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How We Reached Asian Americans With Undiagnosed Hepatitis B in Sacramento County

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Julie Dang, PhD, MPH

 Assistant Professor & Executive Director
Office of Community Outreach and Engagement
UC Davis Comprehensive Cancer Center
Division of Health Policy and Management
Department of Public Health Sciences
University of California, Davis
Davis, California

Julie Dang, PhD, MPH, has no relevant conflicts of interest to report.

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Released: November 18, 2021

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Asian American patients experience the greatest disparities in chronic hepatitis B disease among all US racial and ethnic groups. Accounting for approximately 6% of the entire US population, Asian Americans account for the majority of diagnosed chronic hepatitis B cases and are 8 times more likely to die from hepatitis B virus (HBV) than non-Hispanic Whites. Most Asian American patients infected with HBV are unaware of their infection, and more than one half of this high-risk population has not been screened for HBV. The strongest risk factor for chronic hepatitis B in the United States is nativity, with almost 50% of those chronically infected being immigrants from Asian countries.

The US Preventive Services Task Force recommends HBV screening for all foreign-born individuals from countries with a hepatitis B surface antigen prevalence of ≥2%. This includes all Asian American immigrants and their US-born children. However, most healthcare systems do not offer HBV screening as a part of routine care, aside from during pregnancy. In addition, Asian Americans experience significant barriers to HBV screening and care at the patient, healthcare professional, and health system level, stemming from cultural, social, and economic determinants.

Tremendous progress and efforts have been made to address HBV disparities among Asian American patients. These include community outreach and engagement programs to increase HBV awareness and education, providing free or low-cost HBV screening and vaccination, and linking those diagnosed with chronic HBV infection to appropriate care. In collaboration with the Asian-Pacific Islander community and the health systems that provide care to them, I would like to share our culturally appropriate strategies for HBV screening and care from projects in Sacramento County, California.

Working With the Community
Asian Americans comprise heterogenous groups with diverse socio-cultural norms and economic status. We used community-engaged methodologies to ensure that our HBV outreach and education programs were responsive to the needs of each specific community. Our community interventions included:

  • Development of culturally appropriate and ethnic specific in-language HBV educational materials. Materials were community pretested, assessed for health literacy, and largely employed the use of infographics to convey information.
  • Collaboration with trusted community-based organizations and community leaders (eg, faith-based leaders, lay healthcare workers) to deliver HBV education.
  • Provision of free HBV screenings at community-trusted and community-frequented venues. This also included navigating patients who tested positive to free or low-cost care and providing HBV vaccinations for those in need.

Working With Healthcare Systems
The location where people receive care also varies greatly (eg, federally qualified health centers, medical groups, community clinics, pharmacies). Therefore, we worked in collaboration with each healthcare delivery system to develop and implement clinic-based interventions that facilitated HBV screening and care. This included:  

  • Electronic health system updates such as inclusion of a registry of Asian surnames to identify high-risk patients, streamlining of an HBV order set, systematic data collection of patient nativity, and use of provider reminder/recall prompts.
  • Visual displays of the CDC’s map of endemic countries in every clinic examination room.
  • Availability of community-tested culturally appropriate HBV educational materials in various Asian-Pacific Islander languages for patients.
  • Employment of an HBV case navigator to provide culturally competent screening and care follow-through.
  • Training of medical assistants that focused on HBV cultural humility.

These interventions and programs highlight the importance of recognizing that there is no one-size-fits-all approach to mitigating the burden of HBV among Asian American patients. Not only did we work with each community to customize and tailor strategies that reflected their socio-cultural, religious, and traditional beliefs, but we also worked with healthcare systems to implement interventions that can be realistically incorporated into their current clinic workflow. The foundation and success of our strategies can be attributed to our approach of making sure we meet the community and healthcare delivery systems where they are and engage them in participatory active dialogue and partnership.

Your Thoughts
In what ways have you used community-specific programs to simplify HBV screening and care in populations who experience disparities in HBV treatment and care?

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