carried out a literature search in PubMed using the search terms 'hepatitis B', 'stigma' to identify relevant papers published between 2007 and 2017 (inclusive), with a particular focus on Africa. Results: We identified a total of 32 articles, of which only two studies were conducted in Africa. Lack of knowledge of HBV was consistently identified, and in some settings there was no local word to describe HBV infection. There were misconceptions about HBV infection, transmission and treatment. Healthcare workers provided inaccurate information to individuals diagnosed with HBV, and poor understanding resulted in lack of preventive measures. Stigma negatively impacted on help-seeking, screening, disclosure, prevention of transmission, and adherence to treatment, and had potential negative impacts on mental health, wellbeing, employment and relationships. Conclusion: Stigma is a potentially major barrier to the successful implementation of preventive, diagnostic and treatment strategies for HBV infection, and yet we highlight a 'blind spot', representing a lack of data and limited recognition of this challenge. There is a need for more research in this area, to identify and evaluate interventions that can be used effectively to tackle stigma, and to inform collaborative efforts between patients, clinical services, policy makers, traditional healers, religious leaders, charity organisations and support groups.

Chinese Immigrant Women's Attitudes and Beliefs About Family Involvement in Women's Health and Healthcare: A Qualitative Study in Chicago's Chinatown

Purpose: Healthcare utilization and health-seeking behaviors of Chinese American immigrant women may be influenced by longstanding cultural perspectives of family roles and relationships. An understanding of Chinese immigrant women's perceptions of family social support in health and how these beliefs manifest in healthcare utilization and help-seeking behaviors is critical to the development of culturally appropriate health interventions. Focusing on a sample of Chinese women in Chicago's Chinatown, this qualitative study seeks to describe women's attitudes and beliefs about spouse and adult children's involvement in women's health and healthcare.

Methods: We conducted six focus groups among 56 Chinese-speaking adult women in Chicago's Chinatown between July and August 2014. Focus groups were transcribed, coded, and analyzed for emergent themes.

Results: Women reported that their adult children supported their health and healthcare utilization by helping them overcome language and transportation barriers, making and supporting decisions, and providing informational and instrumental support related to diet and nutrition. Women viewed these supports with mixed expectations of filial piety, alongside preferences to limit dependency and help-seeking because of concern and emotional distress regarding burdening adult children. Women's expectations of the spouse involvement in their healthcare were low and were shaped by avoidance of family conflict.

Conclusion: Findings inform opportunities for the development of culturally appropriate interventions to enhance Chinese immigrant women's health and healthcare. These include patient navigation/community health worker programs to promote self-management of healthcare and family-centered strategies for enhancing family social support structures and reducing family conflict.

A Pilot Program Integrating Hepatitis B Virus (HBV) Screening into an Outpatient Endoscopy Unit Improves HBV Screening Among an Ethnically Diverse Safety-Net Hospital

BACKGROUND

Safety-net hospitals are enriched in ethnic minorities and provide opportunities for high-impact hepatitis B virus (HBV) screening.

AIM

We aim to evaluate the impact of a pilot program integrating HBV screening into outpatient endoscopy among urban safety-net populations.

METHODS

From July 2015 to May 2017, consecutive adults undergoing outpatient endoscopy were prospectively assessed for HBV screening eligibility using US Preventative Services Task Force guidelines. Rates of prior HBV screening were assessed, and those eligible but not screened were offered HBV testing. Multivariate logistic regression models evaluated predictors of test acceptance among eligible patients.

RESULTS

Among 1557 patients (47.1% male, 69.4% foreign born), 65.1% were eligible for HBV screening, among which 24.5% received prior screening. In our pilot screening program in the endoscopy unit, 91.4% (n = 855) of eligible patients accepted HBV testing. However, only 55.3% (n = 415) of those that accepted actually completed HBV testing. While there was a trend toward higher rates of test acceptance among African-Americans compared to non-Hispanic whites (OR 3.31, 95% CI 0.96-11.38, p = 0.06), no other sex-specific or race/ethnicity-specific disparities in HBV test acceptance were observed. Among those who completed HBV testing, we identified 10 new patients with chronic HBV (2.4% prevalence). Only 24.5% of eligible patients received prior HBV screening among our cohort.

CONCLUSIONS

Our pilot program integrating HBV screening into outpatient endoscopy successfully tested an additional 415 patients, improving overall HBV screening from 24.5 to 75.6%. Integrating HBV testing into non-traditional settings has potential to bridge the gap in HBV screening among safety-net systems.

Determinants of uptake of hepatitis B testing and healthcare access by migrant Chinese in the England: a qualitative study

Background

Global migration from hepatitis B endemic countries poses a significant public health challenge in receiving low-prevalence countries. In the UK, Chinese migrants are a high risk group for hepatitis B. However, they are an underserved population that infrequently accesses healthcare. This study sought to increase understanding of the determinants of hepatitis B testing and healthcare access among migrants of Chinese ethnicity living in England.

Methods

We sought to obtain and integrate insights from different key stakeholders in the system. We conducted six focus group discussions and 20 in-depth interviews with community members and patients identifying themselves as ‘Chinese’, and interviewed 21 clinicians and nine health service commissioners. Data were thematically analysed and findings were corroborated through two validation workshops.

Results

Three thematic categories emerged: knowledge and awareness, visibility of the disease, and health service issues. Low disease knowledge and awareness levels among community members contributed to erroneous personal risk perception and suboptimal engagement with services. Limited clinician knowledge led to missed opportunities to test and inaccurate assessments of infection risks in Chinese patients. There was little social discourse and considerable stigma linked to the disease among some sub-sections of the Chinese population. A lack of visibility of the issue and the population within the health system meant that these health needs were not prioritised by clinicians or commissioners. Service accessibility was also affected by the lack of language support. Greater use of community outreach, consultation aids, ‘cultural competency’ training, and locally adapted testing protocols may help.

Conclusions

Hepatitis B among migrants of Chinese ethnicity in England can be characterised as an invisible disease in an invisible population. Multi-modal solutions are needed to tackle barriers within this population and the health system.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4796-4) contains supplementary material, which is available to authorized users.

Epidemiology of hepatitis B and the role of vaccination

Hepatitis B virus (HBV) is a major cause of morbidity and mortality with a disproportionate impact on Asia and Africa. Current guidelines recommend screening at-risk populations for chronic HBV infection so that diagnosed individuals can be linked to appropriate hepatitis care. The vast majority of infected individuals are undiagnosed and untreated, and are at risk of developing cirrhosis, liver failure, and hepatocellular carcinoma. In individuals who are not yet infected, the HBV vaccine is safe and highly effective at preventing disease transmission. Countries with successful vaccination programs have been able to dramatically reduce their HBV prevalence. A concerted effort to screen, treat, and vaccinate at-risk individuals has the potential to eliminate HBV as a public health threat by 2030.

Immune Tolerant Chronic Hepatitis B: The Unrecognized Risks

Chronic infection with hepatitis B virus (HBV) progresses through multiple phases, including immune tolerant, immune active, immune control, and, in a subset of patients who achieve immune control, reactivation. The first, the immune tolerant phase, is considered to be prolonged in duration but essentially benign in nature, lacking long-term consequences, and thus not recommended for antiviral therapy. This review challenges the notion that the immune tolerant phase is truly benign and considers the possibility that events during this phase may contribute significantly to cirrhosis, hepatocellular carcinoma (HCC), and the premature death of 25% of HBV carriers worldwide. Thus, earlier treatment than recommended by current guidelines should be considered. Low therapeutic coverage exacerbated by restrictive treatment guidelines may facilitate disease progression in many patients but also increase the risk of neonatal and horizontal transmission from untreated mothers to their children. While a prophylactic vaccine exists, there are many areas worldwide where the treatment of adults and the delivery of an effective vaccination course to newborns present difficult challenges.