Do Recommendations by Healthcare Providers, Family-members, Friends, and Individual Self-Efficacy Increase Uptake of Hepatitis B Screening? Results of a Population-Based Study of Asian Americans

1. Background

Asian Americans are one of the fastest growing racial/ethnic groups in the United States (U.S.).[1] The U.S. Census Bureau predicts that Asian population will reach 11% of the U.S. population by 2050.[2] Asian Americans are heterogeneous groups with respect to country of birth, socioeconomic status, time since immigration, language spoken, religion and other characteristics that may affect their heath.[3] Table 1 presents key demographic and socioeconomic characteristics of the 10 largest U.S. Asian groups by origin.[4]

Asian Americans have a higher prevalence of Hepatitis B virus (HBV) infection compared to other racial/ethnic groups in the U.S.[5] As the surveillance data collected by the U.S. Centers for Disease Control and Prevention (CDC) report, about one-half of all chronic HBV infections are among persons born in Asia and Asian-Americans who were born to HBV infected mothers in the U.S.[6] Approximately 10% of Asian Americans are chronically infected with HBV, while only 1% of non-Hispanic whites are infected.[7] The disproportional prevalence of HBV infection among Asian Americans is considered to be one of the most important health disparities for Asian Americans.[8,9] HBV infection is etiologically associated with Hepatocellular carcinomas (HCC), which is the fourth most common cause of cancer death among Asian Americans.[10] Over time, one in four individuals who acquire HBV as children will develop primary HCC or liver cirrhosis as adults.[11] Preventive measures including a screening strategy are critical to identify individuals who are infected with HBV because patients with chronic HBV infection are usually asymptomatic until the disease has progressed into a more advanced stage.[8] Therefore, the CDC recommends routine HBV screening for Americans from all countries in Asia.[9] However, previous studies show that HBV screening is not widely practiced in the U.S. among Asian Americans.[12-14]

Recommendations from primary care providers and people who belong to one’s social networks are critical sources for communication about the importance of HBV screening.[12] Recommendation by a health care provider (thereafter called Physician) has been described as a major factor which is associated with HBV screening. Results from previous studies show that physician recommendation was independently and positively associated with HBV screening behavior.[12,15-17] In contrast to physician recommendation, the role of family and friend recommendation has received less attention. A few studies examined the impact of recommendation from family and friends on HBV screening.[12,18,19] Taylor found that family and friend recommendations were not significantly associated with HBV screening test among Vietnamese American women after adjusting for other potential confounders.[12] However, Coronado et al. found that receiving a recommendation from a family member was strongly associated with HBV screening among Chinese Americans (OR = 2.7, 95% CI: 1.3, 5.4).[18]

Perceived self-efficacy was also considered as an important factor that related to HBV screening.[20] Self-efficacy is a central concept within the social cognitive theory (SCT).[21] Bandura has defined self-efficacy as the conviction that one can successfully execute the behavior required to produce the desired outcome in various situation.[21] Prior literature has shown that self-efficacy is related to HBV screening.[20] Ma et al. conducted a cross-sectional study to measure the perceptions of risk, barriers, and self-efficacy of HBV screening in Chinese Americans.[20] They found that self-efficacy was significantly correlated with screening behavior (r = 0.14, P < 0.05). In addition to being independently associated with HBV screening, self-efficacy may work in conjunction with perceived social environmental factors when predicting HBV screening behavior.

A growing number of literature have described the importance of recommendation from multiple sources in terms of HBV screening. But very few studies have focused on how different types of recommendation, such as recommendation from physicians, family members and friends, simultaneously impact screening behavior. Moreover, there is limited understanding about the influence of social cognitive factors on HBV screening among Asian Americans. Identification of the effect of recommendation from social networks and self-efficacy may influence future HBV screening interventions developed for Asian Americans. The goals of this paper were to (1) examine variations of the three types of recommendations (physician, family and friend recommendation) across ethnicity groups; (2) simultaneously test the relationship between different types of recommendation and HBV screening behavior; (3) assess the relationship between self-efficacy and HBV screening; and (4) examine how self-efficacy moderates the relationships between recommendation and HBV screening behavior.

2. Methods

The current study used survey data collected by the Maryland Asian American Liver Cancer Education Program. The program was a randomized controlled trial that tested an intervention to increase Hepatitis B screening among Chinese, Korean and Vietnamese in Washington DC Metropolitan area. Participants were recruited through various community-based or faith based organizations, such as churches, language schools, Asian grocery markets and restaurants, nail salons, universities, and individual networks. Detailed eligibility criteria were discussed in other article.[22] The program received approval for Human Subject Research from the Institutional Review Board of Johns Hopkins Bloomberg School of Public Health.

A total of 877 participants were recruited during November 2009 to June 2010, consisting of 303 Chinese, 294 Koreans and 280 Vietnamese. The analytic sample for this study excluded participants who had missing information on recommendations and self-efficacy (n=13), resulting 864 participants in the final dataset.

3. Results

Table 2 shows the characteristics of the study participants. In our sample, 59% of participants were female, and the average age was about 45 years. Each ethnicity group accounted for approximately one-third of the sample. About 66% of the participants were college graduates or had more than college education. But education level significantly varied across the ethnicity groups. There were more Chinese participants with college education or above (84%) compared to Vietnamese (51%). About 67% of the sample had health insurance coverage and 59% had a regular physician. Overall, only a small percentage of participants received recommendation from their social network. About 20% of the participants reported that they received recommendation from physicians, 22% received recommendation from family members, and 13% received recommendation from friends. Approximately 70% of our sample reported not having received any type of recommendation, 14% had one type, and 17% experienced two or more than two types of recommendation.

Out of the 864 participants, 47% reported that they had received HBV screening. The HBV screening behavior differed significantly by gender, ethnicity, education, health insurance, regular physician, all the measures of recommendation, and self-efficacy. Those received HBV screening tended to be male, more Chinese than Korean or Vietnamese, more educated, insured, having a regular physician, receiving recommendation from physician, family and friends, and high self-efficacy.

The proportions of HBV screening varied across the three ethnic groups. Chinese participants reported the highest proportion of HBV screening (55%) compared to Korean (46%) and Vietnamese (40%). For recommendation, higher percentages of Vietnamese respondents than other subgroups reported having received physician recommendation, family recommendation and friend recommendation (p < 0.001). In addition, receiving physician recommendation was more common among those who had a regular physician or who had health insurance. Regarding self-efficacy, Vietnamese participants showed the highest proportion of high self-efficacy (64%) compared to Chinese (39%) and Korean (41%) (data not shown).

Both unadjusted and multivariate adjusted analyses show that there were significant effects of recommendation and self-efficacy on HBV screening in the total sample (Table 3). The three types of recommendations were strong predictors of HBV screening behavior. After adjusting for other factors, participants reported a physician recommendation was more than 7 times as likely to have a HBV screening (OR = 7.49, 95% CI: 4.79, 11.71), followed by family recommendation (OR = 5.46, 95% CI: 3.66, 8.15) and friend recommendation (OR = 3.75, 95% CI: 2.35, 5.98). Compared to those reported not having received any type of recommendation, respondents who received one type of recommendation were almost 5 times as likely to have HBV screening (OR = 4.87, 95% CI: 3.08, 7.70). Having two or more than two types of recommendations were even 9 times associated with HBV screening behavior (OR = 9.28, 95% CI: 5.69, 15.13). In addition, those who had high self-efficacy were more likely to have HBV screening than those with low self-efficacy (OR = 1.51, 95% CI: 1.10, 2.07). Interactions between recommendation variables and self-efficacy were not statistically significant.

The associations between recommendations and screening behavior varied by three ethnic groups. As shown in Table 4, Vietnamese group had the strongest associations between physician and family recommendations and HBV screening compared to Chinese and Korean. For those Vietnamese who received two or more than two types of recommendations were 12 fold as likely to have HBV screening compared to participants without any type of recommendation (OR = 12.43, 95% CI: 6.00, 25.74). The strongest association between self-efficacy and HBV screening was shown among Korean Americans. Those with high self-efficacy were about 3 times as likely to have HBV screening compared to those with low self-efficacy among Korean Americans (OR = 2.97, 95% CI: 1.77, 4.99). There was no significant association between self-efficacy and HBV screening among Vietnamese Americans.

4. Discussion

Our study identified the importance of recommendation from physicians, family and friends on HBV screening behavior. To our knowledge, this study is one of the first studies to simultaneously address the role of physician, family and friend recommendation to obtain a HBV screening in three ethnic groups. In addition, the study also identifies the effect of self-efficacy on HBV screening behavior. The findings suggest that self-efficacy and recommendations from physician and social networks may impact Hepatitis B screening behavior. We also observed ethnic differences in the relationship between recommendation and screening practice. The association was strongest among Vietnamese group compared with Chinese and Korean.

Consistent with earlier studies, physician’s recommendation is one of the strongest predictors of screening among Asian Americans.[12,15-18] Surprisingly, only 20% of individuals in our study had ever received a physician’s recommendation for HBV screening test. In addition, physicians may be reluctant to recommend HBV screening to patients from Asian countries including China, Korean and Vietnamese because of their own lack of knowledge of screening guidelines for Asian Americans. Therefore, health care providers who usually serve Asian American population should intensify their efforts to encourage patients to prevent HBV infection. Among the three ethnic groups, Korean participants showed the lowest level of physician’s recommendation (13%). This may be partially explained by their lack of health insurance. In our sample, Korean had the lowest health insurance coverage among the three ethnic groups (52% vs. 79% for Chinese and 71% for Vietnamese). Other studies also found that Korean Americans were less likely to have health insurance compared with other Asian-American groups.[25,26] A large number of Korean Americans work in small businesses or are self-employed, so they are less likely to obtain employer-based health insurance.[27]

Additionally, our study identified the role of family and friend recommendation on hepatitis B screening. Prior studies have shown the positive relationship between family and friends’ recommendation and screening behavior. Coronado et al. found that receiving a suggestion from a family member to obtain HBV testing was strongly correlated with testing behavior among Chinese American (OR = 2.7, 95% CI: 1.3, 5.4).[18] Another study shows that almost 60% of Vietnamese-American women who received a recommendation from a family member or a friend indicated they had HBV screening compared to 40% of those who did not receive recommendation.[12] Our results corroborated prior findings. Compared to Vietnamese, Chinese and Korean reported lower level of recommendation from family and friends. One possible explanation for Chinese Americans could be the stigma of chronic Hepatitis B, which is widespread in employment, school, and social discrimination.[28] In China, it is mandatory for health workers to report a positive test result of HBV screening to the patients’ school and employer before 2010.[28] Only in 2011, the Ministry of Health proposed regulations prohibiting hospitals from carrying out HBV tests for companies as part of pre-employment physical examination.[15] But these regulations might not have changed misunderstandings and discrimination among Chinese Americans and this trend may continue in near future. Such reporting policies may deter individuals from getting screened and sharing information about HBV prevention.

Our study is consistent with the SCT theory that individual’s belief in one’s ability to accomplish a task can lead them to take the action.[21] We found that self-efficacy had a significant impact on HBV screening behavior. Interestingly, Vietnamese Americans showed the highest proportion of high self-efficacy compared to Chinese and Korean Americans, but no significant association between self-efficacy and HBV screening was observed among Vietnamese Americans. One possible explanation could be that the differential socioeconomic profiles exhibited among the three Asian subgroups. Compared to Chinese and Korean in the sample, Vietnamese participants were less educated (51% of Vietnamese had college or higher education compared to 84% Chinese and 63% Korean). The lower educated Vietnamese may experience more difficulties to receive HBV screening, even though they had a higher level of self-efficacy. Therefore, other than enhancing self-efficacy, comprehensive interventions should focus on raising individual’s knowledge and understanding of Hepatitis B and early detection, overcoming the access and cultural barriers, and encouraging proactive behavior.

Our study has several limitations which can be addressed in future studies. First, our recruitment is not based on probability sampling method since our population is a hard-to-reach population. It is possible that self-selected population is more knowledgeable about HBV infection and has a greater motivation to get the screening. However, our sample composition closely follows that of the United States 2010 Census data,[29] so non-probability sampling may not have a major impact in interpreting study findings. Secondly, the majority of our study population was first generation Asian Americans. Thus, variability for recommendation and self-efficacy might have been smaller than studies that included more US born Asian Americans. This might have reduced our ability in detect potential impact of self-efficacy and recommendation on HBV screening. Thirdly, our outcome data are based on self-reported HBV screening behavior which may be inaccurate due to recall and social desirability biases. Similarly, self-report of recommendation to get screened may be more likely to be recalled by participants who perceived HBV screening as more important.

5. Conclusion and Global Health Implications

Immigrants from Asian countries to the United States have been dramatically increasing. Health disparities, specifically HBV infection, adversely affect Asian populations. This study will advance our understanding of recommendation and self-efficacy among Asian Americans. The findings of our study provide useful insights on how recommendation from physicians and social networks influence on HBV screening behavior among Asian Americans. Future research may address the cultural context of self-efficacy. The study suggests that educational interventions for Asian Americans involving family and friends and Asian-serving physicians should be effective in increasing the prevalence of HBV screening.