Understanding cultural barriers in hepatitis B virus infection

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The prevalence of hepatitis B virus (HBV) infection in the Asian American population is disproportionately high compared with the US population as a whole. Effective management is difficult because of cultural barriers, which can be better understood with recognition of the diversity of the Asian continent in terms of language and spiritual beliefs. Barriers to care among the Asian American population include educational deficits, low socioeconomic status, lack of health insurance, noncitizenship, inability to communicate in English, negative perceptions of Western medicine, and underrepresentation among health care professionals. Given the diversity of the population, some subpopulations may be more directly affected by certain barriers than others. The resulting delays in seeking care can lead to poor outcomes and risk of HBV transmission to household members. Health care providers are obligated to educate themselves regarding cultural sensitivity and to advocate for improved access to care.


  • Some Asian Americans have limited proficiency in English and are isolated linguistically, limiting their ability to communicate with health care providers.
  • Asian Americans may view Western medicine with suspicion, causing delays in seeking care and making it difficult to successfully manage chronic HBV infection.
  • Sensitivity to cultural attitudes may enhance communication and the likelihood that immigrant patients will accept health care providers’ recommendations; cultural sensitivity training may be helpful.



Asian Americans represent 4% of the population in the United States, and their share of the US population is projected to grow to 9% by 2050.1 These numbers are significant because of the high prevalence of hepatitis B virus (HBV) infection in this community and the cultural barriers to its effective management.

Appreciating the impact of cultural barriers on health care among Asian Americans requires an understanding of the diversity of the Asian continent, which is composed of 52 countries where 100 languages and dialects are spoken. Within each region are religious, cultural, and societal differences. Asians have immigrated to the United States over the course of several generations, and the era in which they immigrated may affect their ability to understand English, integrate into American culture, and navigate the US health care system. Successful integration into American life favors those whose families immigrated several generations earlier.

The overall prevalence of HBV infection in the United States is 0.4%2; however, estimates of prevalence range from 5% to 15% in Asian American populations, and are as high as 20% in some Pacific Rim populations.3,4 The prevalence of HBV infection in Asian Americans differs by subpopulation, with the highest prevalence among immigrants from Vietnam, Laos, and China, and the lowest among those from Japan.

Of the approximately 1 million Americans estimated to be infected with HBV as of 2005, more than 750,000 had access to health care; of these, 205,000 were diagnosed with HBV infection,5 suggesting substantial underdiagnosis. Referrals to specialists were even fewer (175,000), and only about 31,000 patients chronically infected with HBV received antiviral treatment, a figure that has likely increased with greater awareness of HBV and the availability of new antiviral medications.


The barriers to effective management of HBV infection in Asian Americans include cultural, socioeconomic, and accessibility issues (see “Case: Stigma and cultural barriers lead to inadequate care”).

Language and linguistic isolation

Limited proficiency in English is a large, if not the largest, barrier to effective management of chronic HBV infection. According to the US Census Bureau, a person with limited English proficiency is one who does not speak English “very well.”6 This terminology has implications for allocation of federal government resources; ie, the percentage of a community’s residents with limited English proficiency is a criterion for receipt of governmental grants and other forms of assistance, including translation services.6

Linguistic isolation, another barrier to medical care, is lack of an English-speaking household member who is older than 14 years.7 By this definition, more than one-third of Korean, Taiwanese, Chinese, Hmong, and Bangladeshi households, and almost half of Vietnamese households, are linguistically isolated, with limited ability to communicate with health care providers.8

Lack of health insurance and its correlates

The high percentage of Asian immigrants without health insurance is a challenge to providing adequate health care. Health insurance coverage is lacking for about one-third of Korean immigrants, about one in five immigrants from Southeast Asia and South Asia, and about 15% of Filipino and Chinese immigrants.9

One reason for the large proportion of uninsured among these groups is the high rate of small business ownership among Asian Americans and the difficulty that small business owners have in obtaining affordable health insurance coverage. In addition, although Asian Americans are as likely as other US residents to be employed full time, their employment options may be less likely to include health insurance benefits.

Poverty affects the ability to acquire health insurance. Although the popular image of the Asian immigrant is an educated person with high earning potential, the reality is that poverty strikes immigrants from Southeast Asia at a high rate. Almost 40% of the Hmong population, for example, lives below the poverty level, and poverty rates among the Cambodian, Bangladeshi, Malaysian, and several other Asian subpopulations are nearly as high.8

Citizenship correlates with the ability to obtain health insurance; it is estimated that 42% to 57% of noncitizens lack health insurance, compared with 15% of citizens.8 Only half of Asian immigrants become naturalized citizens, with wide variability among subgroups. Two-thirds of Filipinos who immigrate to the United States eventually become naturalized compared with less than one-third of Malaysian, Japanese, Indonesian, and Hmong immigrants.8

Educational achievement is associated with attainment of financial security and health insurance. The vast majority of Taiwanese, Japanese, Filipino, and Korean Americans obtain a high school education or higher, with correspondingly higher rates of health insurance coverage. Among those from Southeast Asia (Hmong, Cambodians, Laotians, and Vietnamese), whose immigration to this country is relatively recent, fewer than half complete a high school education.8

Health care workforce representation

Certain Asian subgroups are underrepresented in the racial composition of the US health care workforce; this imbalance may affect accessibility to the health care system and adherence to medical prescriptions and instructions among underrepresented groups. Racial concordance between patient and health care provider is associated with greater patient participation in care, according to the Institute of Medicine.10 In addition to racial similarity, linguistic similarity enhances communication and adherence to instructions.

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Hepatitis B treatment: Current best practices, avoiding resistance

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