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Next, I will review some of the barriers to screening, evaluation, and treatment that result in these care gaps.
There are several problems that impair detection of HBV in immigrant and minority populations. These can include lack of awareness of HBV transmission, prevention, and treatment, along with a distrust in the medical doctors they see and the healthcare system as a whole. A lower socioeconomic position can impair access to care. Cultural beliefs can be a barrier if patients prefer forms of healing other than Western medicine. It’s likely that many potential opportunities to test immigrants are being missed.
Even for patients who already know they have the disease, several barriers exist to seeking care. Individuals may be afraid of and mistrust the medical establishment, or they may have misconceptions about care.3 Some patients may be in denial or face stigma associated with acknowledging infection and seeking treatment for chronic HBV infection. Inadequate financial resources are a major barrier. Low health literacy can lead to confusion regarding the infection and potential treatment outcomes or complications. And for any patients who have poor language abilities in the primary language of their new countries, communication with healthcare professionals (HCPs) is challenging and can lead to suboptimal understanding.
African immigrant communities in the United States face particular barriers to healthcare access.4 Many individuals in this community lack health insurance, and even those with legal immigrant status may worry about that status being jeopardized. Patients may be reluctant to be seen as active in broader society, including participating in the healthcare system.
Another factor, which may be unfamiliar to people born in the United States, is that immigrants may be considered the luckier ones among their families and communities back home. Those who have immigrated may feel strong connections and responsibilities to those back home. This can lead to a focus on working hard and saving money to send home, with less attention and money devoted to themselves and their personal health.
African immigrant communities reflect the socioeconomic and cultural dynamics of their home countries, so we cannot view our immigrant patients as one community. We need to consider the communities and cultures of the patients’ places of origin. Several factors can affect access to healthcare. Social stigma is a major problem, caused by various misconceptions about HBV. Such stigma can also lead to secrecy, because people are afraid to be known to have this contagious disease.
Socioeconomic factors, lack of insurance, and social geography can all create barriers to accessing care.4 Some patients may view Western medical systems with suspicion or mistrust, and some may prefer spiritual, traditional, or alternative medicine approaches. Dietary patterns common in many of these communities may lead to high exposure to aflatoxins, which significantly increases the risk of liver cancer among these patients. An aversion to invasive procedures and surgery may deter people from seeking care. And finally, we need to keep in mind that immigrants may be likely to be stoic or fatalistic and try to smile and to be resilient in the face of discomfort and adversity. As mentioned previously, they may worry more about people back home than about themselves.
We can see similar factors reflected in these data collected about Asian immigrants in the San Francisco Bay area. These patients were already diagnosed and linked to care opportunities. Among those who met HBV treatment criteria but did not receive treatment, financial difficulties were given as a reason by only a small minority: 12% of those seen in a gastrointestinal group, 7.7% of those seen in a hepatology group, and none of those seen by primary HCPs.5 This tells us that socioeconomic conditions are certainly a consideration, but that cultural, social, and other concerns are also very important.
Overall, when considering the major barriers to HBV care for minority and immigrant populations, socioeconomic concerns are a big problem, as are lack of knowledge, language barriers, cultural barriers, poor awareness, and misconceptions about health and healthcare.
Stigma plays a powerful role, both the social stigma internalized by the affected patients and external structural and institutional stigma.6 Despite its importance, however, working to overcome stigma as a barrier has not received as much attention.
Together, stigma and a lack of knowledge among minority populations lead to HBV-related discrimination, including reduced uptake for disease screening, diagnosis, and treatment; negative attitudes from HCPs; and potential negative impacts on people’s lives, relationships, and mental and emotional health. In many parts of the world, for example, people with HBV may not be able to get a job. However, HCPs and systems in western countries that care for immigrant patients do not always recognize these challenges.