Public Health Model for Prevention of Liver Cancer
Among Asian Americans
Hee-Soon Juon Æ Æ Carol Strong Æ Æ Thomas H. Oh Æ Æ Theresa Castillo Æ Æ
Grace Tsai Æ Æ Leslie D. Hsu Oh
? Springer Science+Business Media, LLC 2008
account for over half of the 1.3 million chronic hepatitis B
cases and for over half of the deaths resulting from chronic
hepatitis B infection in United States. There are very few
studies published about hepatitis B virus (HBV) data in the
Baltimore–Washington metropolitan area. In 2003, the
Hepatitis B Initiative-DC (HBI-DC) worked closely with a
large Korean church, located in Vienna, Virginia. Their
partnership included a pilot-test of a faith-based HBV
program, which educates, screens and vaccinates for the
HBV. This pilot program was later expanded to include a
total of nine Korean and Chinese American churches in this
region, plus a Pastor’s Conference targeting Asian Amer-
ican pastors from around the United States. During 2003–
2006, a total of 1,775 persons were tested for HBV
infection through the HBI-DC program. Of all the partic-
ipants, 2% (n = 35) were tested HBV positive (HbsAg+,
HbsAb-), 37% (n = 651) were HBV negative but pro-
tected (HbsAg-, HbsAb+), and 61% (n = 1089) were
unprotected (HbsAg-, HbsAb-). Most of these unpro-
tected individuals (n = 924) received the first vaccination.
The proportion of the second vaccination was 88.8%
(n = 824). About 79% completed 3-shot vaccine series.
Our study contributes to the literature by providing an
overview of the hepatitis B unprotected rate among Asian
American adults. It indicates that culturally integrated liver
Asian Americans and Pacific Islanders (AAPIs)
cancer prevention program will reduce cancer health dis-
parities in high risk immigrant populations.
Asian Americans ? Health education ? Vaccination ?
Hepatitis B virus screening ?
death in men, although uncommon in North America and
cancer in most of Asia, the Pacific, and sub-Saharan Africa
. In the United States, about 80% of liver cancer is etio-
logically associated with hepatitis B virus (HBV) infection.
Asian Americans and Pacific Islanders (AAPIs) account for
over half of the 1.3 million chronic hepatitis B cases and for
[1, 2]. These numbers are high considering that AAPIs are
only about 4.6% of the U.S. population . In 1999, AAPIs
were 6 to 13 times more likely to die from HCC than Cau-
casians, with Vietnamese Americans at 13 times higher risk,
Korean Americans at eight times, and Chinese Americans at
six times [1, 2]. Hepatitis B infection can be prevented by
effective screening and vaccination programs. Thus, there is
a great need among Asian minority groups for sustainable
vaccination programs in order to decrease their risk of get-
ting HCC . This excess risk can be attributed to high rates
of HBV infection (particularly among first generation
immigrants) combined with low levels of hepatitis B vac-
cination coverage due to cultural, linguistic, or financial
In recent studies, researchers reported the prevalence of
HBV infection among Asian Americans. For example, in
H.-S. Juon (&) ? C. Strong
Department of Health, Behavior & Society, Johns Hopkins
Bloomberg School of Public Health, 624 N. Broadway,
704, Baltimore, MD 21205, USA
T. H. Oh ? T. Castillo ? G. Tsai ? L. D. H. Oh
The Hepatitis B Initiative-DC, P.O. Box 53447, Washington,
DC 20009-3447, USA
J Community Health
New York City data, a total of 1,836 were tested for HBV
infection with a majority of Chinese (61.2%) and Korean
(30.3%) participants; 56.6% of participants had never been
tested for HBV before the study. Among the 925 newly
screened participants, 14.8% had chronic HBV infection,
53.6% were protected, and 31.6% were susceptible to HBV
infection . Of the 116 Korean and Vietnamese Ameri-
cans recruited in the free hepatitis B screening program in
the Rocky Mountain area, 4.3% tested positive for serum
hepatitis B surface antigen and 60% were positive for
serum hepatitis B antibody . These studies indicated
that the prevalence of HBV infection among Asian
Americans varied from 4 to 15%.
The northeastern and northwestern parts of the United
States have published their survey results of HBV screen-
ing rates among Asian populations [11–13]. In a study of
256 Vietnamese Americans with low socioeconomic status
in the Philadelphia and New Jersey areas, only 7.5% had
been tested for HBV and 6.3% had been vaccinated . A
study in Seattle, Washington showed a trend: about a third
to half of the sample had been tested for HBV (38–66%)
among Cambodian and Vietnamese Americans [6, 12–14].
Very few articles have been published about HBV data in
the Baltimore–Washington metro area, although we
expected that it would be a similar rate as other areas in the
In the Baltimore–Washington metro area, the Korean,
Vietnamese and Chinese Americans communities are
among the top four ethnicities comprising the metropolitan
area’s 8% AAPI population . The Hepatitis B Initia-
tive, based on their experiences in Boston , and at the
request of the National Taskforce on Hepatitis B: Focus on
AAPIs, established a Washington, D.C. (HBI-DC) affiliate
in 2002 to reduce health disparities. HBI-DC is the first
hepatitis B organization in the D.C. area to mobilize Asian
American, faith-based communities to adopt hepatitis B
prevention campaigns through church ministries. HBI-DC
serves the metropolitan area by (1) developing culturally
and linguistically appropriate hepatitis B outreach materi-
als, (2) forming collaborative partnerships and resources,
and (3) providing technical assistance for community-
based hepatitis B prevention campaigns. HBI-DC has
reached a large number of Asian Americans successfully,
providing access to free HBV screenings and vaccinations.
CDC and Task Force members recommended that HBI-
DC focus on Korean Americans who are a difficult group
to reach. Korean Americans are the most likely to be
uninsured among AAPIs, and 34.4% of Korean Americans
had no health insurance compared to 13.5% for the entire
U.S. population . About 6.5% of Korean Americans
reside in the Baltimore–Washington metropolitan area,
where Korean Americans are the third largest group of
Asian Americans . Historically, the Korean church is a
focal point for the Korean community. It not only offers
health and social services but plays a large role in pre-
serving, fostering, and shaping Korean American culture
. About 50–75% of Korean Americans attend church
[19, 20]. Therefore, faith-based hepatitis B outreach would
benefit a majority of Korean Americans in the United
Thus, in 2003–2004, HBI-DC, in partnership with the
largest Korean American church in the metro DC area
launched a pilot HBV program. This pilot program tested
HBI-DC’s model which included: (1) needs assessment (2)
hepatitis B education through community empowerment
and participatory learning development , (3) screening
and vaccination events, and (4) evaluation. The success of
HBI-DC’s pilot program created a demand for technical
assistance both locally and nationally. Many community
leaders and organizations modeled HBI-DC’s program.
Eight Korean churches and one Chinese church shared
their data with HBI-DC. HBI-DC’s program not only
demonstrates how urgently those individuals who did not
benefit from the hepatitis B vaccination law require access
to vaccines, but also the enormous cost savings for the
medical system. It is estimated that medical and work loss
costs for HBV-related conditions total $300 million in
direct costs and $700 million in indirect costs per year in
the United States .
The purpose of our study is to examine the prevalence of
HBV infection and unprotected rate of HBV among Asian
Americans living in these areas. Data used for this analysis
include eight Korean faith-based organizations, one Chi-
nese faith-based organization, and one national Korean
American Pastors’ Conference.
Recruitment of Churches
In 2003, HBI-DC worked closely with two Korean chur-
ches, in Virginia, to develop and pilot a faith-based
hepatitis B program. Initially, the success of this program
was shared through social support networks, via word-of-
mouth. By 2004, a total of four Korean churches approa-
ched HBI-DC for technical assistance, in partnership with
local community health programs.
The HBI-DC generated additional community support
by publishing articles in local Asian ethnic media and by
holding educational sessions for key AAPI community
leaders. Two prominent luncheons were held to raise
hepatitis B awareness among local Chinese community and
Korean faith-based leaders. HBI-DC encouraged partici-
pants to self-identify their congregation’s interest in
implementing HBI-DC’s prevention model. The criteria for
J Community Health
choosing partner churches were: (1) a commitment from
the church leadership to support the campaign and (2) a
designated clinical and administrative coordinator to
manage the campaign. Following the luncheons, three
churches qualified and began HBI-DC’s training program
in summer 2005.
Development of Culturally Integrated Educational
Researchers have emphasized the importance of devel-
oping HBV testing and vaccination programs that are
culturally and language relevant [16, 23–25]. Some ele-
ments in Asian culture may shed light on how to
develop culturally integrated educational material to
increase liver cancer awareness. Since 1997, the Hepa-
titis B Initiative, both in Boston and D.C., has worked
closely with members of the Asian American community
in various ways: (1) participatory learning programs, (2)
focus groups, (3) educational seminars and, (4) volunteer
surveys and questionnaires. Through these varied public
health-based programs, HBI-DC has been able to eluci-
date some surprising cultural myths, such as: Chinese
American focus group participants believe that they can
contract hepatitis B from shared chopsticks or from
infected restaurant workers
2005). This validates other cultural myths found in the
literature: Chinese immigrants do not consider vaccina-
tion to be a major means for hepatitis B prevention, and
perceive that a healthy lifestyle will help to improve
one’s natural body defenses .
HBI-DC found out by working closely with the Korean
American community that they firmly believed that exist-
ing booklets targeting Asian American communities did
not pertain to them. In one particular instance, they thought
the artwork ‘‘looked too Chinese’’ and, thus, ‘‘the brochure
doesn’t apply to Koreans’’ (Focus group 2003). In addition,
the brochures in English are often separated from their in-
language counterparts. Due to these complaints, HBI-DC
facilitated participatory learning focus groups where the
community created their own bi-lingual Korean/English
HBV booklet. Unlike other booklets which are translated
and then back-translated to English, separate focus groups
were conducted in Korean and in English so that each part
of the brochure was written in the language of the target
population. It was these valuable insights provided by the
community that created culturally relevant materials for the
Asian American communities with which HBI-DC part-
nered. It is very important to integrate traditional beliefs of
Asian Americans in order to develop a culturally tailored
hepatitis B educational program which may be helpful to
increase liver cancer awareness among high-risk immigrant
populations [25, 26].
HBI-DC Training Process
Three HBI-DC training sessions were given by staff
members to the volunteer coordinators of each church. The
training sessions were held once a month and lasted
approximately 3 h. Two volunteer coordinators—a clinical
and an administrative coordinator—from each of the three
churches attended these training sessions. The first training
session focused on education and raising awareness of
hepatitis B in an Asian American faith-based community.
Volunteer coordinators were provided with a draft of HBI-
DC’s guidebook which includes educational materials
designed through participatory learning development and
reviewed by national experts, such as the HBI-DC’s
bilingual booklets (the first English–Korean booklet pro-
duced for hepatitis B), hepatitis B awareness slides, and
DVDs (one for leaders and one for congregation members).
The guidebook also provides step-by-step instructions on
how to set-up education, screening, and vaccination pro-
grams, as well as forms like volunteer pre and post-test
questionnaires, participant registration, waiver, supply lists,
how to store vaccines, and instructions for volunteers.
The main goal of the first training session was to educate
the coordinators about the importance of raising awareness
of the dangers of hepatitis B in their communities. Vol-
unteer questionnaires with identical questions were passed
out before the session and after the session to evaluate
basic knowledge about hepatitis B. The second training
session focused on the nuts-and-bolts of coordinating a
screening event at their churches. Partner organizations
spoke about the potential problems volunteer coordinators
may encounter when scheduling a screening event. Clinical
coordinators were trained on which local lab companies
would be able to provide phlebotomists and screening
supplies. The third and final training session focused on the
specifics of organizing a vaccination event and the chal-
lenges of following through with a 3-shot series of the
hepatitis B vaccine. Another purpose of these training
sessions was to evaluate the guidebook and gather feed-
back on how to improve it. The prototype guidebook was
also shared nationally at the Pastor’s Conference and an
online version was made available for pastors to review
and provide comments.
Recruitment of Screening and Vaccination Participants
Partner churches recruited participants using the educa-
tional tools provided in the HBI-DC guidebook. These
educational tools included a DVD for leaders, DVD for
congregations, bilingual booklets and testimonials from
families affected by hepatitis B. Using HBI-DC’s suggested
timeline, churches scheduled screening and vaccinations
events in the autumn through spring to minimize attrition.
J Community Health
A main strategy for recruitment was engaging commu-
nity leaders to emphasize the importance of hepatitis B
screenings and vaccinations during church or community
meetings. Churches reported better attendance at screening
and vaccination events when pastors incorporated hepati-
tis B into their sermons and announcements at various
meetings. One church founded a Hepatitis B Ministry and
integrated HBI-DC programs into volunteer fairs, small
group meetings and newsletters. Since churches in the
AAPI community are often divided into the English Min-
istry and the non-English Ministry, partner churches
focused campaigns on the English Ministry first. English
Ministries provided outreach to the non-English Ministries,
and assisted them with their hepatitis B programs. To
ensure participants completed the 3-shot vaccination series,
churches relied heavily on the administrative coordinator to
follow up with individuals after Sunday services and at
home before an upcoming vaccination event.
In 2006, HBI-DC’s faith-based hepatitis B model was
shared with Asian American pastors from around the
nation, convening for an annual conference in Washington,
D.C. HBI-DC provided an educational seminar with
materials the pastors could take back to their congregations
and offered hepatitis B screenings during their free time, of
which 67 pastors out of 100 opted to get screened.
HBI-DC provided partner communities an English and
Korean participant registration form and an Access data-
base tool to collect basic measures: dates of intervention,
demographic data (including country of birth and primary
language), and how participants heard about the program.
During 2003 to 2006, a total of 1,775 persons were tested
for HBV infection through HBI-DC. Unfortunately, not all
nine of the churches were able to yield a complete data set.
Thus, a total of 1,382 persons provided the completed
Blood samples were drawn for each individual’s screening
test to detect the presence of hepatitis B antibodies or
antigens. Hepatitis B surface antigen (HbsAg) marks
infectivity of hepatitis B and a positive result represents
HBV infection. For negative results, the screening exam
needs to be combined with hepatitis B surface antibody
(HbsAb) to determine if an individual needs to be vacci-
nated or not. A result of HbsAg negative and HbsAb
positive indicates an immune response to HBV infection
and no need for further vaccination. People who are
unprotected and need to be vaccinated are those with a
blood test result of negative in both HbsAg and HbsAb.
Hepatitis B Screening
Table 1 shows the HBV screening program from all ten
sites of the Baltimore–Washington metropolitan area dur-
ing the 2003–2006 period. There were 1,775 participants
screened for HBV. Of all the participants, 2% (n = 35)
were tested HBV positive (HbsAG+, HbsAb-), 37%
(n = 651) were HBV negative but protected (HbsAg-,
HbsAb+),and61%(n = 1089)
(HbsAg-, HbsAb-), meaning that they have never been
exposed to hepatitis B and would be protected for life from
hepatitis B through vaccination.
Hepatitis B Vaccination
Of nine community-based organizations (CBOs) and a
pastor conference, three institutions were not included in
this analysis due to no vaccination program or incomplete
vaccination data. Table 2 shows three series of vaccinations
among 984 unprotected participants. Most unprotected
participants (n = 924) received the first vaccination. The
proportion of the second vaccination was 88.8% (n = 824).
About 79% completed the 3-shot vaccine series.
Among 1,382 participants (two CBOs did not provide
informationon demographic information), onefifth (21.4%)
of those in the 40–49 years of age group participated in
screening followed by age group 30–39 (17.9%) and age
group 20–29 (16.6%); about half were males; about 82%
were born in Korea and 8.5% were U.S. born (Table 3).
Table 1 Results for HBV screening, Baltimore–Washington metropolitan area, 2003–2006
Place No. of
Korean faith-based organizations8 33 1,030605 1,668
Chinese faith-based organizations11192040
English Ministry Pastors’ Conference113927 67
Total1035 (2.0%)1,089 (61.3%)651 (36.7%)1,775
* CBOs, Community based organizations
J Community Health
Figure 1 shows how the participants heard about the HBV
screening and vaccination programs. About one third of par-
ticipants (33.3%) heard about the upcoming HBV screening
and vaccination program from their own church newsletter;
were another important source of information (9.3%).
This study is the largest community-based hepatitis B
screening and vaccination program for Asian Americans in
the Baltimore–Washington metropolitan area. HBI has been
providing HBV screening, education, and vaccination pro-
grams since 1997. In Boston, participants are recruited to
health clinics for hepatitis B services. In the Baltimore–
Washington metropolitan area, participants are recruited at
services to locations that community’s gather resulted in
providing service to approximately the same amount of
people in 3 years, compared to HBI-Boston’s method of
recruiting communities to a clinic in 10 years. Therefore,
HBI-DC proved that bringing health care services to loca-
Less than 10% of the study participants were under
19 years of age. HBI-DC did not want to duplicate existing
school vaccination programs. A large amount of effort for
hepatitis B immunization has already focused on Asian
American children [27–31]. However, hepatitis B trends
among adult Asian Americans, especially immigrants, are
still understudied. Our study contributes to the literature by
providing an overview of the hepatitis B unprotected rate
among adult Asian Americans, largely Korean immigrants,
in the Baltimore–Washington metro area.
Table 2 Results for HBV vaccination among unprotected participants (n = 986), 2003–2006
Unprotected Vaccine 1 Vaccine 2Vaccine 3
Korean faith-based organizationsA 680680598 507
B 129 129127 122
C 2423 2120
D 53 5351 51
E 23 21 1813
Chinese faith-based organizationsF 1918 18 16
Total6 928 924 (99.6%) 824 (88.8%) 729 (78.6%)
Note: Three organizations were not included in this analysis due to no vaccination program or no available data
Table 3 Sample characteristics (n = 1382)
50–59 205 14.8
70+ years 423.0
Country of birth
Note: Two organizations were not included in this analysis due to no
Fig. 1 How participants heard about the program. Note: Two organiza-
tionswerenotincludedinthisanalysisduetonoavailabledata(n = 1382)
J Community Health
Three-fifths (61.3%) of our participants tested HbsAg
and HbsAb negative, which means that they have never
been exposed to hepatitis B. HBI-DC was able to protect
these participants who received the hepatitis B vaccine for
life, thereby also protecting them from liver cancer. Most of
these participants had no other means of receiving the
hepatitis B vaccination except through our program.
Members of the Hepatitis B Taskforce agree that our results
are significant. This number is much higher than the New
York data, which reports an HBV infection susceptibility
rate of 32% . The results demonstrate the importance of
advocating for universal hepatitis B immunization as sug-
gested by the National Viral Hepatitis Roundtable Strategic
Plan, Eliminating hepatitis: a call to action . In addition,
the results support the Congressional Asian Pacific Amer-
ican Caucus recommendations for hepatitis B vaccinations
for all high-risk populations, including AAPIs.
HBI-DC has provided significant data to support policy-
immunization. Programs like HBI-DC’s free hepatitis B
screenings and vaccinations are hard to maintain without
funding. And yet, in many communities HBI and programs
In the future, HBI-DC would like to determine why
church attendees did not attend our programs. Perhaps,
people who are certain that they had been immunized or
already know that they are hepatitis B carriers did not
attend the program. This probably also accounts for the
comparably lower percentage of HBV chronic carriers. We
do not know whether the 2% chronic carriers in our sample
were aware of their hepatitis B status prior to the program.
Another main limitation of this study is that we were not
able to collect data from three out of nine study organi-
zations. This was due to partners being primarily interested
in providing religious services and not data collection. Data
reporting was volunteer rather than mandatory. Volunteers
who handled registration did not always ensure that all
fields were completed on the registration form. Sometimes
a participant would use a different name each time he or
she registered. Participants cited that lack of time and
adequate computer-knowledgeable volunteers were also
contributing barriers. There is also a lack of computer-
knowledge among volunteers and lack of time for screen-
ing administrators to finish recording data while assessing
the tests. HBI-DC intended to implement an online data-
base to address a lot of these data collection issues.
In conclusion, these data suggest that we need continued
efforts to develop and implement culturally tailored edu-
cational campaign to reduce the burden of chronic
hepatitis B infection among high risk subgroups of Asian
Americans. Furthermore, HBI-DC hopes to expand this
model program to other ethnicities, all the while tailoring
each program to that communities needs. For example,
for universalhepatitis B
Chinese schools might be the best community gathering
location for Chinese communities. HBI-DC would tailor a
program as such, so that health care services can always be
brought to places where the community gathers.
ment of Health and Human Services’ Office of Minority Health,
Association of Asian Pacific Community Health Organizations, Asian
Pacific Islander American Health Forum, Hepatitis Foundation Inter-
national, Gilead Sciences, Inova Health System Foundation, Inova’s
Congregational Health Partnership, and the Inova Reference Labora-
tory, Merck, Inc., and GlaxoSmithKline. For their support and
cooperation in this project, we thank pastors, leaders and volunteers
Presbyterian Church, First United Methodist Church, HOPE Chapel,
Korean Central Presbyterian Church, McLean Korean Presbyterian
Church, Open Door Presbyterian Church, Pilgrim Korean Community
Sun Hi Kim, Ed Hsu, Mark Kim, Ken Paik, Peter Shin, Pastor Hank
Hahm, Steve Yang, and Christina Yang for their support in helping to
DC Board for their support and cooperation. For more information
about HBI programs, please visit www.hepbinitiative.org.
This study was supported by the U.S. Depart-
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