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PEDIATRICS
Vol. 104 No. 5 Supplement November 1999, pp. 1212-1216
Differences
in Knowledge of Hepatitis B Among
Vietnamese,
African- American, Hispanic, and
White
Adolescents in Worcester, Massachusetts
John
M. Wiecha, MD, MPH
From
the Department of Family Medicine, Boston University School of
Medicine,
Boston, Massachusetts.
ABSTRACT
Objective.
To assess the level of knowledge about hepatitis B of
Vietnamese adolescents, a group at high risk for hepatitis B, and compare it to
the knowledge of adolescents of other races and ethnicities.
Methods.
A sample of 2816 adolescents was surveyed in 1993 in 2
middle schools and 2 high schools in Worcester, Massachusetts, using a
self-administered multilingual questionnaire.
Results.
Knowledge of hepatitis B was low overall. Vietnamese
respondents were more likely than were other students to know that hepatitis B affects the liver
(35.6% vs 22.6%). However, they were much less likely than
were other students to correctly identify sex with an infected
person as a risk factor for infection (13.7% vs 32.8%).
Independent predictors of this knowledge were: white race; older age;
attending high school versus middle school; having been taught
about hepatitis B in school; knowing the definition of
hepatitis B; reporting better grades; having a family member
with hepatitis B; and being more highly acculturated.
Conclusions.
Adolescent knowledge about risk of infection was low in
this study. Attention should be directed at providing health education on hepatitis B to
adolescents, particularly to Vietnamese. Health care
providers, community health educators, and others engaged in the
effort to control and eradicate hepatitis B should be
sensitive to the unique educational and cultural needs of high-risk southeast
Asian adolescent populations.
Key words: adolescent
behavior, health surveys, health promotion, Asians, Asian
Americans, Vietnam, hepatitis.
Reduction of hepatitis B infection is a
national public health priority.1 Hepatitis B infection may
result in acute and chronic morbidity and mortality. Neonatal
hepatitis B infection frequently persists in a chronic carrier
state, and confers significant risk of morbidity and mortality from liver
disease, such as cirrhosis and hepatocellular carcinoma in
early adulthood.2,3 Infection with hepatitis B during adolescence and
adulthood is associated with a lower risk of chronic infection
but, is an important public health problem. In the United
States, >330 000 new cases of hepatitis B occur per year.4
Approximately 70% of new hepatitis B infections occur in
adolescents and young adults.5
Once infection occurs, transmission can
occur horizontally via contact with blood products, through
sexual contact and even through apparent casual contact in the
household.6 Strategies to prevent transmission from persons
already infected include: immunization of nonimmune individuals;
identification of persons with chronic infection with targeted
health education to reduce transmission to household, sexual,
and vertical contacts; and at a community level, promotion of
safe sex practices including the use of condoms.
Seroprevalence studies have demonstrated
that specific populations are at particularly high risk of
hepatitis. Highest risk are persons from southeast Asia with a
seroprevalence of 12% to 16%.7 Since 1975, >1 million
refugees and immigrants have emigrated from southeast Asia to the
United States. Over a half (59%) of southeast Asians who have
come to this country originated from Vietnam, of whom more
than one quarter were children.8 The Vietnamese population in
the United States increased by more than twofold between
1980 and 1990,9 and is projected to reach 4 million by the
year 203010 attributable to fertility and continued immigration.
Relatively few studies have focused on
the health status and health behavior of Vietnamese or other
Asian Americans, and little effort has been directed at health
education on hepatitis for southeast Asian adolescents. Asian
children are relatively undervaccinated for hepatitis B.11
Development and implementation of effective clinical and
public health prevention strategies for hepatitis B are predicated
on an understanding of the knowledge and attitudes among
adolescents regarding hepatitis B infection. In particular, we
need a better understanding of Asian American adolescents'
perception of the risk of sexually transmitted hepatitis B, given
the historical reticence of persons from Asian cultures to
discuss sexuality and death and dying openly.12 This article reports the
results of a survey designed to assess knowledge of hepatitis
B infection by Vietnamese American adolescents, and to
compare their knowledge with other racial and ethnic subgroups
of adolescents.
METHODS
Study Population
Worcester, Massachusetts, is a city of
169 759 (of whom 1.2% are Vietnamese)13 located in central Massachusetts. The target population for
this survey administered in 1993 (part of a larger study on
health knowledge and practices) consisted of all
students at 2 public high schools and 2 public middle schools
in Worcester. These schools were selected as
having the greatest number of southeast Asian students,
according to school department records. The schools selected
represented 66% of the total Asian middle school and high
school population. The study was reviewed and approved by the
Institutional Review Board of the University of Massachusetts
School of Medicine.
Parents were given the opportunity to
exclude their child from the survey via a mailed notification
form. Subjects were instructed that their participation was
voluntary and that they could withdraw from the survey at any
time without penalty. A total of 2816 students returned completed
surveys, for an overall response rate of 80% of enrolled
students. The response rate was 83% in each of the middle schools and
89% and 68% in the 2 high schools. The overall response rate
as a percentage of students present on the day of survey
administration was 92%. Fifteen students declined
participation, and none withdrew during the survey.
Survey Instrument
All items were presented in English,
Spanish and Vietnamese. Each question was visible in 3
languages at all times. The instrument was translated to Vietnamese
by a team of experienced Vietnamese health educators and then
back translated into English and discrepancies resolved in a
group process. In addition, individual Vietnamese American
students pretested the survey to ensure student understanding of
all questionnaire items. Spanish translation was done by a
professional English-to-Spanish survey translation
firm. Questions on hepatitis B were designed to assess basic
knowledge about the infection and past screening, and
included: identification of the correct definition of
hepatitis B ("infection of the liver"); identification of an efficient potential
route of infection relevant to adolescents ("having sex
with someone who has hepatitis B"); awareness of blood testing for
hepatitis B; knowledge of the results of blood test for
hepatitis B if tested; and family members' previous diagnosis of hepatitis
B. Students were also queried regarding exposure to
school-based curriculum on hepatitis B. Race/ethnicity was reported
as Black, Vietnamese, Cambodian, Hispanic, White, Chinese, or
other. Acculturation was approximated by self-report of how
well English was spoken; language use is a reasonable
indicator of acculturation in southeast Asian and other populations.14
The survey was administered by school personnel in lieu of
regularly scheduled classes, or during an extended morning
homeroom period. It was self-administered anonymously with a
separate op-scan answer sheet.
Statistics and Modeling
Data were entered and analyzed with
Paradox 3.5 (Borland; Scotts Valley, CA), EPI INFO 5.0
(Centers for Disease Control and Prevention; Atlanta, GA), Egret
(Statistics and Epidemiology Research Corporation; Seattle,
WA), SAS (SAS Institute; Cary, NC). Differences between
proportions are reported as odds ratios (ORs); 95% confidence
intervals (CIs) of ORs were calculated using normal approximation or
exact methods as appropriate. Associations between independent
and dependent variables were determined by logistic regression
models
RESULTS
Characteristics of the Sample
The respondents identified their
race/ethnicity as follows: 226 (8.1%) Vietnamese; 263 (9.4%) African-American; 545 (19.4%) Hispanic;
1615 (57.5%) White; and 158 (5.6%) other race/ethnicity including Chinese and Cambodian. Of the
Vietnamese, 87% reported their place of birth as Vietnam, 9% the United States, and remainder in other
southeast Asian countries. Additional characteristics are
found in Table 1. Half of Vietnamese respondents had been in the
United States for 5 years or less. Students >15 years old
reported residence in the United States for less time than did
younger students. About one third reported speaking English
poorly or not at all, and 40% made use of at least some Vietnamese
translation while completing the survey.
Characteristics
and Knowledge of Hepatitis B Among Middle and High School
Students,Worcester, Massachusetts, 1993
Knowledge of Definition of Hepatitis B
Among all students, the rate of correctly
identifying the definition of hepatitis B was low (23.6%).
There was no significant difference between girls (24.0%) and boys
(22.1%). Vietnamese respondents were more likely than were
other students to know the definition of hepatitis B,
(35.6% vs 22.6%; OR = 1.89, 95% CI 1.38, 2.58; P < .001).
Students in middle school were less likely than were students in
high school to answer correctly (15.4% vs 30.6%, OR = .41, 95%
CI = .34, .50; P < .001), as were students <16
years old (19.8% vs 30.5% among students 16 years and older,
OR = .56, 95% CI = .47, .68; P < .001).
Students who reported having been tested
for hepatitis B were more likely to correctly identify the
definition of hepatitis than were those students who did not report
having been tested (34.4% vs 22.1%; OR = 1.85, 95% CI = 1.43,
2.39, P < .001).
Several other factors associated with
knowledge of hepatitis are presented in the regression models
discussed below.
Knowledge of Risk Factor for Hepatitis B
Sexual contact with an infected person
was correctly identified as a risk factor for infection by 880
(31.3%) of respondents
Fewer of middle school
students (16.5%) than high school students (44.1%) answered
correctly (OR = 3.94, 95% CI = 3.28, 4.74; P < .001). Students
aged 16 or older were more likely than were younger students
to answer correctly (43.2 vs 24.4%; OR = 2.38, 95% CI = 2.00,
2.82; P < .001). There were no significant gender
differences for this variable.
Vietnamese respondents were much less
likely than were other students to correctly identify sexual
transmission as a risk factor (13.7% vs 32.8%, OR = .33, 95% CI = .22,
.50, P < .001). Additional factors associated with
knowledge of source of infection are presented in the regression
models discussed below. Rates of having been taught about
hepatitis B are presented in Table 1. Middle school students were
less likely than were high school students to report hepatitis
B education (14.8% vs 36.7%; P < .001).
Regression Models
A number of factors were independently
associated with knowledge about hepatitis B (Table 2).
Relative to white students (the largest comparison group), after
adjustment for school level, having received education about
hepatitis B, having been tested for hepatitis B, and gender,
Vietnamese subjects were more likely to know the definition of
hepatitis B (adjusted OR = 1.52), and Hispanic Americans were
less likely. The unadjusted OR for Vietnamese students
relative to whites was 1.62, indicating that the other variables
in the model did not strongly confound this association. Males
were less likely than females to correctly respond to this
item. High school students and students who reported having
been tested for hepatitis B were more likely to correctly identify
the nature of hepatitis B infection. The strongest predictor
overall was having been taught in school about hepatitis B.
TABLE 2
Independent Predictors of Knowledge of Definition of
Hepatitis B Among Middle and High School Students,
Worcester, Massachusetts, 1993
In a regression model, after controlling
for age, having received education about hepatitis B,
knowledge of definition of hepatitis B, poor academic performance,
reported family member with hepatitis B, school level, and
poor spoken English, Vietnamese students continued to be
significantly less likely than all other groups to correctly
identify sex with an infected person as a risk factor for infection
with hepatitis B (relative to whites, adjusted OR = .23;
unadjusted OR = .29; see Table 3). Hispanic respondents were also less
likely than whites to correctly identify this risk factor. The
strongest predictor of identifying sex as a risk factor was
having been taught about hepatitis B in school. Students who
reported below average school performance, and those reporting
poor spoken English, were much less likely to identify this
risk factor.
TABLE 3
Independent Predictors of Knowledge of Sexual Contact
as a Risk Factor for Infection with Hepatitis B. Middle and High School Students,
Worcester, Massachusetts, 1993
To assess literacy effects on question
comprehension, rates of missing data were examined. Vietnamese
American subjects were more likely than were other subjects
to leave blank the item on sexual transmission of hepatitis B
(8.4% vs 4.9%; P = .022). However, the rate of missing
data on this item for Vietnamese was no different from the
rate of missing data for questions judged to have less complex
vocabulary.
DISCUSSION
Subjects in this study demonstrated an
overall low level of knowledge about hepatitis B. Vietnamese adolescents were more likely than were
other students to identify the definition of hepatitis B,
although only about one third were able to do so.
Moreover, Vietnamese youth, who have the highest
seroprevalence of hepatitis B, were much less likely to
identify a critical risk factor for transmission: sexual
contact with an infected person.
Respondents who reported having been
taught about hepatitis B in school were much more likely to
know both the definition of hepatitis B and to correctly identify
a source of transmission, lending indirect support to
school-based efforts to educate adolescents about hepatitis B. During the
year before this study, health education on hepatitis B had
been presented to Vietnamese high school and middle school
students during informal group sessions as part of an Asian
youth health fair. Otherwise, hepatitis B was not a formal
component of the schools' health education at the time of this
study, and had not been introduced at the time of
publication of this study.
Other factors were identified that should
help identify adolescents worthy of particular attention from
health educators, pediatricians, and other providers of
health care to adolescents: less acculturation, as indicated
by low English proficiency; attendance in middle school; age <16
years; and below average performance in school. Students with
these characteristics were even less likely to identify the
risk factor for transmission of hepatitis B, and may benefit
from programs targeted specifically to them with appropriate
attention to cultural competence, curricular complexity, and
language of presentation.
Each year, approximately 5000 persons in
the United States die of cirrhosis of the liver related to
hepatitis B, and another 1500 die of liver cancer related to
hepatitis B.15 Hepatitis B viral DNA can integrate into DNA
leading to oncogenicity, resulting in hepatitis B being the most
common cause of liver cancer worldwide.15 Efforts to control
hepatitis B include: screening of pregnant women to interrupt
vertical transmission; vaccination starting at birth;
immunization of 11- to 12-year-olds and high-risk populations;
screening of blood and other tissue products; community-based
health education to identify persons appropriate for
screening or vaccination; primary care-based health education
to effect risk factor modification and lifestyle change; and
appropriate medical management of hepatitis B carriers. There
is evidence that this strategy is effective. A decrease has
occurred in the incidence of liver cancer in areas that have
implemented hepatitis B vaccination programs.16 According to the
Centers for Disease Control and Prevention, hepatitis B
vaccine is the first vaccine that prevents a type of cancer.17
Maintenance of a high vaccine coverage rate is a goal of The
Initiative to Eliminate Racial and Ethnic Disparities in Health.18
Vaccination of adolescents in geographic regions of high and
average incidence of hepatitis B is economically attractive.19
Hepatitis B vaccination of adolescents should be done as part
of a routine vaccination visit between the ages of 11
and 12 years.11 The design and implementation of effective and
efficient public health interventions to control hepatitis B is
predicated on an understanding of the target population's
knowledge of hepatitis B.
The data presented in this study will be
relevant to public health and medical professionals in the
design of prevention programs at the primary (prevention of
infection), secondary (early detection), and tertiary
(treatment) levels. To be effective, such efforts must be sensitive to the
cultural attributes of Vietnamese and other Asian adolescents
with respect to sexual behavior and communication.20 Culturally
appropriate community health education, and health care
provider-delivered education, will reflect that it may not
be acceptable for Asians to discuss sexuality openly, and that
communication about prevention of sexually transmitted
disease between Asian sexual partners is limited.21 In the
experience of the author, small same-sex discussion groups on hepatitis B
prevention led by peers or young adults are well received by
adolescents. Other effective community-based strategies
include multidisciplinary efforts using mass media strategies,
combined with efforts to address access barriers to
immunization.22
Pediatricians and family physicians can
increase the effectiveness of their counseling of Asian
adolescents by using well trained, confidential, medical interpreters when
appropriate. Developing an understanding of the impact of
cultural norms on adolescent behavior and on adolescents' expectations
of the clinical encounter will also help physicians
communicate with patients from different cultures. Understanding can be
promoted by asking the patient to educate the physician about
his or her culture, including cultural, family and religious
expectations regulating youth behavior, and conflicts arising
from these norms when they confront western lifestyles. This
approach will also dispel stereotypes and increase trust
between adolescents and health care providers. Oftentimes, the discussion can
subsequently progress smoothly to sensitive subjects such as
prevention of sexually transmitted diseases.
Several limitations of this study are
worth noting. Because of restrictions on inclusion of survey
questions about sexual activity, we were not able to inquire about actual
patterns of condom use, or patterns of sexual activity. All
data are self-reported, and we were not able to validate responses to
questions about family members, or about personal testing for
hepatitis B. It is possible that students may have confused
hepatitis B with other types of hepatitis. Students with low
literacy levels, and some younger students in middle school, may
have had difficulty with item comprehension. Although this
study is based on a local sample in Worcester, Massachusetts, we
have reason to believe the findings apply more broadly. The
generalizability of this report is supported by similarities
observed between other characteristics of this sample, such as
smoking, with patterns observed in studies sampling larger or
geographically dissimilar populations of adolescents.23
However, it is possible that hepatitis B education and characteristics
of adolescents elsewhere may differ from patterns observed in
Worcester.
Overall, these results suggest that more
attention should be addressed at providing health education on
hepatitis B to adolescents, and particularly to
Vietnamese American and Hispanic adolescents. A rational
health education strategy would incorporate hepatitis B education with
human immunodeficiency virus health education programs as the
risk factors are similar. It will also continue to be
critical to screen at-risk individuals for hepatitis B to
identify chronic carriers. Such individuals require individual counseling
to reduce the risk of sexual and household transmission, as
well as careful ongoing screening, treatment where appropriate,
and health education for lifestyle modification to reduce the
risk of morbidity and mortality from hepatocellular carcinoma
and cirrhosis.
Future studies should focus on developing
a better understanding of risk behaviors among those at
highest risk of hepatitis B infection, including southeast Asian
American adolescents and young adults (particularly the
foreign-born) to help guide development of effective school and
community-based health education methods and curriculum. In
addition, the goal of reducing short- and long-term
consequences of hepatitis B infection and eventual eradication
can be promoted by developing strategies to better equip providers of
adolescent health services with the knowledge, attitudes, and
skills to provide effective preventive and therapeutic services to
at-risk adolescents.
ACKNOWLEDGMENTS
This work was supported by a Research
Fellowship with the Institute for Asian American Studies,
University of Massachusetts, Boston, and by the
American Cancer Society, through a Cancer Control Career
Development Award for Primary Care Physicians.
Received for publication Mar 29, 1999;
accepted Jun 29, 1999.
Reprint requests to (J.M.W.) Department
of Family Medicine, Boston University School of Medicine,
Dowling 5 South, 1 Boston Medical Center Pl, Boston, MA
02118. E-mail: john.wiecha@bmc.org
ABBREVIATIONS ORs, odds ratios; CIs, 95% confidence
intervals.
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