key: cord-0005150-1fgbpajx
authors: Shiau, Rita; Bove, Fred; Henne, Jeff; Zola, Janet; Fang, Ted; Fernyak, Susan
title: Using Survey Results Regarding Hepatitis B Knowledge, Community Awareness and Testing Behavior Among Asians to Improve the San Francisco Hep B Free Campaign
date: 2011-08-27
journal: J Community Health
DOI: 10.1007/s10900-011-9452-9
sha: d8265364e5ed0c62b7a2b72c565a8560a5f3c08a
doc_id: 5150
cord_uid: 1fgbpajx

Asians are disproportionately affected by chronic hepatitis B (HBV) infection and its fatal consequences. The Hep B Free campaign was launched to eliminate HBV in San Francisco by increasing awareness, testing, vaccination and linkage to care. The campaign conducted 306 street intercept and telephone interviews of San Francisco Asians to assess current levels of HBV knowledge, testing behaviors and effectiveness of existing campaign media materials. One-third of respondents ranked HBV as a key health issue in the Asian community, second to diabetes. General HBV awareness is high (85%); however, a majority could not name an effective prevention method. Sixty percent reported having been tested for HBV; provider recommendation was the most often cited reason for testing. Respondents reported a high level of trust in their providers to correctly assess which health issues they may be at risk for developing and test accordingly, confirming that efforts to increase HBV testing among Asians must simultaneously mobilize the public to request testing and compel providers to test high-risk patients. Regarding community awareness, more than half reported hearing more about HBV recently; younger respondents were more likely to have encountered campaign materials and recall correct HBV facts. Assessment of specific campaign materials found that while upbeat images and taglines captured attention and destigmatized HBV, messages that emphasize the pervasiveness and deadly consequence of infection were more likely to drive respondents to seek education and testing. The campaign used survey results to focus efforts on more intensive provider outreach and to create messages for a new public outreach media campaign.

Abstract Asians are disproportionately affected by chronic hepatitis B (HBV) infection and its fatal consequences. The Hep B Free campaign was launched to eliminate HBV in San Francisco by increasing awareness, testing, vaccination and linkage to care. The campaign conducted 306 street intercept and telephone interviews of San Francisco Asians to assess current levels of HBV knowledge, testing behaviors and effectiveness of existing campaign media materials. One-third of respondents ranked HBV as a key health issue in the Asian community, second to diabetes. General HBV awareness is high (85%); however, a majority could not name an effective prevention method. Sixty percent reported having been tested for HBV; provider recommendation was the most often cited reason for testing. Respondents reported a high level of trust in their providers to correctly assess which health issues they may be at risk for developing and test accordingly, confirming that efforts to increase HBV testing among Asians must simultaneously mobilize the public to request testing and compel providers to test high-risk patients. Regarding community awareness, more than half reported hearing more about HBV recently; younger respondents were more likely to have encountered campaign materials and recall correct HBV facts. Assessment of specific campaign materials found that while upbeat images and taglines captured attention and destigmatized HBV, messages that emphasize the pervasiveness and deadly consequence of infection were more likely to drive respondents to seek education and testing. The campaign used survey results to focus efforts on more intensive provider outreach and to create messages for a new public outreach media campaign.

Keywords Hepatitis B Á Liver cancer Á Asian Americans Á Health promotion Á Immigrants

Asians are disproportionately affected by chronic hepatitis B infection and its sequelae, which include cirrohosis, liver cancer and liver failure. Screening programs in the United States estimate that 10-15% of Asians are chronically infected with hepatitis B virus (HBV), compared to 0.5% of the general population [1] [2] [3] [4] [5] . Most Asians in the US are either born or have parents who were born in Asia [2, 6] , where prevalence of HBV infection is as high at 8-10%. If left untreated, 25% of those with chronic HBV infections will die from liver cancer [7] . Currently in the US, Asians and Pacific Islanders have the highest incidence of liver cancer among all racial/ethnic groups (7.8 per 100,000 persons, compared to 2.6-5.7 in other groups) [8] .

In order to decrease HBV-related disease, the Centers for Disease Control and Prevention (CDC) recommends routine screening of high-risk populations using serologic test for hepatitis B surface antigen (HBsAg) to identify chronically infected individuals and refer them for monitoring and treatment for liver disease [9] . CDC also recommends vaccination for all infants to prevent perinatal transmission, and for all other unvaccinated individuals at high risk for infection, such as Asians.

Assessments among North American Asian populations indicate that in general, the level of knowledge about hepatitis B is low [10] . Screening levels among Asians have also been low, ranging from 9 to 55% [11] [12] [13] . In one study conducted among Asian in the San Francisco Bay Area, two-thirds of those who were chronically infected did not know their infection status [14] . Various studies have indicated that Asians with increased knowledge about hepatitis B-specifically that Asians are at increased risk for infection and that HBV infection can cause liver cancer [11, 15] -were significantly associated with testing and taking their children to be vaccinated against hepatitis B [10, 16] . Thus, assessing gaps in knowledge about HBV is key to creating an effective education message that will lead to actionable results.

The nine-county San Francisco Bay Area has one of the highest concentrations of Asians in the United States [17] ; it also has one of the highest liver cancer rates in the country [18] . Within San Francisco County itself, one-third of its 800,000 residents are Asian, 67% of whom are foreign-born [6]. Summary of data from the San Francisco Department of Public Health Viral Hepatitis Registry indicates that 86% of hepatitis B-positive cases reported to the department from 2007 to 2008 were Asian/Pacific Islander (API), 83% of whom were Chinese, and almost half were found in individuals 35-54 years of age. Eightyseven percent were foreign-born, with Cantonese being the primary language for 56% of cases [19] .

In order to address the high prevalence of potentially unidentified and untreated hepatitis B infections in San Francisco, a citywide coalition of community groups, media organizations, healthcare and governmental organizations, spearheaded by the AsianWeek Foundation, San Francisco Department of Public Health and the Asian Liver Center, launched the San Francisco Hep B Free (SFHBF) campaign in 2007 [20] [21] [22] . SFHBF is a grassroots effort that aims to ''turn San Francisco into the first hepatitis B free city in the nation'' by: (1) creating public and healthcare provider awareness about the importance of testing and vaccinating Asians for hepatitis B, and referring those infected to appropriate care; (2) promoting routine hepatitis B testing and vaccination within the primary care medical community, often encouraging institutional changes to facilitate routine testing; and (3) ensuring access to treatment for chronically infected individuals.

SFHBF's many public awareness activities have been described in detail elsewhere and include in-person educational events, public service announcements through a host of media outlets, community events such as street fairs and cultural shows, and advertisements on billboards, bus shelters and other highly visible areas [20] . In Fall 2008, SFHBF launched the ''B a Hero'' media campaign to convey the message that anyone can be a hero by talking to friends and family about getting tested for hepatitis B (Fig. 1) . The goal of using the upbeat and positive superhero image was to destigmatize the disease within the Asian community by normalizing hepatitis B and bringing the subject into open conversation so that the importance of screening, vaccination and treatment could then be addressed. ''B a Hero'' posters were placed along commute corridors and other high-traffic places. While the campaign message was widely disseminated to the whole San Francisco population in English, Asians were targeted due to their high risk for infection through distributing advertisements through in-language ethnic newspapers and the use of Asian models for the media images.

In order to determine the level of awareness about hepatitis B and evaluate the impact of the ''B a Hero'' media campaign in the San Francisco Asian community, three evaluation projects were launched in July 2009: (1) street interviews conducted over a 2 week period in areas of San Francisco frequented by Asians, (2) telephone survey (landlines only) of a random sample of San Francisco Asian households held both in English and Cantonese, and (3) focus groups of English-and Cantonese-speaking Asians who have not been tested to hepatitis B to provide more nuanced descriptions of prevailing attitudes regarding hepatitis B. This report summarizes results from the two survey projects, and describes how SFHBF used the findings to identify knowledge gaps in our target population in order to create a more focused follow-up media messaging built upon the awareness first raised by the ''B a Hero'' campaign.

Questionnaires and sampling plan were designed jointly by SFDPH and the Henne Group, a company experienced with market research, with input from SFHBF partners. To minimize selection bias, the recruitment script focused on health issues facing the Asian community in order to avoid recruiting respondents who were already interested in or familiar with hepatitis. Domains addressed by the survey include: demographics, respondents' priorities regarding the most important health issues facing San Francisco's Asian community, hepatitis B knowledge, hepatitis B testing behavior and reasons for test/non-test, hepatitis B awareness, recognition of SFHBF campaign materials, and sources for health information. As an incentive for participation, those who completed interviews were entered into a drawing for one of four $50 gift cards. The questionnaire was translated from English to Chinese by SFHBF partners. Bilingual English-Cantonese interviewers were hired and trained by the Henne Group using a standard protocol to conduct both the street intercept and telephone surveys.

Ninety hours of street intercept interviews were conducted over a 2 week period by five Cantonese-English bilingual staff, resulting in 153 successful interviews. With input from campaign staff familiar with San Francisco's Asian community, we selected 14 interview sites frequented by Asians aged 35 years or older; we focused on this age group because a substantially higher percentage are foreign-born individuals (thus, a higher proportion are at high risk of chronic hepatitis B infection) compared to younger age groups [23] . Three of the 14 sites were at bus stops, three outside specific shops frequented by Asians, three outside community gathering places, and five at specific street intersections or along specific stretches of streets frequented by Asians. A convenience sample of potential respondents were recruited as allowed by interviewer availability. Interviewers reported a response rate of one for every six persons approached (16.7%). Respondents who did not self-identify as Asian, who were not San Francisco residents or who did not 

A sample of 5,215 San Francisco landline telephone numbers associated with Asian surnames located in census tracts with high proportions of households identified as Asian was purchased through a sampling vendor. An English version of the street intercept questionnaire was programmed into a computer assisted telephone interviewing (CATI) software, excluding questions evaluating recognition of SFHBF materials because these questions required visual prompting and were not asked in the telephone surveys. Telephone interviews were conducted in the same 2 weeks as the street intercept interviews, during various times of the day and week. Respondents who did not self-identify as Asian or who did not speak either English or Cantonese were excluded from the interview. Out of 2,197 individuals called during the 2 week period, 184 persons did not meet the inclusion criteria, 380 refused or terminated the interview before completion, 1,480 were unreachable (i.e., answering machine only, or wrong or disconnected number). The interview was completed by 153 individuals, giving a response rate of 15.3%. A sample of responses were double-entered into the CATI software to verify accuracy in data entry.

Univariate summaries were performed on all variables from the survey. Pearson's v 2 test or Fisher's exact test for categorical data and the Student t test for continuous data were used to detect statistically significant differences in survey responses on the following variables: age group (\35 years old, 35-64 years old, 65? years old), years lived in the United States (US-born, less than 10 years in the US, 10? years in the US), and mode of interview (telephone vs. street intercept). All hypothesis tests were two-tailed and p values of 0.05 or less were considered significant. Univariate and multivariate logistic regression models were used to estimate risk factors for having been tested for HBV, having asked for a HBV test, and recognition of the B a Hero logo, and perception of greater community awareness about HBV in the last year compared to years before. Covariates include sex, ethnicity, age, years spent in the US and household income. Lastly, because we had many more Chinese respondents than those from other Asian groups, sub-analyses were performed on select variables to determine whether replies from Chinese respondents were significantly different from those who were Asian but not Chinese. All analyses were performed using SAS 9.1.3 for Windows (Cary, NC).

Demographic characteristics of interview the 306 survey respondents are presented in Table 1 . The majority of the interview population were Chinese (86.3%), female (63.4%) and foreign-born (88.2%, 74% of whom were born in China). Of immigrant respondents, a majority have been in the US for more than 10 years (67.0%). Seventy-one percent of respondents chose to answer the survey in Cantonese, and 80.7% spoke Cantonese at home. When comparing the interview population by survey mode, street interview respondents were more likely to be younger (52.3% over 45 years old vs. 65.4% in telephone interviews, p = 0.005), more recent immigrants (40.7% vs. 25.6%, p = 0.001), were monolingual in or preferred speaking Cantonese (81.1% vs. 60.8% for interview language, p \ 0.0001), and less likely to speak languages other than Cantonese at home (89.5% vs. 71.9%, p \ 0.0001).

The interview began with an open-ended question asking respondents to identify the most important health issues facing San Francisco's Asian community (Table 2) . Almost one-third of all respondents stated hepatitis as a key issue, only second to diabetes in the overall ranking of health issues. Concerns about health insurance coverage, heart disease and cancer followed. When stratified by number of years lived in the US, the list of priorities shift slightly. Hepatitis ranks at the top of the list for those who have been here for 10 years or more, and was ranked second and third by those who have been here for fewer than 10 years and those born in the US, respectively. Significantly, hepatitis ranks in the top 3 health concerns when interviewees were not prompted with it as an answer choice. Table 3 describes respondents' current levels of hepatitis B knowledge. General awareness of a medical condition called hepatitis and specifically hepatitis B is high-92 and 85%, respectively. When stratified by age group, awareness of either conditions were significantly higher among younger respondents: for ''hepatitis'', awareness was 94-95% those under 65 year old, and 83.1% for those 65 years old and older (p = 0.01); for ''hepatitis B'', awareness was 88-90% for those under 65 years old and 70.1% for those 65 years old or older (p = 0.007). However, when probed in an open-ended manner about how hepatitis B transmission may be prevented, the most common answer was ''not sure'' (31.7%), with the highest percentage of ''not sure'' answers coming from older respondents (23-30% from those under 65, and 45% in those 65 and over, p = 0.03). Three of the top five methods given involved good hygiene and keeping clear of Sixty percent of our respondents reported having been tested for hepatitis B, with 1 in 10 being unsure whether they had been tested in the past (Table 4 ). Among those who had been tested, half reported having asked their provider for a test. A third were tested in the past year, a third between 1 and 3 years ago, and the rest 4 or more years ago. When asked in an open-ended manner why they decided to get tested, the most commonly cited reason was that their doctor recommended testing (33.3%), followed by testing being part of a physical (15.3%) and a mandate from work or school (13.1%). Among those under 35 years old, 11% cited ''request from family or friend'' as a reason for testing, compared to only 0-2% in respondents 35 or over (p = 0.01).

As for reasons for not having been tested, respondents commonly mentioned a lack of recommendation from their healthcare providers: for 23.6%, the respondents' doctors told them that they did not need to be tested (when stratified by age, 39% among those 65 and over, compared to 13-18% among those under 65, p = 0.02), and for 11.3%, respondents did not explicitly receive a recommendation to test from their providers. Eighteen percent cited a lack of knowledge about the test. Cost was a big concern for younger respondents, with 17% of those under 35 giving ''it's too expensive'' as a reason for not getting tested (vs. 1-3% in those 35 and over, p = 0.008).

Respondents were then asked about their impression of how often and what they had heard about hepatitis B in their community lately compared to a year ago (Table 5) . Almost half of the respondents reported hearing more about hepatitis B in their community recently, with those between 35 and 64 and those under 35 years old having heard more in the past year than those over 65 years old (51% and 43% vs. 34%, p = 0.003). When probed in an open-ended manner, most of the information that respondents have heard about hepatitis in the community lately is correct, with the fact that Asians are at higher risk for infection than those in other ethnic groups being the most common fact they have heard (11.1%). Other correct facts include: ''It can give you cancer'', ''I should get vaccinated'', ''There is a vaccine for it'', and ''There are free testing clinics'' (Table 5) . When examining where respondents had seen or heard about hepatitis B, results differed significantly based on age group: older respondents were more likely to be exposed to Asian newspaper articles (35% vs. 10-25%, p = 0.01) and TV talk shows (17-19% vs. 5%, p = 0.06), middle-aged respondents through a pamphlet or flyer in the clinic (12% vs. 2-5%, p = 0.05) and those under 35 years old through a TV commercial (24-33% vs. 6%, p = 0.001) or bus shelter advertisement (14% vs. 1-2%, p = 0.002). Fortythree percent of respondents reported seeing a flyer about hepatitis B in their community recently, with a clear trend in younger respondents being more likely to have seen a flyer than older respondents (58, 46 and 22% in\35, 35-64 and 65? year olds, respectively, p = 0.0007). Most likely these flyers were seen at a hospital, clinic or doctor's office (30%) and on the street (14%).

To evaluate the penetration of the 2009 ''B a Hero'' media campaign in this group, we asked the street intercept survey respondents about recognition of and reaction to the ''B a Hero'' poster ( Fig. 1) . Forty-one percent reported seeing the poster. When probed in a open-ended manner about what the message of the poster may be, many said ''It's about hepatitis B'', but nothing else. Ten respondents thought the ''Free'' of the slogan represented free testing being available, and ten expressed confusion about the hero image (e. respondents were confused about the involvement of the letter ''B''. Some did correctly interpret the superhero image to mean being one to friends and family by learning more or getting tested/vaccinated for hepatitis B. While the image piqued curiosity in general, some thought the advertisement was from a company rather than a trusted source such as the health department or community hospital. When asked whether the ''B a Hero'' poster would prompt respondents to get tested, vaccinated, see a doctor, learn more about hepatitis B, or to recommend testing to friends or family, more than 60% indicated that they would ''not likely'' do so. Lastly, to guide our planning for more effective media campaign outlets in the future, we asked respondents where they usually obtain health information for a cold, a partner's pregnancy and a family member's heart attack (i.e. health conditions of varying severity), aside from consulting a doctor. Overall, ''word of mouth'' ranked within the top three sources for all three conditions (27-34%), as followed by website/blogs for pregnancy and heart attack (24-29%). Acupuncturist and pharmacist ranked highly for a cold, as did hospital and books for pregnancy. TV, radio, newspaper/ magazine, email forwards, mailing lists and social media tools did not rank within the top five health information sources for the health conditions asked about in the survey.

Because our sample consisted mainly of Cantonesespeaking Chinese respondents, we performed additional analyses to identify differences in responses between these and the rest of the respondents. Most results were similar between the groups, although Cantonese speakers were more likely to identify hepatitis as a problem in the Asian community (31% vs. 17%), more likely to have seen a flyer at a doctor's office regarding hepatitis B (19% vs. 7%), less likely to have heard that they should be vaccinated against hepatitis B (5% vs. 21%), and less likely to hear about hepatitis from ads (8% vs. 25%) or news (3% vs. 17%) on television.

We also performed multivariate logistic regression to examine factors contributing to key outcomes of interest. 

Since its launch in April 2007, the San Francisco Hep B Free Campaign has focused its outreach activities to encourage the San Francisco Asian population to get tested for hepatitis B, know their infection statuses and seek treatment if they are infected. Our surveys, conducted 2 years after SFHBF began and 1 year after its first citywide media campaign, show that awareness about hepatitis B is high and that the disease is already recognized as an important health issue within the Asian community. However, our results also show that our target population still has knowledge gaps, and has a high degree of assumption that medical providers are already screening them for their infection status as a part of their routine physicals because they belong to a group at high risk for hepatitis B infection.

We used the misconceptions identified in our surveys to revise and improve the outreach messages to our target community. Similar to studies conducted in other North American cities, many of our respondents incorrectly cited clean food and water and not sharing utensils as effective prevention methods [10, 15, [24] [25] [26] [27] [28] , with less than 10%, mostly English-speakers, correctly citing protected sex, avoiding blood contact or vaccination. Upon further probing, some respondents admitted to not knowing much about hepatitis at all beyond recognizing the term. These misconceptions may stem from a possible confusion between hepatitis A and B. Hepatitis cases interviewed by SFDPH staff for surveillance purposes have reported patients thinking that the terms A, B and C denote a progression of one disease from one phase to another, as well as inconsistency in how the local Chinese media refers to hepatitis B, with some sources using the English letter ''B'' and some the Chinese character equivalent for ''B''. Questions evaluating the ''B a Hero'' posters and messaging also indicated confusion about the use of the letter ''B'' and upbeat imagery for a cancer-causing disease. We used these findings to inform a new media campaign launched in Summer 2010 (Table 6) , building on the awareness created by the ''B a Hero'' materials by While the SFHBF campaign spent the first 2 years using multiple means to mobilize the public to seek testing, our findings indicate that provider recommendation was the most influential factor for those who have sought testing. Among the of respondents who were tested for hepatitis B in the last 3 years, almost half stated that they were tested because their healthcare provider recommended it or that it was assumed to be a part of the blood panel performed during their routine physical. Similarly, the primary reason for non-test was that the respondents' healthcare provider said that they did not need to be tested. Other studies have also found provider recommendation to be the strongest influential factors for API to be tested [11, [29] [30] [31] . Respondents in general showed a high level of trust in the medical community, some explaining that they expected their providers to give them important health information, be able to correctly assess what health issues they may be at highest risk for developing, and test them for these conditions.

Surveys of clinicians in the San Francisco Bay Area indicate that while almost all knew that Asians were disproportionately affected by hepatitis B infection and liver cancer, levels of hepatitis B screening and vaccination for their Asian patients remain suboptimal [32, 33] . A 1 year follow-up study of a pilot hepatitis B screening effort of Chinese Americans in the area suggest that poor clinical follow-up for screened patients may be due to ineffective communication between patients and their providers, and the lack of awareness on the part of primary care providers about appropriate follow-up actions [34] . Together with our findings, these facts suggest that efforts to increase hepatitis B screening among Asians must both mobilize the public to request testing, as well as educate providers and institute processes that would remind them to test high-risk patients. In this next phase of the campaign, SFHBF is capitalizing on our target population's high level of trust in the medical providers by focusing on outreach to the clinician community (Table 6 ). In addition to continuation of educational events and distributing a screening algorithm developed earlier in the campaign, SFHBF is promoting a clinician's honor roll to encourage clinicians to pledge to test patients at risk for hepatitis B infections, and has created a ''Patient Ask Sheet'' that may be distributed at public venues to help individuals proactively ask their providers for hepatitis B testing and/or vaccination (Fig. 3) .

While our survey provided useful information for refining campaign strategies, it does have the following Fig. 3 Patient ''Ask Sheet''. Available at: http://www.sfhepbfree.org/patientform/ limitations. Because the campaign did not have the resources to conduct a representative-sample survey of the San Francisco Asian population, our results can only be considered an evaluation of our specific outreach program and cannot be extrapolated to all Asians living in San Francisco. Also, even though a wide array of monolingual Asians reside in San Francisco, we only had the resources to survey one monolingual group (Cantonese speakers, the largest proportion of monolingual Asians in San Francisco [6]). By recruiting for our street intercept interviews at locations frequented by Chinese residents and interviewing non-Cantonese-speaking Asians in English only, we overrepresented monolingual Cantonese speakers and may have excluded valuable feedback from non-Chinese Asians that also have high prevalence of HBV infection, such as Vietnamese, Cambodian and Korean residents. Also, while we did find a higher percentage of respondents who were familiar with hepatitis B (90%) compared to studies in similar populations in other parts of North America, (ranging from 56% to 86% [15, 26, 27, 30, [35] [36] [37] [38] ), and that almost half of our respondents reported seeing an increase in hepatitis B awareness within their community in the past year, we are unable to directly attribute these apparent increases to SFHBF due to the lack of baseline data from the period before 2007, with the most recent local data having been produced in 2000 [10] .

Our evaluation project does have some strengths. It is the first recent assessment of hepatitis B knowledge, attitudes and testing behavior among Asian residents of San Francisco. Our use of many open-ended questions and lack of initial prompting about hepatitis B as the survey's subject matter should have elicited objective feedback about how a sample of Asians in San Francisco prioritize hepatitis B in relation to other health issues in their community. We were able to use results from this project to determine where to focus upcoming campaign activities, resulting in a new and nationally-recognized media campaign with messaging that emphasizes the serious consequences of infection and a more focused strategy for clinician outreach. It is our hope that, by simultaneously driving both the Asian community to seek testing from their medical providers and the clinician community to be more vigilant in initiating testing and vaccination, SFHBF and our partner organizations can build a comprehensive and sustainable strategy to significantly decrease the burden of disease caused by hepatitis B in San Francisco.

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Acknowledgments Research support was provided by in-kind donations from San Francisco Department of Public Health and a grant from Gilead Sciences. We would like to acknowledge the Asian Liver Center for its continued leadership and support of the SF Hep B Free Campaign and evaluation efforts, the SF Hep B Free Public Awareness Evaluation Subgroup members Julia Lam, Peter Swing, Kevin Shi and Ellen Lee and the SFDPH Chronic Hepatitis Surveillance Team members Alex Leung, Karen Luk and Martina Li for feedback regarding study design, questionnaire review and translation help; Ellen T. Chang, Grace Yoo for reviewing the manuscript; and Patrick Thompson and Kevin Connors of the Henne Group for providing details on the sampling scheme.