We measured Hepatitis B virus (HBV) transmission knowledge and self-reported screening/testing behavior among Pacific Islanders (Guamanians/Chamorros, Samoans, and Tongans) in Southern California. We also examined access and trust by Pacific Islanders of varying health information sources. We administered and analyzed survey data (
Pacific Islanders in the US face a complex set of health challenges. This population, from a myriad of islands both US governed (e.g., the state of Hawai’i and US territories, including American Samoa, Guam, Commonwealth of the Northern Mariana Islands) and sovereign nations (e.g., Fiji, Federated States of Micronesia, Palau, Papua New Guinea, Samoa, Tonga), are often aggregated with Asian Americans, but are a distinct set of communities with different cultural norms, access to health, and health challenges.
Hepatitis B virus (HBV) infection, and the health problems associated with this (including but not limited to liver conditions such as cirrhosis and hepatocellular carcinoma) are highly prevalent among Asians/Pacific Islanders (APIs) in the US [
In this paper we analyze the results of a recent community needs assessment survey of a convenience sample of Pacific Islanders in Southern California to investigate the associations among information sources, trust in sources, and self-reported HBV screening/testing and vaccination behavior. Though respondents largely reported that they were screened and vaccinated for HBV because of recommendations by their physicians, and that if they had not been screened and vaccinated for HBV, they would seek screening vaccination on advice from their physicians, multivariate logistic regression analysis of the survey results suggest that obtaining information from and trust in physicians were not significant predictors of HBV screening or vaccination. Instead, for those respondents who sought screening/testing or vaccination for HBV, significant factors included employment status and lack of knowledge about HBV.
To present these findings, the paper proceeds in the following manner. First, we describe the data and methods used, including a description of the convenience sample and a comparison of this sample to US Census data on the Pacific Islander population in Southern California. We then provide descriptive analysis of Pacific Islander respondents’ knowledge about HBV transmission, questions about which sources of health information would lead respondents to be screened and vaccinated for HBV, and trusted health information sources. Next, we present the results of multivariate logistic regression analysis of self-reported HBV screening and vaccination behavior. These results show that while respondents tend to report that physicians provide information and are highly trusted by these respondents as sources of information, information from and trust in physicians are not significant predictors of variations in self-reported HBV screening and vaccination. We conclude the paper with implications from this analysis for enhancing HBV screening and vaccination among Pacific Islanders in Southern California, and elsewhere.
A community needs assessment survey of Pacific Islander communities in the counties of Los Angeles, Orange, and San Diego in Southern California was conducted to measure Hepatitis B (HBV) knowledge, screening/testing, and vaccination, and trusted sources of health information.
A survey questionnaire developed originally by the B Free CEED at the Center for the Study of Asian American Health, New York University School of Medicine (originally designed for surveys of Asian immigrants in New York City) was revised by several of the co-authors to be more culturally appropriate for Southern Californian Pacific Islanders. In November 2008, the Center for the Study of Asian American Health at NYU School of Medicine reviewed the adapted questionnaire, and made additional suggestions, including deleting several questions.
There were four English versions created of the survey questionnaire that targeted, respectively, Chamorro, Samoan, Tongan, and other Pacific Islander respondents. The English versions targeting Chamorro and Samoan respondents were translated into Chamorro and Samoan by several of the co-authors, and backtranslated into English. The two English versions (original and back-translated) were compared by one of the co-authors; minor revisions were made to the translated Chamorro and Samoan versions to improve clarity. The English and translated versions were pilot tested in late November 2008 with a total of 21 Chamorros, 1 Samoan, and 1 native Hawaiian; again, minor revisions were made to improve clarity.
The questionnaires were copied such that both the English and in-language versions were included in all questionnaires (English version on front and in-language version on back of each page). Respondents could therefore complete the questionnaire entirely in English, entirely in-language, or could move between the two depending on the respondent’s preferences.
A convenience sampling approach was used. Several of the co-authors distributed and collected the questionnaires from mid-February to mid April 2009 at community/church meetings, cultural gatherings, and other community venues in Los Angeles, Orange, and San Diego counties. To minimize potential respondent bias, individuals were asked to complete the self-administered questionnaire and deposit the completed questionnaire in a sealed box.
The characteristics of the respondents overall and comparison to 2005–2007 Public Data Microdata Sample data Sample characteristics compared to 2005–2007 PUMSDemographic or health variable Respondent characteristics ( Comparison to 2005–2007 PUMS ( Ethnic background 51% Samoan 53% Samoan 49% Chamorro 47% Chamorro Gender 55% female 49% female 44% male 51% male Age Average = 40 years Average = 38 years Range: 16–82 years Range = 16–82 years Place of birth 45% California 46% California 27% Guam 18% Guam 14% American Samoa 10% American Samoa 4% Samoa/Western Samoa 8% Western Samoa Number of years in US (for immigrants only) Mean = 29 years Mean = 28 years Range = 4–55 years Range = 4–55 years English language capacity 62% speak English fluently 80% speak English fluently 24% speak English very well 8% speak English well Pacific Islander language capacity 27% speak Pacific Islander language fluently 9% speak Chamorro/Guamanian 13% speak very well 27% speak Samoan 11% speak not at all 45% speak only English Marital status 43% Married 51% Married 31% Single or never married 37% Single or never married 10% Divorced or separated 9% Divorced or separated Health insurance 17% No insurance N/A Education 9% Elementary school 15% Elementary school 8% Junior high school 4% Junior high school 51% High school or GED 28% High school or GED 11% Tech/vocational school 20% Some college 19% College or university graduate 10% Junior college/college graduate Employment status 63% Full/part time employed 89% Full/part time employed 19% Unemployed 11% unemployed Household size Average: 5.6 Average: 4.9 Range: 1–40 persons Range: 1–12 Household members younger than 18 Average: 1.9 Average: 0.85 Range: 0–13 household members < 18 years Range: 0–6 own children present Household composition 95% Family 99% Family or sub-family Approximate total household income during last year 5% Less than $10,000 2% Less than $10,000 7% $10,000–$19,999 5% $10,000–$19,999 17% $20,000–$29,999 9% $20,000–$29,999 12% $30,000–$39,999 6% $30,000–$39,999 7% $40,000–$49,999 8% $40,00–$49,999 28% $50,000 or more 70% $50,000 or more 24% Not sure/Don’t know
Respondents were asked questions about HBV transmission and ethnic group prevalence to assess their knowledge, about whether they had been advised or referred for HBV screening/testing and vaccination, and their self assessment of risk of HBV transmission (Table Knowledge of Hepatitis B virus transmissionKnowledge variable Response Heard of Hepatitis B ( 63% yes 23% no 14% don’t know In your opinion, in which ethnic group is Hepatitis B most common? ( 3% White 8% Black 1% Hispanic/Latino 4% Asian Americans 4% Pacific Islanders 24% All equally common 56% Don’t know In your opinion, Hepatitis B can be transmitted by: ( 63% unprotected sex 63% using contaminated needles 61% contact blood or bodily fluids from an infected person 38% an infected mother to her baby at the time of delivery 30% heredity 30% eating unclean food 26% sharing food with an infected person 21% sharing utensils/chopsticks 19% kissing 6% other (le ilor, raw food, ti utungo, toilet seat)
Between 61 and 63% of the respondents reported correctly that HBV could be transmitted via contact with blood or bodily fluids from an infected person, via unprotected sex, or via contaminated needles.
Of the total sample, 53 (19%) reported that they had been screened for HBV, and 61 (21%) reported that they had been vaccinated for HBV. These are much lower rates than reported in a recent study of Cambodian and Vietnamese Americans drawing from the Annual REACH 2010 Risk Factor Surveys [
Sizable proportions of respondents reported that they had not ever been told that they should be screened for HBV (40%) or that they had never heard of HBV before participating in this community needs assessment survey (26%). Of the one-third of total respondents who had been told that they should be screened for HBV, most had been advised to do so by a doctor and most of those respondents had been screened or tested for HBV (though about 16% of this group did not know or were unsure if they had been tested).
The 40% of the total respondents who reported that no one had suggested that they be screened for HBV indicated varying reasons for not being screened. The most common reasons were lack of knowledge, feeling well, not being suggested by a doctor, and not knowing where to get screened.
Similar patterns were exhibited concerning whether respondents were ever told that they should be vaccinated for HBV. About one-third of the respondents (36%) reported that they had been told that they should obtain a vaccination for HBV, while 39% reported that they had not ever been told to obtain a HBV vaccination, and 25% reported that they had never heard of HBV before participating in this community needs assessment survey. For the 36% of the respondents who had ever been told that they should obtain a HBV vaccination, almost all of the respondents (87%) were told to do so by a doctor, and about two-thirds of those respondents reported that they had been vaccinated for HBV.
For the 39% of the respondents who reported not ever having been told to obtain an HBV vaccination, the most common reasons for not getting vaccinated included lack of knowledge and feeling well.
Over half of the respondents believed that they were not infected with HBV, but 41% reported that they did not know (6% believed that they might be infected) (Table Hepatitis B risk and most influence in screening/vaccination aTotal percentages may add up to more than 100% as respondents were asked to list all that apply; the only responses that were highly correlated (using Pearson correlation coefficient) were being encouraged by friends and family membersAwareness variable Response What influenced or would influence you to get Hepatitis B screening and vaccination? ( 64% Doctor told you to get screened 35% Family member is a carrier 34% Free screening/vaccination or if covered by insurance 32% Fear of being infected by the virus 31% Encouraged by family members 28% Attended Hepatitis B educational workshop 22% Encouraged by spouse 21% Encouraged by friends 9% Other (Bakura, Teacher, Employer, Galuega, Travel) Do you think you could be infected with Hepatitis B? ( 6% Yes 52% No 41% Not sure/Don’t know Have you ever been diagnosed with Hepatitis B infection? ( 1% Yes 78% No 21% Not sure/Don’t know
Respondents were asked to indicate whether they had obtained information about health and health care from varied provider and community sources. The results are reported here by source, and then by utilization, and degree of trust depending on whether they had whether they had obtained information from specific sources (Table Health information sources and trust (ranked by sources used by respondents)Information source Reported getting information from this source Reported NOT getting information from this source Physician/health care provider ( 79% yes 21% no For respondents who answered “yes” For respondents who answered “no” 89% used source in past year 51% trusted information from this source 97% trusted information from this source Pharmacists ( 53% yes 47% no For respondents who answered “yes” For respondents who answered “no” 90% used source in past year 31% trusted information from this source 97% trusted information from this source Family members ( 48% yes 52% no For respondents who answered “yes” For respondents who answered “no” 89% used source in past year 25% trusted information from this source 83% trusted information from this source Community functions or health fairs ( 46% yes 54% no For respondents who answered “yes” For respondents who answered “no” 84% used source in past year 24% trusted information from this source 92% trusted information from this source Church, spiritual or religious leaders ( 31% yes 69% no For respondents who answered “yes” For respondents who answered “no” 83% used source in past year 18% trusted information from this source 94% trusted information from this source Friends ( 29% yes 71% no For respondents who answered “yes” For respondents who answered “no” 87% used source in past year 13% trusted information from this source 91% trusted information from this source Employee assistance programs ( 26% yes 74% no For respondents who answered “yes” For respondents who answered “no” 90% used source in past year 18% trusted information from this source 97% trusted information from this source Co-workers ( 20% yes 80% no For respondents who answered “yes” For respondents who answered “no” 77% used source in past year 14% trusted information from this source 84% trusted information from this source Traditional healers ( 17% yes 83% no For respondents who answered “yes” For respondents who answered “no” 69% used source in past year 16% trusted information from this source 85% trusted information from this source Telephone advice lines ( 8% yes 92% no For respondents who answered “yes” For respondents who answered “no” 71% used source in past year 13% trusted information from this source 96% trusted information from this source
Respondents reported most often that they had obtained health and health care information from the following sources: physicians/health care providers (79% reported that they had obtained information), pharmacists (53% reported that they had obtained information), family members (48% reported that they had obtained information), and community functions or health fairs (46% reported that they had received information).
Respondents reported less often obtaining information from church, spiritual, or religious leaders (31% reported obtaining information), friends (29% reported obtaining information), employee assistance programs (26% reported obtaining information), co-workers (20% reported obtaining information), traditional healers (17% reported obtaining information), and telephone advice lines (8% reported obtaining information). Respondents who reported that they had obtained information from each of the sources also tended to report that they had used the source in the past year and trusted the information from that source. Not surprisingly, respondents who reported that they had not used each of the sources less often reported that they trusted information from that source.
Similar to the results reported in the earlier section on the descriptive statistics on HBV knowledge, screening/testing, and vaccination, health care providers (including physicians and pharmacists) also appeared to be sources of information that these respondents would trust. In the following section, multivariate analyses are presented to ascertain socio-demographic or HBV knowledge association with trust in health information sources.
Logistic regression models were estimated for the binary dependent variables measuring self-reported HBV screening/testing and vaccination behavior to ascertain how important sources of information, and trust in those sources, were when controlling for socio-demographic and health coverage characteristics, and HBV transmission knowledge. The dependent variables (whether respondents were screened for HBV and whether respondents were vaccinated for HBV) only included those respondents who had ever been told that they should be screened or vaccinated for HBV. In other words, those respondents who had never been told they should be screened or vaccinated for HBV (40%) or who had never heard of HBV (26%) prior to completing the survey were not included in this analysis. Though the resulting sample was smaller, it did provide the opportunity to assess the possible connections between screening/testing and vaccination self-reported behavior and other variables.
To construct the logistic regression models, chi-square tests were conducted of the dependent variables (respondent had been screened/tested for HBV, respondent had been vaccinated for HBV) using each set of variables (socio-demographic characteristics, health coverage, sources of health information, trust in health information sources, HBV transmission knowledge). Only those variables that were statistically significant at the
This suggested that while a very large proportion of respondents reported that they received health information from their physicians, and that they trusted this source, this had little explanatory power with respect to HBV screening/testing or vaccination for those respondents who had been informed that they should be screened or vaccinated for HBV. As the number of observations in each of the models was relatively small (
Table Logistic regression results for Hepatitis B screening/testing (Variable (bolded variables are statistically significant at least at Odds ratio SE 95% confidence interval Demographics/medical coverage Has medicare coverage (1 = yes, 0 = no) 0.32 0.29 −1.27 0.20 0.06–1.86 Highest grade of school completed (1 = elementary school, 6 = post-graduate school) 1.59 0.53 1.39 0.16 0.83–3.07 Currently retired (1 = yes, 0 = no) 7.42 10.19 1.46 0.15 0.50–109.47 Information sources Gets information about health and health care from the Internet (1 = yes, 0 = no) 1.75 1.63 0.59 0.55 0.28–10.94 Gets information about health and health care from Pacific Islander organizations (1 = yes, 0 = no) 4.06 3.87 1.47 0.14 0.63–26.24 Model goodness of fit measures LR chi2 ( 21.11 Prob > chi2 0.01 Pseudo 0.33 Log likelihood −21.52
Table Logistic regression results for Hepatitis B vaccination (Variable (bolded variables are statistically significant at least at Odds ratio SE 95% confidence interval Demographics/medical coverage − Highest grade of school completed (1 = elementary school, 6 = post-graduate school) 1.04 0.30 0.13 0.90 0.59–1.81 Currently employed part time (one part time position) (1 = yes, 0 = no) 0.29 0.25 −1.41 0.16 0.05–1.62 Currently retired (1 = yes, 0 = no) 4.04 5.46 1.03 0.30 0.29–57.03 Hepatitis B knowledge Information sources − Gets information about health and health care from social service provider or community health center (1 = yes, 0 = no) 0.71 0.53 −0.46 0.64 0.17–3.03 Model goodness of fit measures LR chi2 ( 35.32 Prob > chi2 0.01 Pseudo 0.40 Log likelihood −26.74
There is one HBV transmission knowledge question that was significant at least at the
Similar to the model presented previously on self-reported HBV screening/testing behavior, being employed again appeared to be important in explaining the variation in self-reported vaccination for HBV, however, in this model, employment had a negative association. Obtaining information about health and health care from employee assistance programs was negatively associated with HBV vaccination for those respondents who had been informed that they should be vaccinated for HBV.
In this paper, results were presented of an analysis of a recent community needs assessment survey of a convenience sample of Pacific Islanders in Southern California. Because this was a convenience sample and, in addition, because the multivariate analysis used a small subsample of the total sample, the results must be viewed as suggestive rather than conclusive.
The findings indicated that though Pacific Islander respondents reported that physicians and pharmacists, i.e., health care providers, were the most trustworthy and commonly used source of health care information and advice, when multivariate analysis was conducted to explain the variation in self-reported HBV screening/testing and vaccination behavior, trust in and use of physicians for health care information was not statistically significant.
Instead, the factors that were important in explaining HBV screening/testing for respondents who had been told that they should be screened or tested for HBV included being currently employed and receiving health and health care information from friends. Being employed and receiving health and health care information from friends were both associated with much higher likelihoods of being screened or tested for HBV, compared to respondents who were not currently employed or who did not receive health information from friends. The factors that were important in explaining self-reported HBV vaccination behavior were different from those explaining the variation in HBV screening/testing. Not being covered by Medicare, having incorrect knowledge about HBV transmission (confusing HBV with Hepatitis A), and not receiving information from employee assistance programs were associated with self-reported HBV vaccination. These results were somewhat counterintuitive, as more and correct information is usually presumed to result in enhanced screening and health care access.
These findings suggested that though these respondents viewed physicians and pharmacists positively, and a large proportion reported that they obtained health care information from health care providers, that other factors (demographic, knowledge, and information source) were more important in explaining HBV screening and vaccination behavior. One possible interpretation of these findings is that health recommendations for HBV screening and vaccination may need to come from physicians, who are highly trusted sources, but that additional motivations (information from friends) or opportunities for access to health care (being full time employed, presumably with health care benefits) may also be necessary to expand the number of Pacific Islanders who are screened and vaccinated for Hepatitis B. Additional research is needed to ascertain whether these findings hold for other Pacific Islander groups in California, nationally, and on the island jurisdictions.
Funding was provided through a Legacy pilot grant from the B Free CEED: National Center of Excellence in the Elimination of Hepatitis B Disparities of the Institute of Community Health and Research at NYU Langone Medical Center. B Free CEED is supported by Grant Number DP07-707, Racial and Ethnic Approaches to Community Health Across the US from the Centers for Disease Control and Prevention. Special thanks to Dr. Simona Kwon of NYU School of Medicine, and the community members that participated in this project. We take full responsibility for all errors and omissions.
As this was a community needs assessment survey conducted by community organizations, the survey and sampling were not reviewed by any IRB.
Instead of the 2000 Census PUMS 5% sample, the more current pooled data over the three years (2005–2007) of 1% samples of annual data were used for comparison. Samoan and Guamanian/Chamorro self-identified individuals living in the metropolitan areas of Los Angeles-Long Beach, Orange County, and San Diego were aggregated (
This might first appear that age is related to vaccination behavior, but age was not statistically significant using an ANOVA test at the