Medical Care of Hepatitis B among Asian American
Populations: Perspectives from Three Provider Groups
Jessica P. Hwang, MD, MPH
, Aimee K. Roundtree, PhD
, Joan C. Engebretson, PhD
and Maria E. Suarez-Almazor, MD, PhD
Department General Internal Medicine, Ambulatory Treatment & Emergency Care, The University of Texas M.D. Anderson Cancer Center,
Houston, TX, USA;
University of Houston-Downtown, Houston, TX, USA;
The University of Texas School of Nursing, Houston, TX, USA.
BACKGROUND: Physicians can play a significant role
in helping to decrease the hepatitis B virus (HBV)
burden among Asian Americans. Few studies have
described knowledge and practice patterns in the
medical community among different provider types
regarding HBV and liver cancer.
OBJECTIVE: Our study explores the HBV beliefs,
attitudes and practice patterns of medical providers
serving Asian American communities.
DESIGN: We conducted three focus groups with prima-
ry care providers, liver specialists, and other providers
predominantly serving Asian American community. We
asked about practices and barriers to appropriate
medical care and outreach.
PARTICIPANTS: We moderated three focus groups with
23 participants, 18 of whom completed and returned
demographic surveys. Twelve were of Asian ethnicity
and 13 spoke English as a second language. Only eight
screened at least half of their patients, most (72%) using
the hepatitis B surface antigen test.
APPROACH: We used grounded theory methods to
analyze focus group transcripts.
RESULTS: Participants frequently discussed cultural
and financial barriers to hepatitis care. They admitted
reluctance to screen for HBV because patients might be
unwilling or unable to afford treatment. Cultural differ-
ences were discussed most by primary care providers;
best methods of outreach were discussed most by liver
specialists; and alternative medicine was discussed
most by acupuncturists and other providers.
CONCLUSIONS: More resources are needed to lower
financial barriers complicating HBV care and encourage
providing guideline-recommended screenings. Other
providers can help promote HBV screening and in-
crease community and cultural awareness.
KEY WORDS: provider attitudes; Hepatitis B; Asian Americans;
qualitative research; focus groups.
J Gen Intern Med 25(3):220–7
© Society of General Internal Medicine 2009
Hepatitis B virus (HBV) is a human carcinogen responsible for
HBV is transmitted through percutaneous
contact with infectious blood or body fluids, such as sex with
infected partners, needle sharing, or birth to infected
Of the estimated 1.2 to 2 million people in the US
diagnosed with chronic HBV, over half are Asian Americans.
The prevalence of chronic HBV among foreign-born Asian
Americans is approximately 10%
, compared to 0.5% in the
overall US population and 0.2% in whites. A fourth of
individuals with untreated HBV die from liver cancer or
Since Asian Americans have the highest rates of
chronic hepatitis B among all racial and ethnic groups in the
US, they are also at disproportionately high risk of liver cancer,
which is the third leading cause of cancer death among Asian
Americans in the US, compared to 16th among whites.
Previous research in the US has shown that lack of patient
knowledge about HBV is associated with lack of screening.
In turn, lack of screening and delays in diagnosis increase
morbidity and mortality. Physicians play a significant role in
decreasing the HBV burden among Asian Americans by
improving the identification and care of persons with chronic
promoting patient knowledge about HBV and liver
cancer, and advising patients to get screened or follow
communication can improve patients’ use of health care
services and compliance with health care directives.
Problems with communication may negatively affect patients’
perceptions of illness, screening, and treatment.
Little is known about HBV knowledge and practices among
different provider types. One study that targeted providers
serving Asian American communities was a retrospective
cohort study of health care providers’ knowledge and practices
regarding HBV in Chinese-speaking patients. The authors
found that many providers underestimated HBV risk.
veys can provide quantitative accounts of practice patterns,
but more in-depth exploration is needed to uncover factors
that may impact practice. We conducted an in-depth qualita-
tive study to better understand and elucidate the beliefs,
attitudes and practice patterns of medical providers serving
Asian American communities.
After receiving approval from the institutional review board at
The University of Texas M. D. Anderson Cancer Center, we
Received April 24, 2009
Revised September 17, 2009
Accepted October 28, 2009
Published online January 5, 2010