Challenging Dogma

...Using social sciences to improve the practice of public health

Saturday, April 21, 2007

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 United States, Asian Americans account for over half of these cases, and for half of the deaths resulting from chronic HBV infection (3). Pacific Islanders and Vietnamese Americans are up to 13 times more likely to die from liver cancer than Caucasians; Korean Americans are 8 times more likely and the risk for Chinese Americans is 6 times higher. In addition, 80% of the liver cancer cases among Asian Americans and Pacific Islanders (AAPIs) are attributable to HBV infection (4). These statistics point to an increased need to prevent HepB infection in AAPIs by increasing vaccination rates for those who are susceptible and treatment rates for those already infected.

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. China has also developed immunization programs that greatly reduced the rate of disease and death due to tuberculosis (BCG vaccine), diphtheria, tetanus, measles and polio (14). These diseases caused epidemics and high death rates. Unlike hepatitis B, these diseases manifested quickly so they were “visible to the naked eye.” These diseases were “safe” diseases to tackle because their transmission is not the fault of the diseased individual. They are caused by handling infected stool or wound contamination (tetanus), or spread through respiratory fluid (measles, diphtheria and tuberculosis) and the fecal-oral route (polio). Aside from unprotected sexual behavior, HepB could also be “blamed” on other behaviors such as drug use and contaminated blood transfusion—all which are frowned upon. Liver cirrhosis and cancer could also be blamed on heavy drinking, which is either frowned upon in some AAPI cultures or the norm for men in others. It was not until recently in the year 2002 that the Ministry of Public Health of China planned to integrate HBV vaccination into the nationwide Expanded Programme on Immunization (EPI) program with government-provided vaccines.

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 Seattle, those who have received physician recommendation for HBV testing had 2.3 times higher odds of having been tested than those who have not received recommendation (15). This increase in odds was also shown for Cambodian and Vietnamese women in regards to Pap testing (16). These results show that the basis of our public health interventions may focus on having physicians recognize the increased risk of their AAPI patients for HepB and liver cancer.

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, Cambodia is a largely agrarian society and most Cambodians had lived in rural or semi-rural settings before the revolutionary period. Cambodian immigrants are therefore unfamiliar to Western culture, including the biomedical concepts of prevention. Giving them information on vaccination is fruitless if they do not have a concept of the importance of vaccination. There is also a mistrust of Westernized medicine, which more often is held by those immigrants from rural rather than urban areas. A reason for this may be that patients seek allopathic medicine in a late stage of disease that cannot be reversed. In their eyes, the patient had sought Western medicine and died as a result (17). Patients will also refuse vaccination if they perceive vaccines are dangerous.

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 Japan have been linked to the Japanese diet, which includes a large proportion of fish, vegetables, fruits, and rice. Nevertheless, the statistics clearly show a HepB epidemic in AAPIs that physicians need to recognize and emphasize to their patients. Aside from holistic attitudes and mistrust of physicians, there are cultural aspects that may hinder the physician-patient interaction. To show respect and avoid spreading germs to physicians, some older Asian patients may cover their mouths when speaking or only speak as little as necessary (18). In addition, encouraging patients to discuss health issues with relatives may be fruitless as some would feel that discussing illness would lead to bad luck. Others may feel uncomfortable with a non-Asian physician, or feel that a non-Asian physician would not understand their health issues. The interaction can also depend on the quality of the interpreter. Ineffective interaction deprives the patient of valuable information and the physician of the opportunity to effectively encourage the patient to get tested or vaccinated.

The Asian Liver Center at Stanford University has developed “Know HBV” education brochures with information of HBV transmission, prevention and treatment. The brochures has messages such as “Avoid drinking alcohol, “Get vaccinated,” and “Get tested.” All these messages can easily be ignored because of the cultural emphasis on alcohol in social activities, fear of testing and mistrust of physicians. Public health officials and physicians need to work together with the AAPI community to develop culturally sensitive methods to increase HBV vaccination.

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 U.S. implemented mandatory fortification.

There has been a controlled trial promoting HepB vaccinations in Vietnamese-American children in the Houston, Texas metropolitan area and Dallas metropolitan area using media campaign and community mobilization campaign, respectively (25). Both methods showed an increased awareness in HepB using both methods, with a greater increase using the media-led campaign. More parents were aware of free vaccinations, and completion of the three hepatitis B vaccinations increased significantly. In addition, the investigators evaluated the cost-effectiveness of the two campaigns and found the media campaign to be more cost-effective in the long-term. The strength of the media-led campaign was its extensive use of all resources including print, radio and outdoor press. There was a HepB educational booklet titled, Bao Ve The He Moi: Hay Chich Ngua (“Immunize against Hepatitis B to Project Future Generations”). Its emphasis on the children, the “future generation,” may have made it more effective than the brochure from the Asian Liver Center because many Asian cultures require selflessness from the parents and place an enormous emphasis on their children’s upbringing. In addition, this brochure was originally developed in Vietnamese; reviewed by a panel of Vietnamese-American physicians, focus groups of consumers and community leaders; and then translated into English for secondary review. By being first developed in Vietnamese, the brochure is more likely to contain cultural differences, such as the vernacular, that may be lacking if developed first in English.

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 New York City provided two different approaches in targeting interventions (26). At the Buddhist temple in Chinatown, there was no HIV prevention education and an overall lack of HIV knowledge. In addition, there was the perception that the need for HIV education was low. There was a fear that holding HIV education events at the temple would bring a negative image to the institution and be an “oral sin.” This attitude may be due to the taboo of homosexuality and drug use in Chinese culture, and to the fatalistic view of diseases that one either has or has not a “fate” with a disease. It would simply be useless to hand out HBV information packets and brochures in this Buddhist temple because the patrons will ignore them, even if they do read them at all. We cannot expect the patrons to listen to our messages when their religious and community leaders do not welcome these messages either. In this situation, knowing the truth about HBV will not empower people to seek care. In addition, they might not find our messages to be the truth because their source of knowledge is through the Buddhist teachings. In the Hindu temple and Islamic mosque, however, participants felt that the need for HIV education was high. The investigators suggested that this willingness was due to the more prevalent concern about HIV in the native countries of the participants, who were mainly from Pakistan, Bangladesh, and India. These findings also emphasize on the need for public health officials to disaggregate AAPIs when implementing campaigns due to the differences in cultures and religions.

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 United States. In addition, there is a need to dispel the notion that AAPI are a “model minority” in terms of health. It is important to make regular physician visits and vaccinations a social norm by using the Social Learning Theory. Making these acts acceptable fosters a more open environment for discussion and education about HepB. These discussion and education campaigns need to make use of Agenda-Setting Theory to place HepB as a priority in the health concerns of AAPIs. The campaigns crucially need to take into account social and cultural aspects in order to be successful since the target audience would response more favorably to messages that are relatable. Having a public health campaign that allows for HepB vaccination to be acceptable and relatable to the target audience is the missing link that will promote this valuable behavior. It is notable to mention that the HepB vaccine is the first anti-cancer drug!


1. Center for Disease Control and Prevention. Screening for Chronic Hepatitis B Among Asia/Pacific Islander Populations—New York City, 2005. MMWR 2006; 55(18): 505-9.

2. United States Census Bureau. 2000 Fact Sheet: Asian alone. Washington, DC: United States Census Bureau, 2000.

3. Hepatitis B Initiative. HBI: Statistics. Boston, MA: Hepatitis B Initiative. Accessed February 13, 2007.

4. Hsu LD, DeJong W, Hsia R, Chang M, Ryou M and E Yeh. Student Leadership in Public Health Advocacy: Lessons Learned From the Hepatitis B Initiative. Am J Public Health 2003; 93(8): 1250-2.

5. Center for Disease Control and Prevention. Notice to Readers Update: Recommendations to Prevent Hepatitis B Transmission – United States. MMWR 1995; 40(30): 574-5.

6. Center for Disease Control and Prevention. Hepatitis B Vaccination Coverage Among Asian and Pacific Islander Children—United States, 1998. MMWR 2000; 49(27):616-9.

7. Wikipedia. Health Belief Model. Accessed February 13, 2007.

8. Coronado GD, Taylor V, Acorda E, Do HH and B Thompson. Development of an English as a Second Language Curriculum for Hepatitis B Virus Testing in Chinese Americans. Cancer 2005; 104 (12 suppl): 2948-51.

9. YO Rhee Kim. Access to Hepatitis B Vaccination among Korean American Children in Immigrant Families. J Health Care Poor Underserved 2004; 15(2): 170-182.

10. Yoshioka MR and A Schustack. Disclosure of HIV status: cultural issues of Asian patients. Aid Patient Care STDS 2001; 15(2):77-82.

11. Lai AC and F Salili. Stress in parents whose children are hepatitis B virus carrier: a comparison of three groups in Guangzhou, China. Child Care Health Dev 1996; 22:381-96.

12. Wikipedia. Hepatitis B in China. Accessed March 27, 2007.

13. S Okazaki. Influence of Culture on Asian American’s Sexuality. J Sex Res 2002, 39(1): 34-41.

14 Govt. White Papers: Children’s Health and Health Care. China: Accessed March 27, 2007.

15. Taylor VM, Yasui Y, Burke N, Nguyen T, Chen A, Acorda E, Choe JH and JC Jackson. Hepatitis B testing among Vietnamese American men. Cancer Detect Prev 2004; 28(3): 170-7.

16. Chen MS. Cancer Health Disparities among Asian Americans: What We Know and What We Need to Do. Cancer 104 (12 suppl): 2895-2902.

17. L Uba. Cultural Barriers to Healthcare for Southeast Asian Refugees. Public Health Rep 1992; 107(5): 544-8.

18. H Chung, D Nguyen and F Gany. Toolbox: Initial behavioral health assessment of Asian Americans. Part 1. Key Principles. West J Med 2002; 176: 233-6.

19. Social Learning Theory (A. Bandura). Accessed February 13, 2007.

20. Wu TY, Bancroft J and B Guthrie. An Integrative Review on Breast Cancer Screening Practice and Correlates Among Chinese, Korean, Filipino, and Asian Indian American Women. Health Care Women Int 2005; 26: 225-46.

21. Ettner SL. The relationship between continuity of care and the health behavior of patients: Does having a usual physician make a difference? Med Care 1999; 37(6): 547-55.

22. Choe JH, Chan N, Do HH, Woodall E, Lim E and VM Taylor. Hepatitis B and Liver Cancer Beliefs among Korean Immigrants in Western Washington. Cancer 2005; 104(12 suppl): 2955-58.

23. Taylor VM, JC Jackson, N Chan, A Kuniyuki and Y Yasui. Hepatitis B Knowledge and Practices among Cambodian American Women in Seattle, Washington. J Community Health 2003; 27(3): 151-63.

24. Wikipedia. Agenda-Setting Theory. Accessed February 13, 2007.

25. McPhee SJ, Nguyen T, Euler GL, Mock J, Wong C, Lam T, Nguyen W, Nguyen S, Huyhn Ha MQ, Do ST and C Buu. Successful Promotion of Hepatitis B Vaccinations Among Vietnamese-American Children Ages 3 to 18: Results of a Controlled Trial. Pediatrics 2003; 111: 1278-88.

26. Chin JJ, Mantell J, Weiss L, Bhagavan M and XT Luo. Chinese and South Asian Religious Institutions and HIV Prevention in New York City. AIDS Educ Prev 2005; 17(5): 484-502.

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