When Truth Is Not Empowerment: The Missing Link in Programs Using the Health Belief Model to Fight Hepatitis B Among Asian Americans - Judy Yee
In many Asian and western Pacific nations, chronic hepatitis B virus (HBV) infection is the most common cause of cirrhosis and liver cancer (1). U.S. Census Bureau 2000 reports the Asian-American population at 10 million, with Chinese being the largest subgroup (2). While there are 1.3 million cases of chronic Hepatitis B (HepB) cases in the
The Food and Drug Administration licensed HBV vaccination in 1981. During the early 1990s, there was a movement to increase vaccination rates in infants, especially those in racial/ethnic groups with high rates of chronic HBV infection. Starting 1995, the Advisory Committee on Immunization Practices recommended HBV vaccination for AAPI children and for “catch-up” vaccinations for older unvaccinated children (5). However, as of a 1998 survey performed in six cities by the Centers for Disease Control and Prevention (CDC), the rate of completion of the three-series vaccination in children born between 1984 and 1993 ranged from a low of 14% to 67% (6). To date, there are several HepB vaccination programs and organizations developed to target the AAPI population, including The Asian Liver Center at Stanford University; The NYC Asian American Hepatitis B Project; National Task Force on Hepatitis B Immunization, Focus on Asians and Pacific Islanders; and Hepatitis B Initiative. The programs developed by these organizations aim to educate AAPIs about HepB so that they will seek screening and vaccinations. In addition, free or low costs screening and vaccination is usually provided.
On face value, these programs seem to be using effective approaches to target AAPI by eliminating both the financial and educational barriers. While progress is slowly occurring, we are far from the goals of universal vaccination and a decline in chronic HepB cases. The flaw of these programs developed to fight the Hepatitis B epidemic is the adherence to the link between intention and behavior of the Health Belief Model (7). While education is highly important in the developed initiatives, this approach ignores the factors that block this link from occurring, mainly the cultural stigma surrounding diseases—in particular to Hepatitis B—that may likely be transmitted through sexual intercourse. This critique presents AAPIs as a whole group because the cultural stigma affects each nationality individually as well as AAPIs as a whole; however, it is critical that we disaggregate AAPIs into their respective nationalities when applying public health approaches. In addition, this critique focuses on AAPIs who are not fully acculturated to the American lifestyle and still carry cultural aspects of their native countries.
Numerous studies have reported on language barriers impeding AAPIs from seeking HBV vaccination and/or treatment (8, 9). However, elimination of these language barriers would completely fix the HBV epidemic due to the cultural stigma surrounding sexual behavior. Even in their native tongue, messages related to sex are not brought up. This taboo has impeded open discussions on efforts to combat HIV/AIDS, especially among men having sex with other men (MSM). In most Asian cultures, homosexuality is condemned and leads to many MSMs to avoid being tested or revealing their HIV-positive status to partners and family members. The reasons cited stem from the same cultural attitude that prevents open discussion on Hepatitis B, including fear of shame from family and avoidance to communicate regarding highly personal information (10). Lai and Salili reported that Chinese parents who had children who were diagnosed as hepatitis B carriers hid the disease to protect their children from being shunned by society (11). Some employers and universities refuse to accept anyone who tested positive (12). In addition, Asian American adolescents and young adults tend to have a more sexually conservative attitude and behavior, and tend to be reluctant to receive sexual and reproductive care, which puts them in a greater risk of delaying treatment for breast and cervical cancer (13). Whether this attitude results from or contributes to the stereotype of AAPIs as the “model minority” has not been looked into.
This cultural stigma surrounding sex leads to a person to be completely ignorant to HepB vaccination. He or she would feel that by getting the vaccination, others would look upon them as having participated in “unethical and immoral” sexual behavior. If one does not participate in such shameful behavior, why would one need to be vaccinated? By being vaccinated, one might as well wear a large sign calling oneself “immoral” or a “slut.” For the brave individuals who are tested, this social label could be no more apparent.
The attitude of AAPIs towards non-sexually related diseases differ drastically. The severe acute respiratory syndrome (SARS) outbreak in 2003 placed the entire Asian continent in high alert. Many people in infected countries wore face masks; quarantines were extensively used, and medical professionals left their positions to avoid close contact with infected patients.
Considering the cultural attitudes that impeded improvement in HBV vaccination rates, physicians and health care workers need to take these attitudes into consideration when caring for AAPI patients. In a study of Vietnamese men in
Physicians, however, also need to recognize the social and cultural factors that hinder their patients from either seeking medical advice or ignoring the advice. Most Asian cultures adopt a holistic attitude towards health—that disease state is a matter of fate and out of the individual’s control (17, 18). If one has fate with Hepatitis B, one will succumb to infection even if precautions are taken so there is no need for vaccination. In addition, many AAPIs use alternative medical therapies and resort to Western therapies as last resort (opposite of the route taken by patients in Western nations). Looking closely at AAPI in their home country reveals important cultural aspects that influences health behavior. For instance,
Public health officials also need to dispel some physicians’ notion that AAPIs are the “model minority” and are not prone to some diseases as other races or ethnicities are, such as heart disease in African Americans. This stereotype may also be due to the healthy diets of some Asian cultures. For example, low rates of certain cancers in
There is evidence of the use for Social Learning Theory in combating the social and cultural factors in seeking medical care. The Social Learning Theory emphasizes the value in observing and modeling behavior that results in a valued outcome (19). Making the seeking of medical care even in asymptomatic stages a social norm is critical in fighting HepB prevalence in AAPIs. While the Health Belief Model dictates that intention will lead to behavior without any basis, the Social Learning Theory allows for individuals to act on their intentions. It allows the link between intention and behavior to become the automatic thing to do when the behavior can be modeled. It has been shown that AAPI women were more likely to receive mammogram screening if their friends and relatives favored screening, making mammogram screenings an acceptable procedure for these women (20). In addition, care provided to a Korean mother’s support network was highly important in getting her child vaccinated for HepB (9). In order to fight the prevalence of HepB infection in AAPIs, public health officials need to start on the physician level by making it acceptable for patients to see their physicians regularly. In many Asian countries, health care and physician visits are reserved for the wealthy. Those who are in lower socioeconomic classes avoid seeing a physician unless there is a dire necessity because they cannot afford the care; therefore, many resort to herbal or homemade remedies. Patients also feel discriminated when seeking care because they feel that doctors are not providing good care due to their inability to pay. Public health officials need to first dispel this notion because regular physician visits has been shown to increase the likelihood of having preventive medical care (21). In addition, AAPI patients are more likely to receive accurate information regarding HepB when regularly seeing a physician (15, 22, 23).
While addressing the social and cultural impediments, it is still important to educate the AAPI public about HepB prevention. The most efficient method of mass education is through the media; however, the media has to be used effectively, too. Programs should adopt agenda-setting theory as many other successful public campaigns have in the past. The agenda-setting theory provides a cause-and-effect technique of using media campaigns to influence the specific priorities of the public (24). Campaigns emphasize a specific topic, and over time the public views this topic as the more important issue. This theory has been tested hundred of times and is heavily used in political campaigns. Some public health campaigns have used the agenda-setting theory successfully: breast cancer awareness through public service announcements (PSAs) and media coverage has been linked to the increased rates of early detection and survival from breast cancer. A similar increase was seen in the awareness of the benefits of folic acid among women of childbearing age. The number of babies born with neural tube defects has decreased drastically since the
There has been a controlled trial promoting HepB vaccinations in Vietnamese-American children in the
This campaign is an optimistic sign that the inclusion of socially and culturally sensitive media campaigns can greatly increase the rates of HepB vaccinations in AAPIs. The key to the success in using agenda-setting theory is to adopt the cultural values and thinking when designing the campaign. Some cultures such as Chinese and Korean are heavily based on Confucian teachings: the balance of environmental, physical and social harmony as well as vital energy forces (22). Religious institutions are influential in Asian communities, especially in immigrant communities as they provide important spiritual and financial support. Assessing HIV prevention in the Chinese and South Asian religious institutions in
In order to effective fight the prevalence of HepB infection and liver cancer among AAPIs, public health campaigns need to break away from the traditional Health Belief Model and use other health and social science theories. The main factor in the failure of the health belief model is its lack of consideration for the cultural and social factors that impede the transition from intention to behavior. The missing link in existing programs is addressing these cultural concerns that prevent AAPIs from having regular physician visits, receiving correct information about HBV and following the advice of medical professionals. One of the main concerns is the taboo surrounding sexually-transmitted diseases. While HBV can be transmitted by other means—most prevalent in AAPI is from mother to child—HepB has been labeled in these cultures as associated with unprotected sexual behavior and drug use. Mistrust in medical professionals and the health care system in their native countries also contributes to a great extent in why AAPI do not have regular physician visits in the
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