Chronic hepatitis B infections are the second leading cause of cancer in the world, after tobacco use. The disproportionate representation of the Asian American or Pacific Islander (AAPI) population among those living with chronic hepatitis B virus (HBV) is severe: 58% of Americans living with chronic HBV identify as AAPI, even though the overall AAPI populations make up only 6% of people living in America today.1 In 2020, the rate of newly reported HBV cases among AAPI individuals was almost 12 times the rate among non-Hispanic White individuals.2 The reasons behind these figures are complex. While there are a multitude of risk factors, we can start addressing this disparity by taking a close look at some of the most common ones:
- Being born outside of the United States. The Hepatitis B virus is more common in other countries, so some communities in the US reflect this prevalence. It’s estimated that 70% of people living with chronic HBV in the US were born in other countries. This risk factor goes back to the historically lower rates of infant immunization against HBV in China, Korea, Vietnam, and the Pacific Islands. Many Asian or Pacific Islander individuals with HBV were also infected during childbirth, as HBV is frequently passed from parent to infant.3 Infant immunization is becoming more prevalent in Asia as of 2019, with cases in children under five dropping below 1% in nine of the 11 countries in Southeast Asia.4 This is great news, but there’s still work to be done when it comes to screening and prevention.
- Language barriers. The US health care system can be complicated enough for native English speakers. Many people who were born outside the US prefer to speak a non-English language, and these individuals have a higher chance of contracting HBV.5 Without access to language-congruent health literacy materials and practitioners, many AAPI people don’t receive accurate, timely information about the importance of screening, or what their personal HBV risk factors may be.
- Differing views on Western medicine. Many traditional cultural beliefs and practices, including a preference for traditional medicine, can result in AAPI individuals feeling mistrustful of western health care practitioners (HCPs), medical procedures, and test results. These barriers are reinforced by factors in other categories, including poor quality of care, lack of transportation, perceived and experienced discrimination, and high health care costs.6 Many AAPI people also cite a fear of burdening their family or damaging their reputations, a belief that HBV is hopelessly fatal, and/or a lack of trust in preventive care.6/7
- Organizational issues. These include workplace time off policies and clinical policies such as non-routine HBV screening.7/8
- Financial situations. These factors span across the individual and societal levels.7 Low income, lack of access to adequate health insurance (individuals who utilize government-provided insurance such as Medicaid or Medicare are at higher risk8), and poverty have a large impact on every aspect of the HBV treatment process. From screening to access to medication to follow-up care, AAPI individuals are disproportionately limited by a large variation in income and prohibitive cost of care.6
Not surprisingly, many of these barriers exacerbate each other. For example, workplace time off policies can be related to low wages and income. Language barriers can reinforce interpersonal and literacy challenges, such as lack of trust in doctors and transportation to multilingual community clinics.
So, what can HCPs do to address the disproportionate burden of HBV on Asian Americans? The FDA has implemented a multi-strategy approach with a number of useful programs, which you can refer to when developing your own clinical and personal policies:
- A multi-sectoral national coalition on HBV focused on awareness, prevention, and intervention;
- A multilingual awareness campaign which provides a host of resources, including posters, infographics, flyers, and quizzes;
- Digital patient storytelling using the hashtag #justB. This can be utilized by patients and HCPs on all major social media platforms;
- Patient engagement and advocacy efforts, including grassroots, legislative, and administrative advocacy;
- Policy changes, including in professional organizations, health systems, and at the local, state, and federal levels. These involve increasing vaccination coverage, combatting HBV-related discrimination with legal advocacy, and addressing adverse drug tiering implemented by insurance networks.
With a multi-pronged approach and a large majority of HCPs in the US implementing this information into their practices, complete elimination of large disparity in the burden of HBV is possible! A simple, realistic first step you can take is pursuing knowledge on the latest screening guidelines and implementing them as quickly as possible. At CME Outfitters, we aim to make this easy: register for our upcoming webinar on March 8, 2023, Educating Frontline Clinicians to Reduce Missed Opportunities for HBV Screening. Our expert faculty will provide actionable information on what you can do to begin establishing health equity in your practice today!
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