Break the Silence: Using an Integrated Approach to

Grace Ma, PhD, Lewis Katz School of Medicine, Temple University

Break the Silence: Using an Integrated

Approach to Eliminating Hepatitis-Related Liver

Disease Disparities Among Asian Americans

Grace X. Ma, Ph.D.Associate Dean for Health Disparities

Founding Director, Center for Asian HealthLaura H. Carnell Professor and Professor in Clinical Sciences Primary Member, Fox Chase Cancer Center, Temple Health

May 13, 2021


Liver Cancer: Fast Increase In the U.S.

72% 2003 – 2017


Major Preventable Risk Factors

of Liver Cancer in the US

• https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/v iral-hep-liver-cancer.pdf

• https://www.cancer.org/cancer/liver-cancer/causes-risks-prevention/risk-factors.html

• https://minorityhealth.hhs.gov/omh/browse.aspx?lv l=4&lv lid=61

• U.S. Department of Agriculture National Nutrient Database

• CancerToday, https://www.cancertodaymag.org/Pages/Spring2018/Liver-Cancer-

on-the-Rise.aspx

For Example:• Type 2 Diabetes

• Obesity

• Heavy alcohol use• Smoking

About 71% of liver cancer diagnoses in the U.S. are related to preventable risk factors.

https://www.cancer.org/cancer/liver-cancer/causes-risks-prevention/risk-factors.html

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=61


Racial/Ethnic Disparities in Morality Rates

for Chronic Liver Disease in the US

Kim, Donghee, et al. "Changing trends in etiology-based annual mortality from chronic liver disease,

from 2007 through 2016." Gastroenterology 155.4 (2018): 1154-1163.


How Common are Hepatitis B in the US?

Majority of individual living with HBV were foreign-born (~1.6 million)

Immigrants from HBV-endemic countries: Asia and sub-Sahara Africa

CHB prevalence in immigrants: African immigrants 10.3%; Asian 8-15%; Caribbean

immigrants 4.52%https://www.nfid.org/wp-content/uploads/2019/08/hepatitis-b-are-you-at-risk.pdfKowdley, Kris V., et al. "Prevalence of chronic hepatitis B among foreign‐born persons living in the United States by country of origin." Hepatology 56.2 (2012): 422-433.

Hu, D. J. 2008. Issues related to the prevention and control of hepatitis B virus (HBV) infection in the U.S. Paper presented at IOM Roundtable on the Prevention and Control of Viral Hepatitis Infection, Washington,

DC.

https://www.nfid.org/wp-content/uploads/2019/08/hepatitis-b-are-you-at-risk.pdf


HBV in Asian American and Pacific Islanders

AAPI have the highest prevalence rates of HBV

infection than any racial/ethnic groups in the

U.S.

AAPI represent about 6% of U.S. population, but

they represent about 58% of all persons living

with hepatitis B.

https://www.cdc.gov/knowhepatitisb/images/HepB_infographic.jpghttps://www.hhs.gov/hepatitis/learn-about-viral-hepatitis/data-and-trends/index.html


Geographic Distribution of HBV

Incidence in NYC and Philadelphia

Geographic Location of HBV Incidence in NYC, 2019 Geographic Location of HBV Incidence in Philadelphia, 2018


Research Projects Addressing Liver

Disease and Cancer Disparities at

Center for Asian Health, Lewis Katz School of Medicine,

Temple University


Continuum of Interventions for Liver Disease Prevention and Management – RCT Studies

NIH RO1Cluster RCTs

Goal:

HBV Screening and Vaccine

Community-based

Two Arms

NIH R24Intervention

led to Dissemination

Goal:

Dissemination of an Evidence-based HepBIntervention to Korean Churches

- PCORI - NIH RO1

HBV Management

Goal:

HBV Patient

Monitoring Adherence (Doctor Office Visit, Medication)

Patient-Centered

Patient Navigation

Goal:

HBV + accessing to health care

Trained Community Patient Navigators

Primary/Secondary Prevention Program Sustain Patient-Centered Care


Hepatitis B Screening Rates Vietnamese and Korean Americans

NIH RO1, Cluster RCTs

BASELINE POST-INTERVENTION

Grace Ma, PhD, Center for Asian Health, Lewis Katz School of Medicine, Temple UniversityGrace Ma, PhD, Center for Asian Health, Lewis Katz School of Medicine, Temple University

Full Spectrum Multi-level Intervention

Community Engagement

Health

Providers

1. Ma GX, et al., J Health

Care Poor Underserved.

2015;26(2 Suppl):36-52.

2. Ma GX, et al., Cancer.

2018;124(5):973-982.

3. Ma GX, et al., American

Journal of Public Health.

2017;107(3):433-440.

4. Ma GX, et al., Cancer

Health Disparities.

2018;1:e1-e16.


Multilevel Disparities in Asian American Populations

Health Care Access Lack of Health Insurance and a Regular Physician

Lack of Asian language proficiency and cultural sensitivity training

among providers and staff

No Recommendation From Physicians

SES & Lack Of Knowledge Low Socioeconomic Status

Misinformation On HBV Transmission

Not Knowing Where To Go

Sociocultural Barriers and Beliefs Limited English Proficiency/Language Barriers

Discrimination/Stigma

Individual factors: age, gender, infection history, family history

Inadequate Surveillance Non-Adherence to Therapy Advanced Stage Diagnosis

Disparities in Survival &

Health Outcome


A Multilevel Intervention - RCT of Hepatitis B Screening Among High-Risk Vietnamese Americans

(NCI; CA129763 to G. X. Ma.)

American Journal of Public Health. 2017;107(3):433-440


CBPR Approach to Enhancing Hepatitis B Screening and Vaccination for

Underserved Korean Americans(PI: Ma) NIH R24 Cluster Randomized Intervention Trial

Control Group

16 Churches

Intervention Group

16 Churches

Behavior change on increasing Hep B Screening and vaccination

Changes in Knowledge and Attitudes

Perception about Hep B risks, susceptibility and screening benefits

32 Korean Churches

Baseline, Post- 6-M and 12-M Assessments

StratifiedGroup Randomization

Ma, et al. Cancer. November 2017. doi:10.1002/cncr.31134. PMID: 29131316


CBPR Approach to Enhancing Hepatitis B Virus Screening and Vaccination in Underserved Korean Americans

(PI: Ma, NIH/NIMHD R24 RCT)

Cancer. November 2017. doi:10.1002/cncr.31134. PMID: 29131316


HBV Vaccination Rate of Intervention Group at 12-m FU (PI: Ma, NIH/NIMHD R24 RCT)

Sample based on those without HBV immunity, CAH validated data

Cancer. November 2017. doi:10.1002/cncr.31134. PMID: 29131316


Patient-Centered Program to Improve Chronic Hepatitis B Management among Asian-American Patients

(PCORI: AD-1403-12613; PI: Ma)

https://doi.org/10.25302/10.2020.AD.140312613 PCORI final report


Community-Engaged HBV/HCV Liver Cancer Education Initiative (PI: Ma, U54 TUFCCC/HC COC )

Community Partners: • African American Community

• Asian American Community• Hispanic/Latino American

Community

Three Assessment Points

Small Grants to Community Partners

Pre- Post-6-m FL

In-person Workshops

Zoom Workshops


Community Engagement and Capacity Building (PI: Ma, U54 TUFCCC/HC COC)

CBO Partner Social Media

Campaign

on Promoting HBV Screening

Training “How to Zoom”

Training CBO Partner on

HBV/Liver C Education


Community Outreach Campaign(PI: Ma, U54 TUFCCC/HC COC)

Bus Campaign on Promoting

HBV and HCV Screening

Promote Liver Cancer

Prevention in Communities Social Media Campaign

on Promoting HBV Screening


Knowledge Improvement (PI: Ma, U54 TUFCCC/HC COC )

89.30

82.00

63.01

81.94

72.38

78.00

62.34

70.78

59.1756.00

36.99

53.08

89.14

82.00

69.70

83.51

94.79

88.24

94.68 93.77 92.67

84.91

95.6592.26 94.15

77.36

92.47 91.0294.68

90.74

98.8895.17

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Asian African

American

Hispanic Total Asian African

American


American


American

Hispanic Total

HBV vaccine is the best prevention HCV can be cured Baby boomers have the highest rate ofHCV infection

HBV/HCV can cause liver cancer

Percent

(n=388) Pre Post

Know


Knowledge Improvement on Liver Cancer Risk Factors

(U54 TUFCCC/HC COC PI: Ma)

33.8235.71

24.36

31.96

23.19

37.50

25.64 26.10

36.23

66.0767.95

48.39

23.19

16.07

20.51 21.41

17.39

23.2125.64

20.23

53.59

37.50

79.79

57.94

46.41

41.07

82.98

55.15

67.4666.07

91.49

73.54

67.94

39.29

81.91

67.13

60.77

33.93

80.85

61.84

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Asian AfricanAmerican

Hispanic Total Asian AfricanAmerican




Hispanic Total

HBV HCV Alcohol Obesity Diabetes

Percent

(n=388)Pre Post


Goals of

Viral

Hepatitis

NationalStrategic

Plan

2021-2025

Grace Ma, PhD, Center for Asian Health, Lewis Katz School of Medicine, Temple UniversityGrace Ma, PhD, Center for Asian Health, Lewis Katz School of Medicine, Temple University

Opportunities for Eliminating

Hepatitis Health Disparities

Rigorous promotion of hepatitis B vaccination

Screening recommendations and promotion; increasing efforts nationally to get high-risk adults tested for B and C, linkage to care

Community partnership engagement is essential to successful

recruitment, retention and population impact.

Expansion of training and education for community health workers and physicians/clinical staff

Expand hepatitis treatment and access to insurance coverage

Integration of public health and clinical care services

Increasing support to address chronic viral hepatitis in the US & globally


Thank You!

Documents

Break the Silence: Using an Integrated Approach to