Hepatitis prevention project in the Korean American community in Killeen, Texas

Abstract

Educational efforts related to viral hepatitis have the potential to increase awareness and identify chronically infected individuals and can lead to successful vaccination strategies. However, in underserved semirural communities, such as the Korean American community in Killeen, Texas, these outreach activities are lacking. The GanYum (“hepatitis” in Korean) Prevention Project aimed to evaluate thoughts/behaviors, assess vulnerability, and educate Korean Americans on hepatitis B and C. Two outreach events were held at a Korean church and a Korean market (O'Mart) to provide education, screening, and outreach about viral hepatitis. Ninety-six patients were screened at two events. Five patients were found to be positive for hepatitis B surface antigen and were referred to their primary care physicians and the liver clinic at Scott & White Healthcare in Temple, Texas. Fifty-one patients (53%) were found to be immune to hepatitis B, and 40 patients (42%) were hepatitis B vulnerable. We demonstrated that the prevalence of chronic hepatitis B in Koreans in our study is similar to the previously documented prevalence (5%). Our educational efforts were successful in changing perceptions regarding the modes of transmission and exacerbating factors of chronic viral hepatitis and encouraged participants to seek care for their liver diseases, if needed. We found that both venues (the church and Korean market) were appropriate to screen and educate participants; churches seemed to have a more engaged audience.

Viral hepatitis impacts the health status of communities worldwide, including in the United States. Hepatitis B alone is responsible for 80% of the world's liver cancer cases and is 50 to 100 times more infectious than HIV (1, 2). Chronic viral hepatitis can lead to cirrhosis and liver cancer (hepatocellular carcinoma) and is the sixth leading cause of death in the US (3–5). Although the impact of viral hepatitis is global, there are significant disparities between ethnic groups that put some populations at higher risk for complications (6, 7). For example, 10% of foreign-born Asians and 1 out of every 14 Korean natives are infected with hepatitis B (1, 8–10). In contrast, <0.5% of the general US population is infected (1, 11). Since the advent of the hepatitis B vaccine in 1982, these deaths have been entirely preventable. However, the vaccine remains grossly underutilized, especially in high-risk populations (11).

Hepatitis C virus (HCV) is the most common chronic bloodborne infection in the US. About 60% to 70% of persons with chronic HCV infection develop active liver disease, putting them at risk for developing cirrhosis and liver cancer. In the US, 40% of chronic liver disease is due to HCV (3). Increasing numbers of Asian Americans are infected with HCV yearly. In contrast to non-Asian HCV patients, Asians have an increased risk for liver cancer (12).

Despite advances in recognition of the virus through serologic testing and treatment with antiviral agents, many patients with viral hepatitis remain untreated due to inadequate screening and diagnosis in high-risk populations. Since many persons with hepatitis B or C are unaware of their infections until they are diagnosed with cirrhosis or liver cancer, the Centers for Disease Control and Prevention has devised a national strategy to eliminate the transmission of viral hepatitis through routine education, screening, vaccination (for hepatitis B), and possible treatment for high-risk populations (3, 4).

Public health initiatives throughout metropolitan areas in the US have aimed to screen and vaccinate (for hepatitis B) individuals while dispelling myths and stigmas that surround the disease through media campaigns, outreach events, and physician/provider efforts (11, 13, 14). Currently, there remains a void in the semirural and underserved communities regarding outreach efforts for viral hepatitis. In fact, in central Texas, no activities or resources targeted Asian Americans and viral hepatitis (15).

Killeen, Texas, is unique because it includes a vibrant and growing community of Korean Americans. Approximately 6000 to 10,000 Koreans reside in this area, many of whom lack health insurance and do not have regular access to care. Strikingly, 56% of Koreans in Killeen are foreign born and are at risk for viral hepatitis (15).

The purpose of the GanYum Project was to improve prevention and diagnosis and provide treatment (if needed) while offering education about hepatitis B and C to Korean Americans in Central Texas. To achieve this purpose, the project team collaborated with local stakeholders to conduct community-based outreach through education, screening, and vaccinations.

METHODS

Partnerships were created with the Korean Business Association in Killeen, the Killeen Korean Pastors Association, local businesses, and Scott & White Healthcare. Once these stakeholders were mobilized, two health fairs were organized and conducted in Killeen, Texas. Based on input from stakeholders, it was decided that a large Korean church (St. Luke's Episcopal Church) and a local Korean market (O'Mart Korean Market) would be the ideal locations for health fairs on viral hepatitis since these venues would attract a large sample of the Korean Americans living in the area.

The health fairs were designed to have a series of stations where individual activities could take place. Each station was geographically separated from the others, and a group of no more than 5 or 6 participants was taken from one station to the next by bilingual chaperones.

Station 1 was the intake and registration area where participants were given a pretest on a tablet PC that assessed their general knowledge of viral hepatitis. On a separate and secure form, sensitive data including their demographic and health care particulars were collected. Secure data were stored in a locked cabinet and on an encrypted computer. Participants were given a folder with information on viral hepatitis and contact information for the GanYum staff, as well as two identification numbers: one for the order in which they were to be screened and a 6-digit secure ID number to be utilized when they were contacted after their results were available.

Station 2 was the education station where a 10-minute presentation was given in Korean and/or English. Modes of transmission of hepatitis, its complications, and the importance of screening were discussed at length. After the education session, time was allotted for questions and answers. In Station 3, participants had their blood drawn for hepatitis B surface antigen (HbsAg), hepatitis B surface antibody (HbsAb), hepatitis A antibody (HAV Ab), and HCV antibody. In Station 4, participants took a posttest evaluating their knowledge on viral hepatitis. Before they left, they had the opportunity to ask any additional questions. Once results were available, participants were called and asked to verify their 6-digit ID number and were given their results. If needed, they were offered an appointment in the Scott & White Healthcare Liver Clinic.

To compare the responses between the surveys, we used a two-sample proportion chi-square test.

RESULTS

A total of 98 participants were included in the presurvey and 94 in the postsurvey; 96 had laboratory measurements taken. Of the 98 participants, most were women (72%), and their race/ethnicity was Korean (93%); 33% spoke only English, 46% spoke only Korean, and 21% were bilingual. There was an average of 2.3 persons per household (Table 1). Only 2% claimed to have been diagnosed with hepatitis B in the past, and 17% reported that they had been vaccinated against hepatitis B.

Table 1.

Demographic data for the health fair participants

	Site 1, Market (N = 54)		Site 2, Church (N = 44)		Combined (N = 98)
	n	%	n	%	n	%
Gender
Female	39	72%	32	72%	71	72%
Male	15	28%	12	28%	27	28%
Race/ethnicity
African American	1	2%	0	0%	1	1%
African American, Korean	1	2%	0	0%	1	1%
Caucasian, African American	2	3%	0	0%	2	2%
Chinese	1	2%	0	0%	1	1%
Korean	49	91%	42	96%	91	93%
Hispanic/Latino	0	0%	1	2%	1	1%
Vietnamese	0	0%	1	2%	1	1%
Language
English	16	30%	16	36%	32	33%
Korean	28	51%	17	39%	45	46%
Korean and English	10	19%	11	25%	21	21%
Household size
Mean (SD)	2.4 (1.4)		2.1 (1.3)		2.3 (1.4)
Median (Min-Max)	2.0 (1.0–5.0)		2.0 (1.0–6.0)		2.0 (1.0–6.0)

Significant differences were detected between the presurvey group and the postsurvey group for multiple questions (Table 2). After the education program, more interviewees understood how hepatitis B is spread, with no one choosing “bad food” (the only wrong answer) in the postsurvey. Similarly, participants developed a better understanding that alcohol is injurious to the liver. The option “fatty food” should also be a risk factor for hepatitis B, but the difference in participants' responses on this question in the postsurvey was not significant. There was a significant difference in participants' knowledge of the presence of the hepatitis vaccine in the postsurvey period, but fewer participants chose “yes” (the correct answer) after the survey (36% presurvey and 14% postsurvey). In the postsurvey period, most participants correctly indicated the symptoms of hepatitis B/C and identified both cirrhosis and liver cancer as complications of hepatitis.

Table 2.

Comparison of survey results before and after the health fair educational intervention

	Presurvey (N = 98)		Postsurvey (N = 94)
	n	%	n	%	P value*
How is hepatitis B spread?
Bad food	39	40%	0	0%	<0.001
Injection	34	35%	91	97%	<0.001
Transfusion	41	42%	85	90%	<0.001
Sex	25	25%	93	99%	<0.001
Mother	50	51%	78	83%	<0.001
What makes the liver more sick in people with hepatitis B?
Alcohol	70	71%	84	89%	0.002
Fatty food	28	29%	17	18%	0.09
Can you prevent hepatitis B with a single shot vaccine?
Yes	36	37%	13	14%	<0.001
What is the most common symptom of hepatitis B and C?
Nothing	30	31%	91	97%	<0.001
Nausea/vomiting	16	16%	1	1%	<0.001
Jaundice	48	49%	0	0%	<0.001
Abdominal pain	4	4%	3	3%	0.74
What are some of the complications of having hepatitis?
Cirrhosis	19	20%	0	0%
Liver cancer	16	20%	5	5%
Both	63	64%	89	95%	<0.001

^*Two-sample proportion test.

As shown in Table 3, most participants had negative anti-HCV (99%). Although most people had positive HAV Ab (95%), 44% had a negative HbsAb, 53% had a positive HbsAb, and 95% had negative HbsAg.

Table 3.

Laboratory test results for health fair participants

	Site 1, Market (N = 54)		Site 2, Church (N = 42)		Combined (N = 96)
	n	%	n	%	n	%
Hepatitis C antibody
Negative	54	100%	41	97%	95	99%
Positive	0	0%	1	3%	1	1%
Hepatitis A antibody
Positive	51	94%	40	95%	91	95%
Hepatitis B surface antibody
Negative	26	48%	16	38%	42	44%
Positive	28	52%	23	55%	51	53%
Grayzone	0	0%	3	7%	3	3%
Hepatitis B surface antigen
Negative	52	96%	39	93%	91	95%
Positive	2	4%	3	7%	5	5%

DISCUSSION

Our study showed that grassroots community outreach efforts can lead to increased awareness and knowledge around viral hepatitis in an at-risk population. The community outreach events that we participated in showed that it is possible to successfully engage the Korean community via local leadership around their health (especially liver-related health). Businesses, local churches, and community leaders participated with Baylor Scott & White Healthcare in the marketing, community development, and organizational tasks related to the health fairs. Second, our study demonstrated that with 10-minute education sessions, participants could dispel common myths and misconceptions regarding viral hepatitis. Furthermore, it was also successfully demonstrated that both places of commerce (O'Mart Korean Market) as well as places of worship (St. Luke's Episcopal Church) were effective venues for outreach events regarding the liver-related health status of a Korean community. Lastly, the laboratory data we collected suggested that the prevalence of hepatitis B in the Korean community in Killeen, Texas, was similar to nationwide data. It was also remarkable that a significant percentage of the population surveyed (53%) had been successfully vaccinated against hepatitis B. Through phone conversations, high-risk individuals (those who had a positive HbsAg or were vulnerable to hepatitis B) were scheduled in the liver clinic at Scott & White Healthcare (all five positive HbsAg patients). Several patients declined to come into the clinic and were referred to their primary care physicians for follow up. Our study was limited by the sample size of the population surveyed, as there were 94 participants who completed all follow-up tests and we had only two health fairs.