status (Lin et al., 2007). The lack of awareness in foreign-born populations from HBV-endemic countries is compounded by gaps in knowledge and preventive practice among health-care providers, particularly if they are serving a large number of foreign-born, high-risk patients (see Chapter 3).

Cultural and institutional impediments are particularly important for the foreign-born. For example, culture-specific stigmas may be attached to a diagnosis of chronic hepatitis B. In China, there is discrimination against people who are chronically infected with HBV, and such people reportedly have been expelled from schools, fired from jobs, and shunned by other community members despite the recent passage of national antidiscrimination laws (China Digital Times, 2009). Such social stigma and discrimination may contribute to the reluctance of immigrants from HBV-endemic countries to undergo HBsAg testing or to seek medical attention for a positive test result after settling in the United States.

Institutional barriers include administrative procedures and the absence of culturally responsive support services. For example, a recent survey of hospitals in the San Francisco Bay area—a region where 29% of the population is foreign-born—found that fewer than half routinely collect information on patients’ birthplaces (Gomez et al., 2003). The collection of information on the birthplace of patients’ parents is even rarer—but relevant for risk assessment. English-language proficiency and cultural preferences of foreign-born patients may pose additional challenges to institutions that are not prepared to work with these patient factors. Non-English-speaking patients report that physicians are intolerant and impatient toward them and fail to use interpreter services, even when available, to facilitate communication (Barr and Wanat, 2005; Giordano and Cooper, 2009; Giordano et al., 2009). As a result of patient–physician language discordance and impaired communication, such patients have poorer comprehension of medical conditions, testing, and treatment; have low compliance; and are more likely to miss followup appointments (Giordano and Cooper, 2009; Giordano et al., 2009; Jacobs et al., 2006; Manson, 1988; Zickmund et al., 2004).

There is a need for evidence-based strategies and programs to disseminate information about hepatitis B transmission, infection, and treatment to culturally and demographically diverse populations. A community-based participatory research approach, in which communities are actively engaged in equal partnership with scientists, is needed to ensure that the programs are acceptable, accessible, and sustainable in the communities where they are based. Such programs should also be flexible and scalable so that other communities can tailor them to their own needs. The committee believes that these tasks are best accomplished with the approach outlined in Recommendations 3-1 and 3-2 in Chapter 3. The community-based approach as outlined in Recommendation 3-2 would be strengthened by additional



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