Medical Care of Hepatitis B among Asian American
Populations: Perspectives from Three Provider Groups
Jessica P. Hwang, MD, MPH1, Aimee K. Roundtree, PhD1,2, Joan C. Engebretson, PhD3,
and Maria E. Suarez-Almazor, MD, PhD1
1Department General Internal Medicine, Ambulatory Treatment & Emergency Care, The University of Texas M.D. Anderson Cancer Center,
Houston, TX, USA;2University of Houston-Downtown, Houston, TX, USA;3The University of Texas School of Nursing, Houston, TX, USA.
BACKGROUND: Physicians can play a significant role
in helping to decrease the hepatitis B virus (HBV)
burden among Asian Americans. Few studies have
described knowledge and practice patterns in the
medical community among different provider types
regarding HBV and liver cancer.
OBJECTIVE: Our study explores the HBV beliefs,
attitudes and practice patterns of medical providers
serving Asian American communities.
DESIGN: We conducted three focus groups with prima-
ry care providers, liver specialists, and other providers
predominantly serving Asian American community. We
asked about practices and barriers to appropriate
medical care and outreach.
PARTICIPANTS: We moderated three focus groups with
23 participants, 18 of whom completed and returned
demographic surveys. Twelve were of Asian ethnicity
and 13 spoke English as a second language. Only eight
screened at least half of their patients, most (72%) using
the hepatitis B surface antigen test.
APPROACH: We used grounded theory methods to
analyze focus group transcripts.
RESULTS: Participants frequently discussed cultural
and financial barriers to hepatitis care. They admitted
reluctance to screen for HBV because patients might be
unwilling or unable to afford treatment. Cultural differ-
ences were discussed most by primary care providers;
best methods of outreach were discussed most by liver
specialists; and alternative medicine was discussed
most by acupuncturists and other providers.
CONCLUSIONS: More resources are needed to lower
financial barriers complicating HBV care and encourage
providing guideline-recommended screenings. Other
providers can help promote HBV screening and in-
crease community and cultural awareness.
KEY WORDS: provider attitudes; Hepatitis B; Asian Americans;
qualitative research; focus groups.
J Gen Intern Med 25(3):220–7
© Society of General Internal Medicine 2009
Hepatitis B virus (HBV) is a human carcinogen responsible for
liver carcinoma.1HBV is transmitted through percutaneous
contact with infectious blood or body fluids, such as sex with
infected partners, needle sharing, or birth to infected
mothers.2Of the estimated 1.2 to 2 million people in the US
diagnosed with chronic HBV, over half are Asian Americans.3
The prevalence of chronic HBV among foreign-born Asian
Americans is approximately 10%2, compared to 0.5% in the
overall US population and 0.2% in whites. A fourth of
individuals with untreated HBV die from liver cancer or
cirrhosis.4Since Asian Americans have the highest rates of
chronic hepatitis B among all racial and ethnic groups in the
US, they are also at disproportionately high risk of liver cancer,
which is the third leading cause of cancer death among Asian
Americans in the US, compared to 16th among whites.2,5,6
Previous research in the US has shown that lack of patient
knowledge about HBV is associated with lack of screening.7–10
In turn, lack of screening and delays in diagnosis increase
morbidity and mortality. Physicians play a significant role in
decreasing the HBV burden among Asian Americans by
improving the identification and care of persons with chronic
HBV,11promoting patient knowledge about HBV and liver
cancer, and advising patients to get screened or follow
treatment recommendations.12–16Effective patient–physician
communication can improve patients’ use of health care
services and compliance with health care directives.17–19
Problems with communication may negatively affect patients’
perceptions of illness, screening, and treatment.20,21
Little is known about HBV knowledge and practices among
different provider types. One study that targeted providers
serving Asian American communities was a retrospective
cohort study of health care providers’ knowledge and practices
regarding HBV in Chinese-speaking patients. The authors
found that many providers underestimated HBV risk.22Sur-
veys can provide quantitative accounts of practice patterns,
but more in-depth exploration is needed to uncover factors
that may impact practice. We conducted an in-depth qualita-
tive study to better understand and elucidate the beliefs,
attitudes and practice patterns of medical providers serving
Asian American communities.
After receiving approval from the institutional review board at
The University of Texas M. D. Anderson Cancer Center, we
Received April 24, 2009
Revised September 17, 2009
Accepted October 28, 2009
Published online January 5, 2010
performed a qualitative study involving focus groups with
primary care providers (internal medicine, family and general
practice), specialists (hepatologists and gastroenterologists),
and other providers (pediatricians, obstetrician/gynecologists,
other surgeons, and acupuncturists) who serve Houston’s
Chinese, Korean, and Vietnamese communities, and manage
health issues related to HBV. We included liver specialists,
acupuncturists, and physicians of gastroenterology, hepatol-
ogy internal medicine, family practice and obstetrics and
gynecology because they play a similar role in HBV-related
diagnosis, treatment and care for Asian Americans. In order to
conduct the focus group in English, we excluded non-English-
We gathered a purposive sample of physicians serving the
Asian American community, stratified into three specialty
groupings (primary care physicians, liver specialists, and other
providers). We compiled names and contact information for 41
primary care providers, 39 liver specialists, and 64 other
medical providers from community resources such as the
Asian yellow pages, advertisements in Asian newspaper clas-
sifieds, Houston Asian physician organizations, and word-of-
mouth. We sent all 144 potential participants a mailed
invitation, and then followed-up by e-mail, fax, or phone
describing our study and asking individuals to participate. All
groups were comprised of Asian and non-Asian physicians
stratified by medical specialty. Homogeneous groups encour-
age willingness among those with similar experiences to share
and are recommended in investigating complex or sensitive
motivations and issues.23Each participant was asked to
complete a demographic and clinical practice questionnaire.
Focus groups were conducted at local restaurants, and
participants received meal reimbursements up to $75.
Each focus group included five to nine participants, an
optimal number to ensure an intimate, trusting environment
and still retain significance, variety, and representativeness of
the ideas shared.23,24The moderator (J.H.) followed an inter-
view training manual created for use in qualitative research in
hepatitis among Korean American,25,26which she adapted for
medical providers. The guide was developed for focus groups of
Asian Americans, then adapted for health care providers by our
study’s principalinvestigator.Themoderatorfollowedascript of
questions (see Table 1) but allowed probes and participant
interest redirect the conversation. Focus group sessions were
conducted in English, audiotaped and transcribed. Transcripts
were validated against the recordings to ensure accuracy.
We used grounded theory methods to code the tran-
scripts,27,28an approach that allows building a theory that
fits data and encourages new insights by coding quotations for
emerging themes and building consensus between coders
about the relationships between themes. Two investigators
coded each transcript independently, and then met to compare
codes and resolve discrepancies through discussion. We
conjoined similar codes, eliminated duplicates, categorized
codes into major themes, and identified relationships and a
framework interconnecting and explaining those themes.
Transcripts were imported into NVivo® software (Melbourne,
Australia) which was used to record our consensus themes,
tally code frequencies, and code relationships. We used a
constant comparison method, by which we tested and applied
our coding categories to each new transcript.
We sought to explore the attitudes, behaviors and social
realities that inform how providers deliver HBV care to Asian
American communities. The basic social problem facing
providers was how to provide care, given cultural and
financial barriers. Providers suggested solving the problem
by trying to bridge cultural differences with translators,
community-based outreach, and CAM awareness and by
streamlining screening and care to cut expenses. We identified
eleven core themes that occurred most often when providers
were asked about clinical knowledge, barriers to care and
recommendations for outreach. (See Table 2 for theme defini-
tions.) Several common emerging themes occurred in all three
focus groups, but some differences were also observed among
Overall, providers felt that financial barriers to patients
affected how they practiced. Some demonstrated gaps in
provider knowledge that might weaken the role they play in
patient education. As well, language barriers, cultural differ-
ences, complementary and alternative medicine (CAM), and
community buy-in were important in outreach to patients.
Demographic and Practice Characteristics
Twenty-three medical providers participated in the three focus
groups, 18 of whom (all six primary care providers, seven of
nine liver specialists, and five of eight other providers)
Table 1. Core Focus Group Questions
Barriers to appropriate
What are the major medical problems of
In your patient population, what is the
prevalence of HBV among Asian Americans?
What are the barriers to medical care?
What are the best ways to reach out and
educate the Asian American community?
What future interventions would be
helpful to the Asian American community?
Describe what you and your patients do to treat HBV
What are patients’ knowledge / attitudes about HBV?
Why are Asian Americans at high risk?
Blood attitudes? Language? Transportation? Money?
Is there low interest among Asian Americans? Why?
What should we do to improve interest?
Physician network? Screening? Education? What role
can the community MD play?
Interferon, Adefovir, Lamivudine, Entacavir? How
do most patients get their medicines?
What unconventional methods have worked?
What have some of your patients done to
treat HBV themselves?
What are effective alternative and unconventional
primary treatments you have prescribed for HBV patients?
Hwang et al.: HBV Medical Care in Asian Americans
completed an optional demographic survey. Participant char-
acteristics of these 18 medical providers are summarized in
Table 3. Three quarters of those who completed the survey
were male, ages 40–65 (78%), more than two thirds were Asian
and spoke English as a second language and the majority had
graduated from medical training programs outside the US.
Four liver specialists reported screening 75% or more of their
patients for HBV; three primary care providers, 50% to 75%;
and four other providers, 25%. Most of the providers used the
hepatitis B surface antigen test (HBsAg), either alone or in
combination with other tests, to screen patients for HBV and
served patient populations who were up to 50% Asian. Two out
of three reported that only a quarter of their patients had
health insurance, and a similar proportion stated that they
used translators as needed during office visits with Asian
American patients. Houston’s Asian American population is
49.7% male and 74.9% adult (ages 18 and over). The median
household income is approximately $66,414 and about 10%
fell below the poverty line.29
Our findings below reflect responses from all 23 focus group
participants, including 5 who did not complete demographic
When asked to describe HBV treatment, providers responded
that financial impediments deterred treatment and screening,
and they acknowledged that patients lacked linkage to care—
e.g., limiting health options for HBV-positive patients—which
discouraged patients and providers from screening. Partici-
pants admitted being somewhat reluctant to diagnose HBV
because of anticipated problems with the affordability of care.
Knowing that patients might not seek care discouraged
providers from screening. Several responses compared the
expensiveness of Western medicine to the accessibility and
inexpensiveness of complementary and alternative medicine
“[T]hey’re coming to us to have screening. But the
problem is after screening, if they’re positive for
[HBsAg], they do not have the money or support for
process for diagnosis or treatment.”
“[CAM is] ready for them to use and cheap.”
The cost of care influenced decisions regarding whom to
immunize and screen and how to do it. Providers made
attempts to streamline screening to make the process faster
and more affordable, although cutting corners could ultimately
miss patients who were positive for antibody to hepatitis B core
antigen, but negative for HBsAg. Some used other cost-
minimizing screening strategies.
“[I]f you do the three tests, it doesn’t make…sense…I’m
antibody. Ifyou are negative, you don’t havetoworry. You
“[I]f you order the panel—that is cheaper than if you
have to order labs separately. If you use HBsAg [alone],
that costs more than the panel with A, B, and C.”
Discussions revealed both accuracies and limitations of provider
knowledge. Most physicians accurately described the biological
mechanisms of HBV transmission—i.e., through exchange of
bodily fluids, vertical transmission from mother to child, and
“[T]hey [are] spreading inadvertently—people going to
nail salons, get their nails filed all the time. My wife used
to go and her fingers were always bleeding.”
Some providers had incorrect information about HBV
transmission in the Asian population, attributing its spread
to cultural dietary practices and poor hygiene.
“Because Korean custom is we eat together like when
you drink wine and we made soup, if bowl soup, we eat
together. We don’t separate.”
Participants felt confident about the efficacy of treatments
for HBV, but many believed that the Asian American commu-
nity did not share their confidence.
“[A]fter the treatment stops, [they fear] that the [disease]
will return. ... They don’t trust the [treatment].”
Language Barriers and Cultural Differences
Across groups, language and cultural differences were men-
tioned as barriers to the role providers played in education and
outreach. Even though most participants used language
translators in their clinical practice (67%), and for many an
Asian language was their native tongue (51%), language
differences still prevented optimal HBV screening and optimal
education about important aspects of HBV care. Failure to
Table 2. Definitions of Emerging Themes, in Alphabetical Order
Community buy-inSuggesting venues, community
involvement, and other recommendations
for promoting awareness
Describing uses of and knowledge
and attitudes about complementary
and alternative medicine
Sharing an awareness of cultural habits,
values and statistics related to HBV
Describing problems affording HBV
care and insurance
Describing language differences
and translation problems
Understanding the risks and causes
of liver cancer
Sharing strategies for and attitudes
Sharing knowledge about HBV prevalence,
referrals, and the provider’s role in
awareness and education
Linking to liver cancer
Hwang et al.: HBV Medical Care in Asian Americans
translate medical directives and jargon discouraged follow-up,
and providers feared this would widen information gaps and
increase prevalence of HBV.
“You can tell even [when you’re explaining it] in
Vietnamese…; they still don’t understand that point. I
can stand there…hours talking about hepatitis. They
[come] out of the room and they tell my secretary ‘What
did [the doctor] talk about?’”
“We try to get them to understand the basis of their
disease and half the time it works very well and half the
time it doesn’t. I can tell you people have left my clinic
and never come back.”
Table 3. Demographics of Study Participants
No. (%) of Participants
Completed US Residency?
Graduate of US medical school?
% of patients who are Asian American
% of patients with insurance
Use translator as needed during visits with Asian American patients
HBV screening testsa
% of patients screened for HBV
5 (83)6 (86)3 (60) 14 (78)
6 (100)6 (86) 3 (60)15 (83)
1 (17) 3 (43)3 (60) 7 (39)
aHBsAg, hepatitis B surface antigen; anti-HBe, antibody to hepatitis B early antigen; anti-HBc, antibody to hepatitis B core antigen
Hwang et al.: HBV Medical Care in Asian Americans
Language and cultural barriers discouraged non-Asian
physicians from providing HBV outreach to the Asian Ameri-
can community and prioritized the role of the Asian physician
essential as educator and advocate.
“[T]here’s a certain resistance to seeing non-Asian physi-
cians, especially for people born in Asian countries, and
as a physician, I don’t know what we can do about that.
We’ve actually…hire[d] an Asian physician, thinking they
would be a better reach into a community that may not
very open to coming to a non-Asian center.”
Complementary and Alternative Medicine (CAM)
Providers had mixed attitudes about the virtues of CAM, which
includes medications and practices not generally taught in
Western biomedical education. Physicians were hesitant about
CAM, in particular, ingested substances. Providers worried
that CAM might interfere with Western medicine.
“Some of the [CAM] people take is extremely poor, not
very well made…Every year we see a couple of people
with [liver or kidney] failure…because they taking some
herb that someone told them it’s good for them.”
“Most of our protocols have involved research of [the]
liver…most of them will prohibit botanicals and alter-
native complementary medicine.”
Despite admitted reservations, participants understood the
importance of CAM in providing medical care to the Asian
American community. Other providers shared CAM treatments
they had either prescribed or considered prescribing to their
patients, including acupuncture, vitamins, energy medicine,
and herbs. They also discussed using CAM as a complemen-
tary treatment to be used alongside Western medicine. Liver
specialists saw CAM as an opportunity to demonstrate mutual
respect for different medical traditions. In turn, they thought
negative attitudes about CAM might be misconstrued by
patients as cultural insensitivity.
“[I]n the same way I don’t disrespect them, I’m asking
them not to disrespect the things I’ve been trained so
that we continue in parallel.”
“You can read the protocols and most of them will
prohibit botanicals and alternative complementary
medicine. You know, and that may be a mistake because
road blocks saying I reject where you’re coming from,
therefore you’re rejecting them from their very entry,
how can you expect to bridge a line with them?”
Participants shared what they perceived were their patients’
attitudes about CAM. Primary care physicians acknowledged its
as a safe alternative to Western medicine. Patients were known to
use CAM, but kept this information from their physicians.
“I think like most of the Asian population who believe in
herbal medicine, and they believe herbal medicine is a
non-chemical kind of treatment, therefore there will be no
side effects, they don’t know that those that take herbal
medicine can get liver pain but they don’t know”.
“[M]ost people will not admit to me that they’re using
Participants recommended particular outreach methods—e.g.,
community buy-in (or targeting community through cultural-
ly-specific organizations and venues such as Buddhist temples
and Asian-language newspapers). Providers stressed the im-
portance of developing culturally sensitive messages for cul-
turally specific media outlets. Many suggested modeling Asian
American outreach campaigns on best practices employed for
other ethnic groups and cities and for other public health
initiatives. Community centers, churches and temples, com-
munity organizations, and Asian-language newspapers, TV
stations, and radio stations were the most often recommended
“I think that if we want to reach these patients, we
should try to identify positions that are close to the
Primary care providers. The theme most often discussed by
primary care providers was cultural differences that complicated
care and outreach. In particular, participants feared that Asian
American communities underestimated the disease and its
prevalence. “I feel that even in Chinese American population, the
appreciation is…they know hepatitis B is no good, but they really,
not quite realize how serious that is.”
Liver specialists. The theme most often discussed by liver
specialists was outreach methods. Participants were
interested in lowering barriers, offering incentives, and
exploiting pre-existing fixtures of the community to increase
community buy-in regarding screening, treatment, and
prevention. “If we want to reach these patients, we should try
to identify positions that are close to the community.”
Other medical providers. The theme most often discussed by
other medical providers was CAM. Overall, the group clarified
how and why they used CAM—namely, (1) for very specific
physical effects (“I can say main function of acupuncture is [to]
dilate blood vessel…circulation of oxygen…to cells. So one of [its
uses] is [for] blood clots.”), (2) as a complement to Western
medicine for treating side effects (“If someone said, ‘I was
nauseated and acupuncture made me feel better,’ I’m not going
to argue with them. I’m going to say, ‘Great! If it makes you feel
better, that’s fine.’”), and (3) for alleviating fatigue (“For
hepatitis and AIDS, like that, for some immune system low
patients, I give them some energy medicine or something like
that.”). Screening concerns were among the three most
Hwang et al.: HBV Medical Care in Asian Americans
frequently discussed issues among primary care providers and
liver specialists, but not among other providers.
Our study revealed factors that influenced HBV screening and
treatment practices: financial barriers, provider knowledge,
language barriers, cultural differences, CAM, and community
buy-in (Figure 1).
Financial concerns not only hinder patients from seeking
and sustaining care, but also drive physician behavior.
Patients’ lack of resources influenced physicians’ approaches
to HBV screening and management. Whether patients can
afford care often influenced the types of serologic tests that
physicians ordered, despite guidelines which recommend that
all persons born in regions with high or intermediate endemic-
ity be screened for HBV.30–35Furthermore, providers felt
conflicted about diagnosing patients who could not afford
follow-up treatment. Other studies have found variance in
how practitioners handle HBV prevention and treatment.36–39
Our study revealed financial domains of influence. If this
finding were to be replicated in a larger, nationally represen-
tative sample of providers, it could help policymakers and
insurance providers find better ways to encourage guideline-
recommended services to high-risk groups.
We also found that provider knowledge may be an obstacle
to appropriate care. While primary care providers and other
medical professionals accurately explained the general etiology
of HBV, some did not accurately explain disease transmission
among Asian Americans. Other studies have reported gaps in
physician knowledge about the natural history, risk factors,
and test results for hepatitis.22,40Our study identified disease
transmission as a new area in which there is an information
gap. Patients’ understanding of transmission and disease
treatment has been found to deviate from clinical knowledge
and recommendations.22,41–44Continuing medical education
(CME) for providers in HBV transmission might serve to bridge
Our findings suggest that providers perceived cultural
differences between themselves and patients as affecting
patient education, outreach and patients' healthcare deci-
sions. We found that, even in instances where providers and
patients shared racial or ethnic concordance, it was difficult to
translate complicated medical terms and directives. Other
studies have found that providers misunderstand Asian
community conceptions of illness, prevention, and pain.45
Race and ethnic concordance between provider and patient
have been associated with providers' willingness to screen for
HBV, patients’ perceptions of physician bedside manner, and
patients' willingness to comply with health-care directives.46–48
However, there are other means by which physicians can
demonstrate respect or trust without requiring race or ethnic
concordance, including increasing familiarity with patients
and understanding their cultural values and beliefs.49,50
Finally, CAM presented itself as a topic that physicians
leveraged to demonstrate cultural sensitivity. Physicians’ and
patients’ attitudes about CAM reflected cultural differences
that affected care. Physicians saw potential for CAM as
complementary to Western medicine, but they feared that
patients’ use of CAM—and patients’ suspicions that Western
medicine providers distrust CAM—might increase HBV mor-
bidity by discouraging and delaying Western medical treat-
ments. Increasing awareness on the part of physicians about
the acceptable uses of CAM might serve as a means to help
bridge cultural differences between patients and providers.
Our findings show that, while providers might not have
approved of their patients relying solely on CAM, they have a
growing understanding of CAM as a complement to Western
treatment and as a means to bridge cultural differences. These
findings are in agreement with studies suggesting that, though
Western medicine practitioners may be unfamiliar with the
specifics of CAM, they are increasingly accepting of it.51–55Our
findings are also in agreement with studies showing that CAM
and traditional medicine providers are interested in collabo-
rating on outreach and research.56,57Acupuncturists and
other medical provider groups should be encouraged to work
in concert with liver specialists and primary care physicians to
encourage screening. Furthermore, since prevention was
mentioned less frequently by liver specialists and primary care
physicians, these providers should be enlisted to encourage
Variations in major themes by clinician group type reflected
each group's natural concerns. The other medical provider
groups felt compelled to explain their practice of CAM. Liver
specialists felt it important to find more effective ways to
increase HBV awareness, and primary care physicians—who
may see patients most often—frequently discussed how cul-
tural differences affected provider-patient communication and
Physician demographics may have affected response out-
comes. Most of our participants were male, and while most
completed US residencies, fewer than half of the primary care
physicians and liver specialists graduated from US medical
schools. The other medical providers were younger than the
liver specialists and primary care physicians. Studies suggest
that how long a provider has been in practice and whether a
provider is male or female can influence quality of care,
provider–patient communication, and provider attitudes about
CAM.58–60Where providers obtained their medical training
may also play a role.61,62However, qualitative studies are local
and include small sample sizes; therefore we cannot generalize
Our findings also give a glimpse into participants’ levels of
cultural competency, or providers’ sensitivity to cultural health
Figure 1. Conceptual model of factors affecting provider practices
regarding HBV screening and treatment.
Hwang et al.: HBV Medical Care in Asian Americans
beliefs, commitment to hiring a diverse staff and providing
language assistance services and document translation, and
awareness of patients as individuals capable of making their
own healthcare decisions rather than as stereotypes.5,63By
these standards, our participants demonstrated cultural com-
petency, insofar as they suggested solutions to language
barriers, respected CAM as an integral part of Asian American
culture and a means by which patients’ attempted to be
proactive about their healthcare, and recommended recruiting
more physicians and advocates from within the Asian Ameri-
We were surprised that women’s health and health practices
did not emerge as a code category, particularly since women
are often both a vector of transmission and an influential
figure in the Asian American community. Adding homoge-
neous focus groups of pediatricians and OB/GYNs might have
lent more data in this regard, given that these two groups
provide perinatal and post-partum neonatal care—two impor-
tant entry points in HBV care. Finally, liver cancer and HBV
did not thrive as a code category, possibly because physicians
were of the opinion that eradicating HBV to prevent liver
cancer might not be directly applicable over a heterogeneous
cohort of Asian American patients.
Our study was qualitative and not designed to produce
generalizable findings. Nevertheless the insights uncovered
here may have some applicability to other populations and
settings. Having conducted more focus groups might have
yielded more discussion of emerging themes. Typically, con-
ducting at least two groups per variable of interest is recom-
mended to ensure theme saturation.23Our focus groups
represented a variety of perspectives. the constant comparison
method used to analyze all three transcripts ensured internal
validity.24Although this study addressed clinicians’ perspec-
tives, we recognize that patient perspectives are also important
in obtaining a more complete understanding of HBV outreach
and barriers to care.
Our results suggest implications for outreach strategies for
all providers. Liver specialists and primary care providers
could play more of a key role in promoting prevention;
acupuncturists and others beyond liver specialists and prima-
ry care providers could play more of a key role in promoting
screening and treatment. Other practitioners do not provide
usual HBV care, but they do provide services such as prenatal,
postnatal, and CAM care for Asian American patients — all
important medical points of contact.
Future studies should explore the prevalence and effects of
these themes in the medical community at large. Providers
mentioned nail salons, Asian grocers, and other fixtures of the
Asian American business community. Future research might
survey or interview small business owners about their knowl-
edge, beliefs and attitudes regarding HBV and prevention.
More collaboration between Eastern and Western medicine
practitioners are needed, as are more initiatives and resources
to help make screening and treatment available to underin-
sured and underserved patients. Future studies should also
investigate factors affecting care provided by nurses, physician
assistants and ancillary providers who play an important and
unique role in HBV care. We believe that CME for providers of
care to high risk groups about liver cancer, CAM, and HBV
transmission, could also help increase HBV awareness among
providers and patients alike. More resources are needed to
lower financial barriers to care and encourage guideline-
recommended screening. Other providers can help promote
Acknowledgements: The authors acknowledge Jing Peng for
coordinating the focus groups and data entry; Mahfam Mohseni,
Cheryl Rogers and Roz Bryant for assisting in coding transcripts;
and Stephanie Deming for providing editorial assistance. Drs.
Roundtree and Suarez-Almazor are investigators at the Houston
Centers for Education and Research on Therapeutics, which
receives core support from the Agency for Healthcare Research and
Quality (5 U18 HS016093). The research reported in this manuscript
was supported by a grant from Gilead, Inc.
Conflict of Interest: None disclosed.
Corresponding Author: Jessica P. Hwang, MD, MPH; Department
General Internal Medicine, Ambulatory Treatment & Emergency
Care, The University of Texas M.D. Anderson Cancer Center,
1515 Holcombe Blvd., Box 1465, Houston, TX 77030, USA
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