Break the Silence: Using an Integrated Approach to ...
Transcript of 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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
Liver Cancer: Fast Increase In the U.S.
72% 2003 – 2017
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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.
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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.
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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.
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
Research Projects Addressing Liver
Disease and Cancer Disparities at
Center for Asian Health, Lewis Katz School of Medicine,
Temple University
Grace Ma, PhD, 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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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.
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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
Hispanic Total Asian African
American
Hispanic Total Asian African
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
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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 Asian AfricanAmerican
Hispanic Total Asian AfricanAmerican
Hispanic Total Asian AfricanAmerican
Hispanic Total
HBV HCV Alcohol Obesity Diabetes
Percent
(n=388)Pre Post
Grace Ma, PhD, Lewis Katz School of Medicine, Temple University
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