“Know Hepatitis B:” A Multilingual Communications Campaign Promoting Testing for Hepatitis B Among Asian Americans and Pacific Islanders

Abstract

The “Know Hepatitis B” campaign was the first national, multilingual communications campaign to promote testing for hepatitis B virus (HBV) among Asian Americans and Pacific Islanders (AAPIs). This population comprises fewer than 5% of the total U.S. population but accounts for more than half of the up to 1.4 million Americans living with chronic HBV infection. To address this health disparity with a national campaign, CDC partnered with Hep B United, a national coalition of community-based partners working to educate AAPIs about hepatitis B and the need for testing. Guided by formative research, the “Know Hepatitis B” campaign was implemented in 2013 with a two-pronged communications strategy. CDC used available Chinese, Korean, and Vietnamese media outlets on a national level and relied on Hep B United to incorporate campaign materials into educational efforts at the local level. This partnership helped facilitate HBV testing among the priority population.

Chronic infection with the hepatitis B virus (HBV) affects an estimated 800,000 to 1.4 million Americans^1,2 and an estimated 240 million people worldwide.³ Many people are believed to have acquired the infection during childbirth or in infancy, and before the widespread availability of hepatitis B vaccine. Once infected, up to 90% of infants will develop chronic HBV infection. Left untreated, approximately 15%–25% of those with chronic HBV infection develop serious liver disease, including cirrhosis, liver damage, and even liver cancer.^4,5

Because HBV infection disproportionately affects Asian Americans and Pacific Islanders (AAPIs), HBV has been identified as a major health disparity for this population. High rates of liver cancer deaths among AAPI populations further underscore this disparity.^6,7 In response, the U.S. Department of Health and Human Services (HHS), through its National Action Plan for Viral Hepatitis, called for a national education campaign and charged the Centers for Disease Control and Prevention (CDC) with leading the effort.⁶ To develop and implement the campaign, CDC partnered with the Hep B United (HBU) coalition (www.hepbunited.org), a national coalition of community-based partners working to educate people about hepatitis B and increase testing, especially among AAPIs. The “Know Hepatitis B” campaign was launched in 2013 with support from HHS and the White House Initiative on AAPIs⁸ and represents the first national, multilingual communications campaign developed by the federal government to promote HBV testing among AAPIs.

METHODS

The “Know Hepatitis B” campaign

CDC, the American Association for the Study of Liver Diseases, and the U.S. Preventive Services Task Force all recommend HBV testing for people who were born in a country with moderate or high rates of hepatitis B (i.e., ≥2% prevalence) or U.S.-born people who were unvaccinated at birth and whose parents were born in a country with a high prevalence of hepatitis B.^7,9,10 HBV is common in many parts of the world, including much of Asia.⁷ Nearly 70% of Asian Americans are foreign born,¹¹ and an estimated 58% of foreign-born people living with HBV immigrated from Asia.¹² Although they comprise fewer than 5% of the U.S. population, AAPIs account for more than 50% of chronic hepatitis B cases. Estimates indicate that one in 12 Asian Americans has chronic HBV infection, two-thirds of whom are unaware of their infection.¹³

People of Chinese, Vietnamese, and Korean heritage, most of whom are foreign born, represent the largest groups of AAPIs in the United States and were the target or priority populations for the “Know Hepatitis B” campaign. Among many AAPIs, English proficiency is limited, and a strong preference for in-language information exists (Table).¹⁴ As a result, CDC developed the campaign's main components in Chinese, Vietnamese, and Korean, with English translations for those who did not speak these languages. A smaller set of campaign materials was developed in Hmong, Lao, Khmer, and Burmese as resources permitted.

Table.

Estimates^a for Asian Americans' place of birth and language preferences used to plan the “Know Hepatitis B” campaign, United States, 2013^b

^aEstimates derived from U.S. Census Bureau 2006–2010 American Community Survey.

^bThe “Know Hepatitis B” campaign was a national, multilingual communications campaign to promote testing for hepatitis B virus among Asian Americans and Pacific Islanders.

Formative research

To inform development of the “Know Hepatitis B” campaign, CDC undertook formative research activities, including literature reviews, ethnic media market analyses, focus groups, key informant interviews, in-depth discussions with leaders in AAPI health and hepatitis B, and a needs assessment of community health and social services providers. The overarching goal of the formative research was to understand cultural attitudes, knowledge levels, and practices related to hepatitis B, and use this enhanced understanding to develop culturally competent messages and strategies.

Findings across the formative research activities were consistent, regardless of the method. CDC found that, among AAPIs, knowledge levels about hepatitis B were low and people were confused about how the virus was transmitted. Stigma toward those infected with HBV was also common. A pervasive fear was that people with HBV infection could be fired, forced to leave school, or even deported. Additionally, many AAPIs feared the financial and social costs of a potential diagnosis, which was a barrier to testing.¹⁵

During the three years of planning the “Know Hepatitis B” campaign, CDC conducted 35 exploratory focus groups with 286 AAPIs in five U.S. cities: New York, New York; Los Angeles, California; Houston, Texas; Washington, D.C.; and Boston, Massachusetts. The results identified many different and enduring misconceptions about hepatitis B. Common myths included the belief that hepatitis B could be spread through sharing food or utensils or through the air. Some focus group participants thought that the disease was genetic and did not understand that perinatal transmission was a major cause of chronic infection. Many participants reported low susceptibility because they thought they would “not be exposed” to hepatitis B in the United States and that the environment in the United States was “cleaner” than in their home country (Unpublished data, CDC, Division of Viral Hepatitis, 2012–2014).

Although some participants acknowledged that AAPIs might be more likely to have hepatitis B, they also stated it was not “their” problem. Focus group participants also assumed that anyone with the disease would have symptoms, such as yellow eyes. Furthermore, they thought their doctor would let them know if they needed to be tested. Focus group participants reported a hesitancy to get tested, both because of the social consequences that could ensue and the belief that no treatments existed. Results from the focus groups, perhaps more so than from other research, indicated the need for basic information on HBV transmission, testing, and treatment.

To add to the challenge of low knowledge levels, all formative research efforts highlighted the linguistic isolation faced by many AAPIs. This linguistic isolation supported the use of in-language media outlets, as many AAPIs cannot be reached through mainstream English-language media. However, community leaders noted that ethnic media sources provided few or sometimes inaccurate stories about hepatitis B. Additionally, the lack of educational materials about hepatitis B from scientific or other credible sources (e.g., CDC) contributed to the low level of hepatitis B knowledge. Many AAPIs, especially those with limited English proficiency, prefer interacting with professionals and community members who speak their language and are familiar with their culture.⁵ However, most AAPIs do not have easy access to health professionals who are fluent in their native language, and it was common to hear stories about individuals driving four or five hours to find a doctor. Such findings supported an in-language media approach, supplemented with community outreach.

CDC's own needs assessment reinforced the importance of working with local AAPI groups, which are best suited to address the social, cultural, linguistic, and financial barriers non-English-speaking Asian Americans face. Additionally, local groups offered culturally and linguistically appropriate services, as well as free or low-cost HBV tests. These groups were trusted within their communities and could often provide linkage to local medical services and care, especially for those who were uninsured or underinsured.¹⁵

Partnership with Hep B United

Recognizing that local groups have the cultural expertise and infrastructure to facilitate HBV testing among the campaign's priority populations, CDC partnered with HBU. HBU is a national organization comprising local partners in 14 U.S. states and more than 20 cities that is committed to addressing the public health challenge of hepatitis B. Although varying in size and composition, most local partners represent a combination of community health centers or clinics, community groups, civic organizations, and social services agencies. Collectively, the local partners reach more than 3.6 million AAPIs and maintain established programs, culturally competent staff members fluent in multiple Asian languages, and trusted relationships with the local population. HBU partners provide hepatitis B testing services, education, outreach, and medical care that align with the campaign's goal of increasing identification of HBV infection among AAPIs.

HBU members were involved in the campaign throughout the process, providing valuable insights into the attitudinal, cultural, and structural barriers encountered by many AAPIs. HBU members also reviewed draft campaign materials and provided feedback on the formats and types of materials that would support local educational and outreach efforts. As a result, the “Know Hepatitis B” campaign was co-branded with CDC and HBU.

“Know Hepatitis B” campaign

Campaign goals and objectives.

The campaign included messages designed to increase knowledge of how the virus is transmitted, educate people about who is most affected, decrease stigma, and debunk commonly held myths about hepatitis B. The messages were designed to reinforce the main message of the campaign: “If you or your parents were born in Asia or the Pacific Islands, get tested for hepatitis B.”

Ensuring cultural competence.

CDC took several steps to ensure comprehension, acceptability, and cultural appropriateness of the campaign. First, CDC contracted with a vendor that specialized in Asian American communications to ensure that materials were developed in-language by native communication professionals. Draft materials were tested in focus groups comprising foreign-born Mandarin speakers (with simultaneous translation for CDC observers) and foreign-born English-speaking AAPIs. (Limited resources prohibited testing materials in-language with other AAPI populations in the early part of the campaign's development.) This process helped identify the campaign materials that were most likely to persuade AAPIs to get tested and which ones to drop because of poor comprehension, confusing messages, or other unintended effects.

To further ensure cultural appropriateness, linguistic experts oversaw broadcast and print materials production and conducted back translations (i.e., in-language to English back to in-language) to ensure accurate messaging. Broadcast materials featured actors who were native speakers. Additionally, CDC shared final materials with HBU members for quality assurance.

Campaign elements.

The campaign comprised a variety of multimedia materials produced in English, Korean, Vietnamese, and Chinese, with Mandarin and Cantonese dialects used for broadcast media. Campaign elements included television and radio public service announcements (PSAs), as well as digital and print materials. Print materials included fact sheets, posters, flyers, and a risk assessment that determined whether individuals should be tested based on their or their parents' birth country (Figure). Local groups could add their own information about local services to the posters and flyers. CDC also developed a “Know Hepatitis B” website (http://www.cdc.gov/knowhepatitisB) to provide detailed information about hepatitis B, answer frequently asked questions, and house campaign materials.

Figure.

Collateral used for the “Know Hepatitis B” campaign,^a United States, 2013

^aThe “Know Hepatitis B” campaign was a national, multilingual communications campaign to promote testing for hepatitis B virus among Asian Americans and Pacific Islanders.

Communication strategy.

The campaign launched in 2013, with new campaign materials developed and released annually across the United States during the last three years. The campaign dissemination strategy employed a two-pronged approach, with CDC working nationally and HBU members focusing on community-based education efforts. Most of CDC's efforts focused on ethnic media because many AAPIs prefer, understand, and trust information in their native language.

To reach the priority audiences, CDC identified Chinese, Korean, and Vietnamese television, radio, and digital media outlets throughout the United States. The television PSAs relied primarily on donated space. CDC had a modest budget to purchase in-language digital, radio, and print advertisements for a recurring six-week period during summer 2013. The advertisements were placed in the largest online news outlets or video hosting websites and brought viewers to the various in-language PSAs posted on CDC's YouTube channel. In cities with an HBU partner, CDC collaborated with the local partner and used news media outreach strategies to disseminate campaign messages. By identifying an appropriate HBU spokesperson and promoting stories in local television, radio, or print outlets, HBU members were able to educate the community about hepatitis B and, more importantly, tell people where they could get tested. Regardless of whether or not in-language media outlets were available, CDC encouraged HBU members to integrate in-language “Know Hepatitis B” campaign materials into their educational and outreach efforts to help spread the word about hepatitis B and promote local services.

OUTCOMES

As of mid-2015, the “Know Hepatitis B” campaign had generated nearly 315 million audience impressions (i.e., the standard media measurement for the number of times a communication piece was viewed or heard) worth an estimated $2.2 million. Relying on donated time from the small number of in-language television stations nationwide, CDC's video PSAs were played more than 4,500 times, representing an estimated media value of almost $1 million and a total of 75 million impressions in Chinese, Vietnamese, and Korean. Paid digital advertisements supplemented the effort, generating an additional 51 million impressions and more than a half-million views of the video PSAs housed on CDC's YouTube channel. Digital advertisements also helped the campaign website garner nearly 130,000 visits. Paid radio advertisements on ethnic radio stations garnered more than 54 million impressions, while print advertisements in local ethnic newspapers garnered more than 4 million impressions. Several in-language educational articles and an infographic that was worth almost $600,000 had an estimated audience reach of 59 million supplemented print outreach.

CONCLUSION

Although these process measures were helpful in assessing campaign exposure, the ultimate goal of the campaign was to increase testing for HBV infection. HBU and its local chapters used their strong community ties to conduct educational programs and testing events across the country. HBU members incorporated campaign materials into their community outreach strategies and facilitated hepatitis B testing in local communities. CDC continues to work with the national HBU coalition to examine how this partnership has affected hepatitis B testing among AAPI populations. The efforts described in this article are ongoing, and future reports will describe how this unique government-community partnership may have made a difference in the lives of many AAPIs.