Hepatitis B testing among Vietnamese American men

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Abstract

Vietnamese American men are over 10 times more likely to be diagnosed with liver cancer than their white counterparts. This health disparity is attributable to high rates of hepatitis B virus (HBV) infection. Our study objective was to examine factors associated with HBV testing among Vietnamese men. A population-based survey was conducted in Seattle. The questionnaire content was guided by an earlier qualitative study and the Health Behavior Framework. The survey was completed by 345 men (response rate: 80%). About one-third (34%) of the respondents reported they had not been tested for HBV. The following factors were associated (P<0.01) with previous testing in bivariate comparisons: having a regular source of care and regular provider; knowing that HBV can be spread during childbirth; believing HBV can cause liver cancer; and doctor(s) had recommended testing as well as had asked doctor(s) for testing. Three variables were independently associated with HBV testing in a logistic regression model: regular source of care (OR=4.5; 95% CI=2.6–7.9), physician recommendation (OR=2.3, 95% CI=1.3–4.0), and knowing HBV can be spread during childbirth (OR=2.1; 95% CI=1.2–3.9). Low levels of HBV testing remain a public health problem in some Vietnamese American sub-groups. Health education about HBV transmission may stimulate patients to seek testing. Intervention programs should specifically target Vietnamese men without a regular source of health care and physicians who serve Vietnamese communities.

Introduction

Vietnamese immigrants came to North America in three waves. The first wave occurred in 1975, following the fall of Saigon, while the second wave started in 1979 as political turmoil escalated in Southeast Asia. Finally, the third wave of immigrants began in 1989 when the Vietnamese government began allowing emigration under the auspices of the Orderly Departure Program and Family Reunification Program [1]. In 2000, the United States (US) Census documented 1.1 million Vietnamese Americans [2]. Because of continued immigration and high fertility rates, there will be an estimated four million Vietnamese in the US by 2030, and they will soon constitute the second largest Asian sub-group [3], [4]. Compared to the general Asian American population, Vietnamese are economically disadvantaged, linguistically isolated, and particularly unfamiliar with Western culture [5], [6].

While hepatocellular carcinoma (HCC) is an uncommon tumor among individuals born in the US, it is the most common malignancy in many Asian countries [7], [8]. About 80% of HCCs among Asian immigrants are etiologically associated with hepatitis B virus (HBV) infection [8], [9]. Male:female HCC incidence ratios are heavily biased toward men; the reasons for this gender discrepancy are not resolved, but may include a greater likelihood of developing chronic HBV infection and androgenic steroids [10]. The rate of chronic hepatitis B infection among Vietnamese Americans is over 10%, compared to the general population rate of <1% [11], [12]. Further, cancer registry data show that Vietnamese men are over 10 times more likely to be diagnosed with liver cancer than their non-Latino White counterparts, and liver cancer is the second most common malignancy in this group [13], [14].

Exposure to HBV often results in a self-limiting infection that can be asymptomatic or present as acute hepatitis, usually followed by immunity [7]. However, a significant proportion of those exposed to hepatitis B become chronically infected; these individuals continue to be potentially infectious to others and are at considerable risk of HCC as well as chronic active hepatitis and cirrhosis [7], [15], [16]. In 1986, a National Institutes of Health Clinical Conference Panel concluded that patients with chronic HBV infection should be screened (with serum testing for liver tumor markers and radiologic imaging techniques) for HCC at least once a year [7]. Additionally, chronically infected individuals should be considered for treatment with lamivudine, interferon, adefovir, liver transplantation, and new drug therapies as they become available [16], [17], [18], [19], [20], [21].

In Southeast Asian communities, there is evidence that horizontal transmission is responsible for a substantial number of new cases of hepatitis B infection among the family members of chronically infected individuals [22], [23], [24], [25]. Additionally, those who are sexually active with other Southeast Asians are at risk of infection [26]. Vaccines that are effective in preventing hepatitis B infection have been available since 1981 [26], [27], [28]. Consequently, the vaccination of young adults from areas of high HBV endemicity (e.g., Vietnam) and family members of individuals with chronic HBV infection has become part of routine clinical practice.

Liver cancer control intervention programs for Vietnamese communities should include routine HBV serologic testing to identify chronically infected individuals as well as susceptible individuals (who are at risk of infection) [16]. While there is little published information about the hepatitis B testing behavior of Vietnamese Americans, it is of note that one 1992 California study found that only 24% of Vietnamese adults had been serologically tested for HBV [29]. Our project, Cancer Control in a Vietnamese American Population, aims to collect qualitative and quantitative information about the liver cancer prevention behavior of Vietnamese men as well as design and evaluate a culturally appropriate liver cancer control outreach program. We collaborate with a coalition of Vietnamese community members which provides invaluable input on planning and implementation. As part of this project, we conducted a population-based survey in Seattle, Washington during 2002. Our goal was to obtain information about hepatitis B testing barriers and facilitators that could be used to develop intervention strategies for Vietnamese American men. In this analysis, we used our survey data to examine variables associated with previous hepatitis B testing.

Section snippets

Sampling methods

Census data indicate that Seattle’s Vietnamese community is concentrated in the southern part of the city [30]. Therefore, our survey sample was drawn from seven contiguous south Seattle zip codes. McPhee and his colleagues at the University of California have shown that over 95% of Vietnamese families share 23 last names [31]. We applied this list of names to the 2001 telephone book for metropolitan Seattle. Specifically, we identified 1639 Vietnamese households that were located in the target

Survey response

The questionnaire was completed by 345 men. The disposition of the remaining 248 addresses in the original sample was as follows: not a residential address (i.e., vacant dwelling or business) −25, eligibility not established (i.e., no contact after five attempts) −22, verified to be ineligible (i.e., household not Vietnamese or no Vietnamese man aged 18–64 years) −131, and eligible but refused −70. The overall estimated responses rate was 80% (assuming the proportion of eligible households was

Discussion

We found that rates of serological testing for hepatitis B among Vietnamese American men (66%) were considerably higher than those reported by Cambodian women (38%) in an earlier Seattle study [36]. This discrepancy may reflect the success of a recent hepatitis B education program targeting Asian Americans in the Seattle area and/or over-reporting of hepatitis B testing among Vietnamese men. However, while the overall rate of hepatitis B testing was relatively high in our study, testing rates

Acknowledgments

This study was supported by Grant CA82326 and cooperative agreement CA86322 from the National Cancer Institute. Our project works closely with a coalition from Seattle’s Vietnamese community. The authors would like to thank the community coalition and the organizations they represent. Additionally, we thank Ms. Hien Lam, our lead interviewer, and the other Vietnamese survey workers for their outstanding work.

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