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Next, I will talk about some solutions to help overcome these barriers to HBV care and treatment for immigrants and members of minority populations. So far, we have primarily talked about immigrants. However, there are also indigenous minority groups in the United States and many other parts of the world, including China, New Zealand, Australia, and others, that are disproportionately affected by HBV. Unfortunately, data show that native minority populations also face greater barriers to care than other populations in the same country.
Community engagement is a key strategy for addressing care disparities. Patients, HCPs, and researchers in the community all need to be engaged in the process to develop culturally appropriate engagement and to leverage community venues that can reach these populations. Minority groups can often go “unseen” within the larger population. Reaching target communities may involve approaching faith-based community centers or other community areas where members of these populations gather. Many larger cities in western countries have neighborhoods, such as Chinatown and Koreatown, and predominantly Hispanic communities, that may be good target areas to receive focused efforts and resources.
We need more research into disparities that includes outcome measurements to identify what works and what does not work. This research must be designed with inputs from patients and their communities, and the results must be brought back to the community and used to inform practice. Community-based interventions should address community awareness to reduce social stigma and silence about HBV.
We also need to advocate for structural change in the medical and civic institutions that care for these patients. Community leaders and institutions can be trusted partners in healthcare by providing health information and increasing awareness of positive outcomes from science-based medicine. Community leaders can help provide information specific to members of their community.
For example, a patient with liver cancer may be hesitant to receive a liver transplant because the process sounds so invasive. A trusted leader from within their community could help the patient understand that a transplant is the best long-term outcome and provide information and support for post-transplant care.
Emphasis is needed in several areas to improve management. First, knowledge is key. An understanding of basic epidemiology is critical and will come from better data collection and analysis. This information should be used to create community health education focused on minority groups and culturally relevant community interventions.
Practical considerations include things like assistance for social services, voluntary operations, and cultural mediators. Cultural mediators can establish trust and help community members navigate barriers to care.
For example, patients may be afraid to seek care if they do not know how to find the right clinic. They may be afraid to talk to a doctor because they do not speak the language of their new country. Volunteer translators, ride assistance to clinics, and other guidance are little things that make a big difference.
In addition to clinical support, minority populations will benefit from psychosocial and legal management and assistance. Many minority groups are relatively small and can be more vulnerable than members of majority populations. Focused support should be a major objective of good government.
Education is another important component of reducing barriers to care. Educational efforts and materials should focus not only on available treatments, but also on the basic epidemiology of the infection to help patients to understand the burden of HBV in their community. Education about the different routes of transmission can show the effect of household clustering and help people to be more adherent to screening as well as vaccination to protect those in their households.
Mother-to-child transmission is actually the main route of HBV transmission among people from developing countries. Immigrants should be informed about the very safe and effective vaccine that is available, as well as treatment for expectant mothers during the third trimester to prevent transmission to their babies.
Other exposure may come via sexual transmission, occupational exposure, or illicit drug use that leads to parenteral needlestick transmission.
Finally, education needs to include an explanation of costs. This aspect is easily overlooked in areas where many people have good insurance coverage or where there is universal coverage for medical care. In the United States, approximately 60% to 70% of patients have private health insurance. However, data from people with private insurance in the United States show that only 20% of patients are diagnosed, and many are undertreated.7 This suggests that even individuals with financial coverage for screening and treatment may be unaware that they have this coverage.
Of course, healthcare system‒based strategies are needed to complement community-based strategies. Some can be implemented at the level of the care provider, and others may have a broader, system-wide context and application.
Individual providers must show compassion and genuine concern for their patients. This may take extra time and effort, but it is key to establishing a nonprejudicial environment that helps people from all backgrounds feel comfortable and supported. Such an environment can help normalize illness and treatment and proactively address concerns, such as fear of deportation. It is especially important for overcoming mistrust in western medicine and addressing any cultural preference for alternative approaches that may not be effective against HBV. Ideally, healthcare systems could develop a system-wide screening and treatment algorithm for minority patients that is practical and simple for HCPs to implement.
Systems should work to increase the diversity of their workforce and provide culturally congruent mediators who can help patients navigate their care. HCPs should also consider noninvasive screening and treatment strategies, such as elastography and radiation therapy, that may be more readily accepted by patients concerned about invasive procedures.
Improving the accessibility of healthcare for indigenous groups can require special considerations. Such groups often live far from HCPs and may have limited financial and practical resources. Outreach clinics are a useful way to bring health services to indigenous patients directly, whether in remote locations or even in big cities.
For example, many immigrant communities live within 1 hour of the clinics where I work at Stanford University. However, many patients from these communities will not travel to Stanford—perhaps they are unfamiliar with big cities and hospitals where the clinics are housed, or they cannot speak English and are worried about navigating the distance. Some may face transportation difficulties.
To help reach these patients, Stanford organizes outreach clinics. Every week, I go to an outreach clinic in San Jose, California, approximately 1 hour from Stanford. The outreach clinics include staff who speak the languages spoken in the local communities, which helps patients feel comfortable and be more likely to seek care there.
Other strategies can include providing transportation to clinics, offering flexible scheduling (such as early morning or Saturday appointments), and even providing home visitation in some communities.
To address cultural competence, acceptability, and appropriateness, it’s important to build relationships with your local communities that are grounded in trust and mutual respect. These relationships must be genuine and should be based on empathy and knowledge of the culture of the minority and indigenous groups we work with. This may include recruiting indigenous HCPs who can deliver culturally safe services and working with community elders and kinship networks.
In summary, the majority of patients with HBV in western countries, such as the United States, are foreign born. Across the globe, many minority, indigenous, and immigrant communities have a high prevalence of HBV, and intervention efforts must to be culturally sensitive to be effective.
We need to remember that even patients with good insurance coverage in western countries are severely underdiagnosed for HBV, with only approximately 20% diagnosed.7 The diagnosis rate globally is estimated to only be approximately 10%.
Even among diagnosed patients, most do not undergo optimal evaluation and monitoring, and even patients already linked to care and known to meet treatment criteria have a very low treatment rate. That includes patients with severe disease, such as cirrhosis or liver cancer.
We know more provider and community awareness, education, and engagement are needed to address HBV care gaps. We also need a simplified and practical screening and treatment algorithm that HCPs can use to better assess communities, identify and diagnose more of these patients, and help them receive care.