The mission of SFHBF is to make San Francisco the first hepatitis-B-free city in the nation. The objectives of SFHBF are: (1) to create public and health care provider awareness about the importance of testing and vaccination to decrease the burden of hepatitis B in the API community; (2) to promote routine hepatitis B testing and vaccination, and make them the standard of care in the primary medical community; and (3) to ensure access to treatment for chronically infected individuals. To accomplish these objectives, the program uses culturally targeted strategies to increase hepatitis B testing, vaccination, and treatment services in the high-risk API community; and it promotes general knowledge about hepatitis B to create broad public awareness and institutional change toward ending hepatitis B infection.

SFHBF was designed as a grassroots, community-based health initiative with these guiding principles: (1) to maximize use of existing resources and community organizations, rather than to create a new standalone institution; (2) to be self-sustaining and integrated into the existing health care system; (3) to adopt practices that could be readily replicated elsewhere; (4) to pursue all available funding opportunities, but not wait for funding before taking action; (5) to remain focused on the primary goal of hepatitis B control; (6) to reflect and take advantage of specific characteristics of the API community, and (7) to use a multi-faceted approach targeting the API community, the health care system, policy makers and public officials, and the general public. Many of these guiding principles follow the theoretical framework of Community Coalition Action Theory [25], which posits that through collaboration and synergy, community coalitions can bring about changes that the contributing members would be unable and, often, unwilling to accomplish individually [26].

San Francisco possesses unique characteristics that served as both an impetus and a challenge to the initiation of SFHBF. APIs comprise one-third of San Francisco’s nearly 800,000 residents, and 67% of those APIs are foreign-born [6]. At the county level, San Francisco has the highest incidence rate of liver cancer in the nation [27]. Because 91% of API adults in San Francisco have health insurance [28], SFHBF could function within existing medical infrastructure by encouraging people to visit their regular health care provider for hepatitis B testing, vaccination, and follow-up.

In April 2007, SFHBF was launched after 6 months of strategic planning by the founding Steering Committee. This committee’s makeup reflects the depth and breadth of experience among partners in the campaign, and includes a specialist in health promotion (from the San Francisco Department of Public Health [SFDPH]), an academic and clinical expert on hepatitis B and liver cancer (from the Asian Liver Center at Stanford University [ALC]), and an API community and media leader (from the AsianWeek Foundation [AWF]).

SFDPH has been involved in hepatitis B prevention and detection efforts since the 1990s. In 1997, SFDPH permanently allocated general funds to purchase adult hepatitis B vaccine for distribution to clinics and other community partners serving low-income, uninsured patients. SFDPH’s commitment to SFHBF was critical for enlisting involvement of other health care players, adding legitimacy to interactions with community groups and the public, and contributing expertise in health promotion and education. SFDPH houses all data collected for SFHBF, and oversees campaign documentation and evaluation efforts.

ALC was established at Stanford University in 1996 as the first non-profit organization devoted to addressing chronic hepatitis B and liver cancer among APIs. ALC provides SFHBF with expertise in hepatitis B outreach, education, advocacy, and community-based research. In 2004, ALC partnered with SFDPH to launch “3 For Life,” a 1-year pilot program that offered semi-monthly hepatitis B testing and vaccination for a discounted fee at a non-clinical community setting in San Francisco. The results of this project offered proof of the need for expanded hepatitis B testing and education for San Francisco APIs [29].

AWF was founded in 2004 to organize and develop the API community. AWF provides SFHBF with strategic and tactical expertise on mobilizing the community to action. AWF also provides media expertise in reaching the API and general markets, understanding of the nuanced cultural protocols of the API community, and using community networks to engage public officials. In 2006, AWF invited ALC to the Asian Heritage Street Celebration in San Francisco to conduct the largest ever one-day hepatitis B screening event, at which 536 adults were screened in 5 h. Over the next few months, AWF brought together the San Francisco Health Commission and California Assembly Speaker Pro Tempore Fiona Ma to share the vision for universal hepatitis B screening for API adults. These discussions led to the creation of the Hep B Free model.

Fiona Ma was a San Francisco Supervisor in 2006, when she authored a resolution unanimously approved by the Board of Supervisors “establishing the goal of universal hepatitis B screening and vaccination for Asian and Pacific Islander residents of San Francisco.” Ms. Ma, who herself is chronically infected with hepatitis B, provided leadership and motivation for SFHBF by publicly discussing her own experience with hepatitis B. She has become a national spokesperson for hepatitis B awareness, prevention, and detection efforts, and provides SFHBF with guidance on policy making and assistance with motivating high-level decision makers in public and private organizations to take more active roles as SFHBF partners.

Before officially launching SFHBF, the Steering Committee established certain minimum infrastructure requirements, including the campaign’s name, mission, project description, website, and logo, and conducted basic research on the size, demographic characteristics, and health insurance coverage of the at-risk population.

The Steering Committee first conducted preliminary meetings and conversations with health care, industry, and community groups to assess interest in and feedback on a community-wide hepatitis B control effect. This process identified key issues, needs, and messages to ensure buy-in from key stakeholders and constituencies. In addition, the Steering Committee sought strong advocacy by garnering the support of high-profile leaders including Ms. Ma and San Francisco Mayor Gavin Newsom.

Obtaining commitments from all public and private county hospitals was critical to the campaign’s success. Hospitals and clinics were initially approached individually, after which the Steering Committee presented collectively to hospital chief executive officers at the San Francisco Hospital Council, a regional trade association. Each hospital took on a different role in SFHBF, with no single hospital designated as leader. By mid-2007, all San Francisco hospitals had pledged to prioritize elimination of hepatitis B. SFDPH committed to providing follow-up care to uninsured patients with chronic hepatitis B, and Hospital Council members pledged back-up support. In addition, health care institutions coordinated to create public hepatitis B testing and vaccination sites in the community, arrange continuing medical education courses, network with corporate sponsors, and perform research on hepatitis-B-related health care.

Non-health-care community partners, including virtually every local API community group, were recruited or volunteered to join the campaign by incorporating hepatitis B prevention into their own program as appropriate with their existing mission and resources. This integration encouraged increased participation and ownership by each partner organization, while the absence of minimum “membership” requirements enabled partners to contribute at whatever level was practical. For example, local merchants distributed SFHBF branded shopping bags, while two local colleges instituted campus-wide education, screening, and vaccination programs for all students, staff, and faculty. Community partners helped to disseminate campaign messages in culturally effective ways and ensure that the activities and policies of the campaign reflected community needs and cultural practices.

A core group of approximately 40 organizations have been considered as active partners that participate in monthly working meetings to plan strategies, implement activities, share resources and best practices, report on progress, and request assistance when necessary (Table 1). Specific tasks are accomplished by separate working groups with designated point persons. Active partners complete a survey every 6 months to detail their involvement via activities, expenses incurred, and services provided. The remaining community partners participate by attending and supporting SFHBF events and disseminating educational information via their own networks.Table 1

Actively participating partner organizations of the San Francisco Hep B Free Campaign, 2007–2010

SFHBF was conceptualized and launched with no formal funding source. Each participating organization finds its own funding for its own programs. SFHBF uses a neutral fiscal agent to manage funds, and raises funds only for public awareness and education efforts, community outreach, and program evaluation. The campaign secured nearly $2.5 million through 2009 in direct and in-kind donations from partners, government agencies, corporations, and private donors, as well as approximately 8,000 volunteer hours. Sources of funds include community fundraising events, corporate sponsorships, and grants from foundations, corporations, and the federal government.

To incorporate routine hepatitis B testing of all API patients into standard health care, education of health care providers is essential. SFHBF began educating providers through ongoing grand rounds and continuing medical education events throughout the city. In addition, a physician working group collaboratively developed a quick-reference hepatitis B diagnostic flowchart for testing, test interpretation, and clarification of common misconceptions about hepatitis B and liver cancer. To further engage physicians, all health care providers in the city were asked to sign a pledge form stating that they would follow the CDC recommendations to test every API patient for hepatitis B. Physicians were contacted by sending fax messages from SFDPH, making telephone calls to physicians’ offices, recruiting physician champions from each health care institution, and networking through medical groups and independent practice associations.

General community awareness about hepatitis B was promoted through grassroots community organizing, outdoor advertising on billboards, taxi tops, train stations, and bus panels and shelters, and advertising and news coverage in major mass-media covering the general and Asian print, radio, television, and internet markets (Fig. 1). Advertising campaigns were designed pro bono by leading Asian American advertising agencies. Media placements were funded through in-kind donations and cash in an approximately 4:1 ratio. Educational materials, including brochures, posters, and public service announcements, were translated into Cantonese and Mandarin Chinese, English, Korean, Tagalog, and Vietnamese by local API media and medical students and undergraduates with background knowledge of hepatitis B. SFHBF’s community involvement also provided unique access to public officials. SFHBF leaders worked with community advocacy groups, policymakers, and lobbyists to promote opportunities for legislative or regulatory changes regarding hepatitis B prevention, management, and research.Fig. 1

Examples of San Francisco Hep B Free advertising campaign materials. a Bus side advertisement with San Francisco Mayor Gavin Newsom and California State Assemblywoman Fiona Ma. b “B a Hero” Bay Area Rapid Transit poster. c “B a Hero” promotional vehicle donated by Subaru of America. d “Which One Deserves to Die?” campaign poster featuring beauty pageant contestants

A key component of SFHBF is provision of testing, vaccination, and follow-up for hepatitis B through existing health care providers. Hospital and clinic-affiliated testing and vaccination sites were funded, staffed, and managed by their independent institutions. Seven standalone public sites providing free hepatitis B testing and low-cost vaccination were established throughout the city beginning in 2007. These sites supplemented rather than replaced private providers or clinics, by making services more convenient for those with existing primary care, and to fill an unmet need for those without health insurance. Sites were manned by bilingual hospital/clinic staff and trained volunteers. Each site was separately managed according to its host institution’s infrastructure.

At the outset, clinical partners convened to agree on overall goals and strategies, establish minimum standardized testing and vaccination protocols, and define the basic data points on participant registration forms. Each partner site informed clients about their serological test results and recommended follow-up steps using a variety of methods. Clients found to be protected against hepatitis B were sent letters, while susceptible clients (who were advised to be immunized against hepatitis B) or chronically infected clients (who were advised to seek follow-up medical care) were contacted via a combination of letters, phone calls, e-mail, and in-person appointments.

At each testing/vaccination site, clients completed a standardized registration form providing basic demographic and health-related information. By request, hospital laboratories and independent diagnostic laboratories serving San Francisco provided data on the total number of HBsAg and anti-HBs tests ordered annually. Results from partner surveys and patient registration forms were analyzed using SAS version 9.1.3 (Cary, NC). We used logistic regression analysis to estimate unadjusted or multivariate adjusted odds ratios for associations with HBsAg positivity or anti-HBs negativity. All tests of significance were two-sided, and p-values ≤ 0.05 were considered statistically significant.

SFHBF officially commenced in April 2007 with a community dinner with nearly 500 attendees representing over 150 community groups that pledged support for the campaign. Invited groups included hospitals, health care organizations, community-based organizations, academic institutions, student groups, professional societies, social service agencies, government agencies, media and advertising companies, and corporations. Additional partners asked to join the campaign or were recruited over time. As of 2010, more than 160 groups are partners in SF HepB Free, including more than 40 active partners (listed at http://sfhepbfree.org/aboutus/ and in Table 1).

Among the 24 major partner organizations that completed a survey at the end of 2009, 13 (57%) were from the health care sector, 4 (17%) were academic institutions, 3 (13%) were community organizations, 3 (13%) were media organizations, and 1 was a government representative. Ten partners continuously offered free HBsAg screening and referrals to follow-up care for chronically infected patients; 9 conducted additional one-time community screening clinics at cultural festivals and other events; 6 provided continual free or low-cost hepatitis B vaccination; 10 participated in fundraising; 7 were involved in public outreach and marketing; and 5 conducted educational events for health care providers.

These 24 partner organizations raised $1,274,000, including 85% from grant funding, to support SFHBF activities, and spent approximately $2,752,000 on the campaign, including $1,270,000 (46%) for paid staff, $670,000 (24%) for marketing, $272,300 (10%) for supporting volunteers (who contributed 8,000 h), $124,000 (5%) for laboratory costs, $64,000 (2%) for vaccinations, and $340,000 on other expenses such as travel and venue rental fees.

Between 2007 and 2009, more than 40 educational events on hepatitis B were held, reaching over 1,100 health care providers in the city. In addition, laminated hepatitis B diagnostic flowcharts were distributed by SFDPH to all primary care physicians as a resource for hepatitis B testing. Among primary care physicians asked to sign a statement pledging to test all APIs for hepatitis B, 60% did so and were listed by name in a “Clinical Honor Roll” published regularly in local general and ethnic print media.

SFHBF partners published 280 billboards and bus panels, 488 newspaper public service announcements (PSAs), 62 television PSAs, 1,240 radio PSAs, 72 newsletters, 63 website banners and advertisements, and e-mail messages that reached an estimated 260,000 readers. In addition, campaign partners hosted informational booths, gave presentations, and distributed flyers and souvenirs at more than 120 community events, including street fairs, cultural shows, fashion shows, conference presentations, and classroom seminars; total attendance was approximately 200,000 people. Because community demonstrations and rallies are less culturally favored activities for the API community, SFHBF organized community banquets as a more culturally appropriate, intergenerational forum for increasing hepatitis B awareness.

At the seven public standalone SFHBF testing and vaccination sites, most clients were between ages 18 and 50 years, and 61% were female. Eighty percent were of API background, including 55% Chinese, and just over half spoke primarily in an Asian language only (Table 2). More than two-thirds of clients at the standalone sites were foreign-born, and 60% of those born in North America had at least one foreign-born parent. Only 18% reported ever having received immunization shots for hepatitis B, and 4% reported having previously been diagnosed with hepatitis B. The majority (59%) of clients had current health insurance, although fewer than half (46%) reported having a current medical provider.Table 2

Demographic and health-related characteristics of clients tested for hepatitis B at standalone San Francisco Hep B Free sites

At the seven standalone SFHBF testing and vaccination sites, 4,427 clients were serologically tested for HBsAg and anti-HBs, including 3,315 clients of API background. Among the APIs, 6.5% (N = 224) were chronically infected, 41.6% (N = 1,381) were susceptible, and 51.9% (N = 1,719) were immune (Table 2). When the serological results were further restricted to the 2,639 API clients born in Asia, 7.9% (N = 208) were chronically infected.

Of note, among clients who provided information on whether or not they had already been diagnosed with hepatitis B by a doctor, 66 of 147 (44.9%) chronically infected individuals reported that they had not previously been diagnosed, and 29 of 147 (19.7%) were unsure whether they had been diagnosed. Thus, up to two-thirds of clients with chronic hepatitis B were previously unaware of their infection. In addition, 16 of 655 clients (2.4%) who reported having received immunization shots for hepatitis B were in fact chronically infected.

After mutual adjustment, we found that being between ages 41 and 60 years, male, of API background, born outside North America, and without a current medical provider were statistically significantly associated with a higher risk of being chronically infected with hepatitis B (Table 3). In addition, individuals who had not received hepatitis B immunization shots, had previously been diagnosed with hepatitis B by a doctor, or had a family history of hepatitis B were at significantly elevated risk of chronic infection. Factors associated with a higher risk of being unprotected against hepatitis B were older age, birth outside Asia and the Pacific Islands, and a non-Asian primary spoken language (Table 3). Results were essentially unchanged when the analysis was restricted to API clients (data not shown). Table 3

Associations of demographic and health-related characteristics with hepatitis B infection status among clients tested at standalone San Francisco Hep B Free sites

At all hospital and independent diagnostic laboratories serving San Francisco, 69,821 tests for HBsAg and 54,340 tests for anti-HBs were ordered in 2006, the year before SFHBF was launched. In 2007, 72,678 tests for HBsAg (a 4% increase over 2006) and 56,001 tests for anti-HBs (a 3% increase over 2006) were ordered. In 2008, 75,122 tests for HBsAg (an 8% increase over 2006) and 63,462 tests for anti-HBs (a 17% increase over 2006) were ordered.

Based on reports from the seven standalone SFHBF testing and vaccination sites, 69% of clients found to be chronically infected were enrolled in follow-up clinical care. Of nearly 2,000 clients found to be susceptible, 52% received at least the first shot of hepatitis B vaccine, and 49% of these completed the three-shot vaccine series at one of the standalone sites.