Overcoming Barriers to Care for Hepatitis B Virus Among SE Asians in King County: Literature Review

Purpose

The purpose of this literature review is to explore the extent to which Southeast Asian immigrants in King County, WA, are impacted by HBV, the existing barriers to testing and intervention, and evidence-based practices to promote optimal rates of screening, vaccination and treatment of HBV in this population. 

Introduction

HBV infections which put people at high risk for hepatocellular carcinoma are preventable and treatable, and the vaccinations are widely available. In addition to reduced morbidity and mortality from HBV, the cost of treating hepatocellular carcinoma is very high. By increasing provider awareness of patients at greater risk of HBV infection and the best practices in treatment, testing, vaccination and retention in care in this population, we can successfully reduce prevalence of this disease in the U.S.

HBV is endemic in Asian countries, including the Southeast Asian countries of Vietnam, Cambodia, Laos and the Philippines. As individuals and families from these areas have relocated to the United States as immigrants and refugees, the virus has traveled as well, resulting in an 8.8% to 13.8% prevalence among Vietnamese Americans in California while the prevalence in Vietnam is only slightly higher at 11.4% to 15.3% (Dam et al., 2016). Because immigration has been a major contributing factor to HBV rates in the U.S., it is helpful to understand the history of immigration from Southeast Asian countries. 

Prior to 1975, immigration of Southeast Asians to the United States occurred in relatively low numbers (less than 1,000 persons per year on average since 1955) primarily as a result of student visas and spouses of United States military personnel moving to America at the end of soldiers’ foreign deployment. These patterns changed abruptly with the passage of the Indochina Migration and Refugee Assistance Act of 1975 and the Refugee Act of 1980, which marked the dramatic shift in immigration volume as a result of refugees coming to America following communist capture of Vietnam, Cambodia, and Laos. In 1975 alone, the United States received approximately 130,000 refugees from Southeast Asian countries, the vast majority of whom were from Vietnam (Gordon, 1987). 

While immigration numbers have varied year to year, Asian-born individuals have continued to relocate to the U.S. steadily until present day with recent statistics revealing that there are currently over 20 million Asian Americans nationally with nearly 35% noting a Southeast Asian country of origin (Lopez, Ruiz, & Patten, 2017) and over two thirds being foreign-born (Chen, 2014). Current projections further anticipate that Asians will comprise the largest immigrant group in America by the year 2055 (Lopez, Bialik, & Radford, 2018). Considering the local impact, over 55% of foreign-born individuals in King County are from Asian countries as compared to 31.2% nationally (Demographic trends, 2017). According to King County, immigration has been a major source of population growth in the region in recent years with Vietnamese being the most dominant east Asian language (Felt, 2017) and Vietnamese-speaking households being most concentrated in the Burien, White Center, Skyway and Mt. Baker regions with significant populations also residing in areas of Kent and Renton (Lowe, 2011). According to King County, acute and chronic HBV case rates mirror the Southeast Asian population distribution with the majority of cases occurring in the south end of the county (Thiede, Barash, Kent, & Koehler, 2009).

By combining an understanding of the endemicity of HBV in Southeast Asian countries, the history of immigration from these countries to the U.S, and current King County demographics, the need for a thoughtful and appropriate health strategy for this group becomes evident. The Washington State Department of Health further reports that the prevalence rate of HBV within King County more than doubled from 2013 to 2017 (Hepatitis B, n.d.). As of 2010, the numbers of Asian Americans in Washington State impacted by HBV far exceeds that of any other racial/ethnic group (Chen, 2014). These statistics confirm the call for health systems and practitioners to take action on his issue 

Methods

Information on the research topic was obtained through searches in multiple scholarly databases. Databases queried include PubMed, PubMed Central, Google Scholar and the library catalogs of Seattle Central College and the University of Washington. Key terms utilized were: Asian, “Southeast Asian,” refugee, immigrant, stigma*, “stigma reduction,” “reduce stigma,” health, healthcare, “health care,” attitude*, perspective*, perception*, barrier*, belief*, culture*, HBV, hepatitis B, “liver cancer,” “hepatocellular cancer,” “infectious disease,” Seattle, “King County,” Washington, and American. Quotation marks were used when needed to limit results to those including key phrases and complete concepts such as “Southeast Asian.” MESH terms were not utilized. In order to obtain local statistics, Google search was employed utilizing search terms including Asian, “Southeast Asian,” Vietnamese, Cambodian, Filipino, immigrant, population, demographics, language, “country of origin,” and “King County.”

Results

Over one hundred potentially useful articles were identified using the above search methods, and eighteen scholarly articles were selected for inclusion in the research review. Not all potentially useful articles were explored due to time limitations. The populations studied in the selected articles include Asians and Southeast Asians living in Asia or as immigrants in Canada or the United States. Some populations studied had a diagnosis of hepatitis B virus or hepatocellular cancer while others did not. While not the focus of our research, some selected articles also included non-Asian populations as the studies more generally assessed HBV knowledge and barriers among immigrants from various countries of HBV endemicity, including some African countries such as Somalia. Individuals residing in or born in one of twenty-nine countries were represented in the selected articles. 

Health Perspectives of Communities

Research on the topic of HBV and intervention planning for the target population begins with exploration of the perspectives of health unique to the culture of this group as it is from a grounded understanding of existing health knowledge and beliefs that respectful, non-harming, and effective health promotion initiatives can evolve. Four articles in our research provided insight into this arena. First, a study of Koreans living in Western Washington revealed that health and wellness are often defined in terms of energy balance (Choe et al., 2005). Traditional healing modalities such as acupuncture and herbal medicine were cited as being frequently utilized as adjuncts to Western medicine but not a replacement for it. 

A separate study by Hwang, Roundtree, & Suarez-Almazor found that traditional healing modalities were most commonly employed by Vietnamese, Korean and Chinese individuals living in America when Western medicine had failed or was inaccessible due to financial constraints (2012). Participants in this study reported having hope in the healing power of traditional medicine and indicated that it addresses the root causes of ailments. Importantly, participants indicated that they sought the counsel of community members as well as healthcare providers when making health-related decisions. While a third study further found that immigrants from countries of high HBV prevalence associated illness with lifestyle factors and imbalance of the body, it also revealed that fate and karma may also be credited for these occurrences (Owiti, Greenhalgh, Sweeney, Foster, & Bhui, 2015). The final article in our research which addressed cultural views of healthcare which may be applicable to Southeast Asian immigrants highlighted cupping and coin-rubbing as important traditional healing methods. Blood is often regarded as a sacred source of energy, and both traditional and Western medicine may only be sought for illness after symptoms are present (Clough, Lee, & Chae, 2013).  

Prevalence of HBV among Asian Americans

The second theme explored in our research is that of the prevalence of HBV among Asian Americans. It is estimated that over two million people in the United States are living with HBV with foreign-born individuals being most affected by far (Smith, 2012). Asian Americans in particular are disproportionately impacted by HBV as they comprise only 6% of the population yet represent approximately 60% of those affected by the virus (Chen Jr., 2015). It was noted that Asian Americans are affected by HBV at over thirty times the rate of non-Hispanic whites in America (Lee, Fawcett, Kim, & Yang, 2016). A study published in 2018 which examined a diverse cohort of individuals with chronic HBV and hepatocellular cancer across a span of 14 years found that Asian heritage was independently associated with higher rates of hepatocellular cancer (Kennedy, Graham, Arora, Shuhart, & Kim, 2018). As chronic hepatitis is considered the most significant cause of liver cancer among Asian Americans (Choe et al., 2005), it is important to examine both liver cancer and the virus itself when assessing impact of the disease. 

Barriers to Screening, Vaccination and Treatment

The barriers to HBV screening, vaccination, and treatment in Asian immigrants in many studies has revealed the effects of social stigma about the disease. One study of Chinese immigrants in Toronto, Canada, showed that only about 47% of HBV positive people were willing to discuss their illness with friends or family (Li et al., 2012). Greater levels of stigma have been associated with decreased likelihood of testing and treatment for hepatitis B infection. Stigma has been shown to affect those who test positive for hepatitis B by causing fear of exclusion and discrimination leading to non-disclosure of disease and potentially increasing infection rates (Lee, Fawcett, Kim, & Yang, 2016). One study showed that a major reason identified by patients for avoiding care to treat hepatitis B was not wanting to upset or shame their families (Dam et al., 2016). A lack of education about hepatitis B in Asian immigrants was a recurring problem identified in many studies reviewed. 

Interventions 

Areas of education need primarily include modes of transmission (Dam et al., 2016) and effectiveness of treatment and vaccination (Owiti, Greenhalgh, Sweeney, Foster, & Bhui, 2015). Interventions to improve education regarding hepatitis B had little positive effect on rates of testing or vaccination (Vedio, Liu, Lee, & Salway, 2016; Hislop et al., 2012); however, education was shown to reduce stigma about the disease (Lee, Fawcett, Kim, & Yang, 2016) which may lead to reduced transmission and increased treatment rates. The largest barrier to testing has been shown to be healthcare providers missing opportunities for testing and vaccination (Vedio, Liu, Lee, & Salway, 2016). This will be discussed more with best practices. Other barriers identified include lack of resources including transportation to appointments (Owiti, Greenhalgh, Sweeney, Foster, & Bhui, 2015; Clough, Lee, & Chae, 2013), lack of insurance (Choe et al., 2005) and patient-provider language barriers resulting in a negative impact to care (Clough, Lee, & Chae, 2013).

Community health programs with the aim of overcoming barriers to testing, treatment and vaccination in Asian Americans and Asian immigrants have been most successful when they prioritize community engagement (Yoo, Fang, Zola, & Dariotis, 2015). Community and faith-based organizations were identified as a key to successful engagement in these communities. In particular, one study recommends the following in the development of programs: maintaining a strong community presence though building relationships with community leaders, establishing partnerships and linkage to care processes, developing a sustainability plan, and ensuring the presence of dedicated program staff (Stanford, Biba, Khubchandani, Webb, & Rathore, 2016). As discussed above, a major barrier to testing and vaccination identified in several studies were missed opportunities by healthcare providers (Vedio, Liu, Lee, & Salway, 2016). Thus, provider awareness of patients most at risk for the disease is important. The Centers for Disease Control and Prevention (CDC) recommends any immigrant from or person who has at least one parent from a country with high or moderate prevalence of HBV (greater than 2%) be tested for infection. Further recommendations for people who test positive (HbsAg+) include additional testing to determine acute or chronic infection and screening of household members, sexual contacts and family members (Viral Hepatitis, 2015). 

One study showed that Asian Americans were more likely to go to a healthcare provider that speaks their native language (Hwang, Roundtree, & Suarez-Almazor, 2012). When this was not possible, the availability of interpreter services and patient navigators within the healthcare delivery system were shown to be very helpful in reducing barriers to care (Clough, Lee, & Chae, 2013). Successful interventions to increase education and reduce stigma include mass media education (Owiti, Greenhalgh, Sweeney, & Foster, 2015) and involving community leaders to help promote the campaign message (Rice, Wu, Li, Detels, & Rotheram-Borus, 2014; Yoo, Fang, Zola, & Dariotis, 2015). A trauma-informed approach is also noted as being important when engaging Asian Americans who may have relocated as refugees. Refugees face unique challenges as a result of previously living in a region of political instability and may experience low social capital, fewer financial resources and psychological trauma (Djoufack et al., 2017). Programs that acknowledge and address these unique hardships may be more likely to be successful. 

Discussion

According to the CDC, less than 5% of the United States population identifies as Asian American and Pacific Islander yet this group accounts for the majority of chronic HBV cases with 58% of foreign-born individuals with chronic HBV being from Asia (Asian Americans and Pacific Islanders, 2016). In Washington State, the largest Southeast Asian subgroups are Vietnamese, Cambodian and Filipino. According to a 2008 achievement gap report, Vietnamese and Cambodian communities have been shown to have lower education levels, which may include hepatitis B and health information. Vietnamese people in Washington State have high levels of limited English proficiency, highlighting the need for interpreter services for this community (Hune & Takeuchi, 2008). While Asian Americans often are reported as having relatively high levels of education and socioeconomic status as compared to other minorities, the aggregation of such data from many Asian countries of origin obscures the disparities faced by those from Southeast Asia. For example, those immigrating from countries such as India who may be coming with higher levels of education and social capital often experience more optimal outcomes than those who move to America to flee poverty or political unrest (Clough, Lee, & Chae, 2013).

The following are recommendations based on the research reviewed in this paper. Healthcare providers should be refugee-sensitive and trauma-informed. If healthcare providers do not speak the native language of the patient, interpreters and/or patient navigators have been shown to be beneficial. Care of patients in this community should embrace both Western and traditional medicine. Community health campaigns with the goals of increasing testing and vaccination should engage the entire community rather than focus on individuals. Community leaders have been instrumental for success in these campaigns. Knowledge of HBV and stigma should also be addressed in attempt to encourage treatment and reduce transmission.

Limitations of this research include the non-systematic selection of scholarly articles and the non-exploration of all potentially useful articles as a result of time constraints. The findings of this research are limited by the mixed populations studied in many of the articles. Very few studies focused exclusively on HBV in Southeast Asian immigrant communities in America, and thus, inferences have been drawn based upon research that included residents of and immigrants from other parts of Asia and non-Asian immigrants. Care has been taken so as to not overstate the significance of the findings of mixed population research given that nuances of the target population may be missed in these cases. 

Conclusion

As the Southeast Asian immigrant population continues to grow in King County, increased awareness of higher prevalence of this disease and the areas where this community primarily resides presents an opportunity for health care providers to provide compassionate health care services that are financially, linguistically and culturally accessible and appropriate. By understanding the impact of the HBV on Southeast Asians in the local community and deploying best practices for screening, prevention and treatment as discussed in this paper, there is hope that rates of HBV and hepatocellular cancer can be meaningfully reduced, resulting in a higher quality of life to those who have come here seeking safety, opportunity, and well-being.

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