Culturally Relevant Tools to Increase Hepatitis B Screening in Asian American Communities

The Risks of Hepatitis B

Hepatitis B virus (HBV) infection is a major global cause of chronic liver disease affecting up to 2.2 million Americans. Chronic HBV can progress to cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC). Long-term suppression with antiviral treatment is the standard of care for patients meeting treatment criteria. These agents effectively reduce viral replication, mitigate hepatic inflammation and fibrosis progression, and lower the risk of transmission and hepatocellular carcinoma, though they require indefinite administration in most cases.

While no curative therapy exists, HBV is vaccine-preventable. The HBV vaccine is >95% effective when administered at birth and maintains high efficacy in adults. Given the persistent burden of chronic infection and the absence of a cure, prevention through universal vaccination and early detection via HBsAg screening remains central to public health and clinical strategies. Unfortunately, an estimated 3 in 4 individuals chronically infected with HBV are not aware of the infection.

Chronic HBV infection, especially when left untreated, is a major risk factor for HCC. Individuals with chronic, untreated HBV infection have a 10-25% lifetime risk of developing liver cancer. With a 5-year survival rate of 22%, liver cancer is one of the deadliest cancers in the country.

Some populations have a higher endemic prevalence of HBV, and these communities carry a higher burden of both HBV infection and HCC. Asian Americans born outside of the U.S., for instance, are twice as likely as non-Hispanic whites to die from liver cancer. Screening is an important tool for all populations’ liver health, but even more so for communities with increased risk. CDC recommends screening all adults aged 18 and older for hepatitis B at least once in their lifetime using a triple panel test and additional screening for infants, pregnant women, and people at increased risk. To ensure increased access to testing, anyone who requests HBV testing should receive it regardless of disclosure of risk. 

The Advisory Committee on Immunization Practices (ACIP) recommends hepatitis B (HepB) vaccination among all infants at birth, unvaccinated children younger than 19 years of age, adults aged 19–59 years, and adults aged 60 years and older with risk factors for hepatitis B or without identified risk factors but seeking protection.

A Successful App-Based Intervention

Despite this universal screening recommendation, rates for screening are below 50%, including among Asian-Americans. To bridge this gap, an interdisciplinary team from the University of California, San Francisco conducted a cluster-randomized clinical trial with 452 Asian American patients over 18 (mean age 57) at primary care locations with no prior HBV testing to evaluate the impacts of a culturally and linguistically appropriate education on viral hepatitis on discussion about and receipt of an HBV screening test.

The intervention group received the Hepatitis App, which delivered interactive videos about viral hepatitis in English, Cantonese, Mandarin, or Vietnamese, compared with nutrition and physical activity education. The app included branching logic integrating a brief assessment, in-language video messages from a doctor based on patient responses, and a printout with sections of information for both the patient and provider based on the responses. It was well-liked by participants (80%). Both groups received a Provider Panel Notification. After 3 months, the intervention group was more likely to have discussed HBV with their provider (70% vs. 16%), had an HBV test ordered (44% vs. 10%), and received an HBV test (38% vs. 8%), with an odds ratio of 7.6 for test ordering and 7.5 for test receipt. The authors concluded that the app-based educational intervention was well-received by the cohort of primary care clinics.

Findings in Context

A few results point to the mechanism of success. Awareness of HBV transmission was higher in the intervention group, and a higher proportion of intervention participants strongly agreed that they felt more comfortable asking their provider for a hepatitis test. Most of the intervention group reported that they liked the Hepatitis App. Interactive, in-language applications focused on the patient were found to be impactful tools and valuable for patient-provider communication. Despite an older, majority-immigrant population, the app was effective in changing beliefs, attitudes, and behavior.

Other studies have supported the idea that culturally appropriate interventions can promote health-seeking behaviors related to viral hepatitis B in Asian American communities. These studies include mass media campaigns, the use of community health workers, and small-group educational sessions in community churches. Similar success has been found in a study with West African faith-based communities.

What Should a Clinic Do with These Findings?

• • Implement universal HBV screening protocols following CDC guidelines. Integration into HR systems can help prompt routine tests.
  • Combat stigma by offering hepatitis B testing to every adult who has an unknown HBV status, without inquiring about stigmatizing risk factors.
  • Adopt culturally and linguistically tailored digital tools (videos, apps, stories) to educate patients in the waiting room or at home. Consider collaborating with existing programs or with local community groups.
    • HepBStories.org
    • CDC Community-Specific Hepatitis B Resources
  • Incorporate notifications or alerts to inform eligible patients about available screenings.
  • Consider piloting low-cost, app-based interventions or options integrated to existing patient portals to empower your patient population to seek screening.