Hepatitis B Knowledge and Behaviors in Asian Immigrants

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Hepatitis B and Liver Cancer Prevention in Asian
Americans How Culture Affects the Research
Endeavor Centers for Disease Control and
Prevention Health Promotion Research
Initiative John H. Choe, MD, MPH University of
Washington
D. WeXler, Immunization Action Coalition
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Overview

• Context of the clinical and public health problem
  of hepatitis B infection in Asian immigrants
• Recent and ongoing work in hepatitis prevention
  among Asians in Seattle
• Community participatory methods and the interplay
  between qualitative, quantitative methods in
  developing tailored interventions
• Examples from current K01 work
• How culture affects the research endeavor
  lessons
• Moving beyond ethnicity in tailoring
  interventions?

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Hepatitis B Clinical Implications

• Hepatitis B viral (HBV) infection can be acute
  (active) or chronic (often silent)
• Chronic HBV infection leads to primary liver
  cancer or cirrhosis in around one-quarter
• Liver cancer is potentially vaccine-preventable
• U.S. control measures focused on maternal ? child
• Programs for adults to reduce horizontal
  transmission mainly modeled on familiar high
  risk populations (STD, homeless, IVDU, prisoners)

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HBV in Immigrants

• Asians are half of all chronic HBV infected in
  the U.S.
• Chronic infection prevalence between 4-18
• Peak complication from chronic HBV 4th-5th
  decades
• Immigration from endemic areas continues
• Transmission within households often several
  generations in one home
• Focus upon children and adults with high risk
  behaviors miss this large pool of HBV infected
• Language/ cultural appropriateness of prevention

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Asian Americans and Liver Cancer
Age-adjusted Liver Cancer Incidence Men,
1988-92
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Hepatitis B versus C and HIV

• World
  US
• HIV 31 million
  0.8 million
• Hepatitis C 170 million 4.0
  million
• Hepatitis B 400 million 1.3
  million
• In US 130,000 new hepatitis B infection /year
• 5,000 die from hepatitis B liver
  disease

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Tailoring HBV Interventions

• Active and recent prevention research in Asian
  immigrant communities in Seattle
• Vietnamese
• Cambodians
• Chinese
• Koreans
• Culturally and linguistically appropriate
  education to increase serologic detection of
  chronically infected
• Moving beyond tailoring messages by ethnic
  group?

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Tailoring HBV Interventions

• Active and recent prevention research in Asian
  immigrant communities in Seattle
• Vietnamese
• Cambodians
• Chinese
• Koreans
• Culturally and linguistically appropriate
  education to increase serologic detection of
  chronically infected
• Moving beyond tailoring messages by ethnic
  group?

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CBPR for Cultural Context

• Community-based participatory methods
• Trust-building and listening ? Time and
  opportunities
• Also other cultures, including research
  culture, university culture, and social service
  agency culture
• Community advisory board as equal partners
• For me, took at least four years

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Qualitative Tools
Previous Experience/ Mentors
Quantitative Tools
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Qualitative Tools
Previous Experience/ Mentors
Quantitative Tools
Intervention
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Qualitative Tools
Previous Experience/ Mentors
Quantitative Tools
Community Board
Intervention
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Community Partners

• Korean Aging Service Coalition
• Korean Community Counseling Center
• Korean Womens Association
• Washington Korean Dry Cleaners Association
• Korean American Professionals Society
• Asian Counseling and Referral Services
• Kawabe Memorial House
• Washington State Asian Pacific Islander Task
  Force on Hepatitis B

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Example Travel for Healthcare

• Qualitative data from interviews revealed many
  regularly travel to Korea for routine medical
  care
• I had a language problem so Every time when I
  went to visit my mother in Korea, I went to see
  Dr. Kim for yearly checkup.
• Community advisory board confirmed this was
  common, and some even did this themselves

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Example Travel (cont.)

• Quantitative survey data (467 Korean adults)
• Have you ever traveled to Korea to take care of
  a medical problem? ? Yes 10
• Challenges for intervention
• Continuity of care
• Diagnosis can sometimes require careful clinician
• 3-dose vaccine given over a course of up to a year

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Example Food as HBV Vector

• Qualitative interviews
• Lots of Korean families sit together sharing
  food in the same bowl We all share a part of a
  stew by dipping everybodys spoon, not like in
  the U.S. lack of sanitation causes more
  hepatitis through sharing same utensils.
• Quantitative survey Factors that spread HBV?
• Eating unclean food 82
• Sharing eating utensils 79
• Eating food prepared by someone with HBV 51

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Example Food (cont.)

• Community advisory board
• Cant avoid it
• I use serving plates, but everyone thinks its
  strange
• If you make me give up kim-chee, Im not Korean
• Challenges for intervention
• More people believe this, than know childbirth or
  sexual intercourse as routes of transmission
• Need for repeated education on this point
• No need to change deep-seated cultural practice

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Lessons Learned Process

• Translation time and money costs significant
• From other projects garbage in garbage out
• Academic vs. Community cultural differences
  are as significant a barrier as any ethnic
  differences
• Finding right cultural broker important the
  wrong one can slow down or damage project (4
  years)
• Small communities ? Small politics

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Lessons Learned Opportunities/ Threats

• Investment time and opportunity costs are very
  high
• Stakes higher for junior investigator (but
  grateful for the protection of the K01!)
• High payoff potential Community opportunities
  open when the investigator gives freely

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Third Generation Studies

• Pasick et al argued for cross-culture studies
• 1st Gen Health promotion programs without regard
  to race/ ethnicity 2nd Gen Tailored race/
  ethnic specific research and programs
• 3rd Generation Comparative studies across groups
• Finding common elements shared between groups
  will allow more refined health programs,
  segmenting according to specific health beliefs
• For greater efficiency and economy

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Acknowledgements

• Vicky Taylor
• Beti Thompson
• Jeffrey Harris
• Shin-Ping Tu

• Carey Jackson
• Scott Ramsey
• Yutaka Yasui
• Roshan Bastani

Community Advisory Board members and supporting
community organizations CDC Health Promotion
Research Initiative
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