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Examining the Influencing Factors of Chronic Hepatitis B Monitoring Behaviors among Asian Americans: Application of the Information-Motivation-Behavioral Model

past one,2,* , one,2 , 1,3 , 1 , 1 , 4 , five , 5 , six and 7

ane

Center for Asian Wellness, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United states of america

ii

Department of Urban Health and Population Science, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United states of america

3

Department of Sociology, Higher of Liberal Arts, Temple University, Philadelphia, PA 19120, USA

4

Center for Cancer Health Disparities Research (CCHDR), Hunter College, Metropolis University of New York, New York, NY 10065, USA

5

Pull a fast one on Chase Cancer Middle, Temple University Health System, Philadelphia, PA 19111, USA

6

Nutrition Program, Hunter College, Metropolis University of New York, New York, NY 10065, USA

seven

School of Public Health, University of Maryland, College Park, MD 20742, The states

*

Writer to whom correspondence should be addressed.

Academic Editors: Ken Batai, Francine C. Gachupin and Yamilé Molina

Received: 12 Feb 2022 / Revised: 5 April 2022 / Accustomed: 8 April 2022 / Published: 12 April 2022

Abstract

Groundwork: Compared to non-Hispanic whites, Asian Americans are lx% more likely to die from the affliction. Doctor visitation for chronic hepatitis B (CHB) infection every vi months is an effective approach to preventing liver cancer. Methods: This study utilized baseline data from an ongoing randomized controlled clinical trial aimed at improving long-term adherence to CHB monitoring/treatment. Guided by the information-motivation-behavioral skills (IMB) model, we examined factors associated with CHB monitoring adherence amidst Asian Americans with CHB. Multivariable logistic regression was conducted to test the associations. Results: The analysis sample consisted of 382 participants. Multivariable logistic regression showed that HBV knowledge (OR = one.24, p < 0.01) and CHB-management motivation (OR = 1.06, p < 0.05) are significant predictors of having a doc's visit in the past vi months. Both factors were positively associated with the likelihood of having had blood tests for HBV in the past half-dozen months. Determination: We found that greater HBV-related cognition and CHB-management motivation are significantly associated with performing CHB-monitoring behaviors in the past six months. The findings have critical implications for the development and implementation of evidence-based interventions for CHB monitoring and liver cancer prevention in the Asian American community.

i. Introduction

Asian Americans are disproportionately affected by liver cancer and viral hepatitis [i,2,3]. The incidence of liver and intrahepatic bile duct (IBD) cancer is much higher amongst Asian Americans than in non-Hispanic whites (19.9 versus x.8 per 100,000 men, and seven.4 versus 3.seven per 100,000 women) [iv]. Asian Americans are also 70% more likely to die from liver and IBD cancer than their not-Hispanic white counterparts [4]. One major contributor to such alarming disparities is chronic hepatitis B (CHB) infection. Hepatitis B virus (HBV) infection is the leading cause of cirrhosis, and hepatocellular carcinoma (HCC) [2,five,six,7,8,9,x,eleven,12]. Almost two.2 million individuals in the U.Southward. are living with CHB infection. Up to 70% of infected individuals are from non-U.S.-born populations, with the highest prevalence among persons from Asia (58%) [12,13,14,xv,16,17,18,19,20,21,22,23]. Prevalence rates of CHB in Asian Americans range from eight% to 13%, a figure that is significantly higher than the 1% rate observed in non-Hispanic Whites (NHW) [i,22].

Regular monitoring for CHB is critical for tracking disease progression, treatment adherence, and risk for the development of HCC [24]. Guidelines from the American Association for the Study of Liver Disease (AASLD) recommend regular monitoring of individuals living with HBV at vi-month intervals, with an assessment of liver part, HBV viral load, ultrasound, and alpha-fetoprotein (AFP) levels [25]. Routine monitoring for liver disease action can inform treatment decisions aimed at reducing HCC adventure [25]. Unfortunately, adherence to HCC surveillance has been suboptimal amidst Asian Americans, with less than 50% of those who are eligible to undergo regular CHB monitoring [26,27,28]. Several studies have suggested that limited English proficiency, not having a regular source of care, and lack of wellness insurance coverage are among the major barriers that prevent Asian Americans from receiving regular CHB monitoring [28,29,thirty,31,32,33].

Research has too found that depression knowledge of and lack of sensation of hepatitis and liver cancer risk is another pregnant predictor of poor monitoring in various Asian American subgroups [33,34,35,36]. In addition, psychosocial factors, such every bit cocky-efficacy, and motivation have been suggested as predictors of adherence to CHB monitoring [29,37,38], yet empirical evidence was defective. In recent years, a theoretical model known as the information-motivation-behavioral skills (IMB) model has been used to better explain factors that influence healthy beliefs [39]. The IMB model draws from rational behavior theory and social cerebral theory to propose that healthy behaviors are based on three components: information, motivation, and behavioral skills. Information refers to an accurate cognition of the specific healthy beliefs. Motivation refers to personal and social motivation to perform a specific beliefs. Behavioral skills include an individual'due south self-efficacy and confidence in performing the beliefs [40]. While the IMB model has been widely used in research on the prevention and direction of HIV/AIDS [41,42,43] and diabetes [44,45], information technology has not been practical to adherence to CHB monitoring, to the all-time of our knowledge.

Guided by the IMB model, we examined factors associated with CHB monitoring adherence amongst Asian Americans living with CHB. Our findings advance the understanding of relationships among cognitive, emotional, and behavioral skills factors that influence CHB monitoring behaviors in the IMB model and have critical implications for the development and implementation of evidence-based interventions for CHB monitoring and liver cancer prevention in the Asian American community.

two. Materials and Methods

2.one. Study Participants

From March 2019 to March 2020, 382 Asian American CHB patients, including 298 Chinese Americans and 84 Vietnamese Americans, were enrolled through combined recruitment approaches in the Greater Philadelphia Area and New York Metropolis to participate in a randomized control trial on long-term CHB monitoring and antiviral treatment adherence. The eligibility criteria for new subjects were: (one) aged xviii or above; (two) self-identified Chinese or Vietnamese ethnicity; (iii) CHB infection with positive HBV surface antigen (HBsAg); (iv) CHB diagnosed for at least 12 months; (5) non-compliance with HBV monitoring and handling guidelines for more than than 6 months; (half-dozen) cell phone attainable by receiving text messaging; (vii) not enrolled in any other HBV Management intervention (to prevent a potential plan impact). We excluded cases with missing data on HBV monitoring behaviors. The analysis sample consisted of 378 participants, including 295 Chinese and 83 Vietnamese Americans.

2.2. Procedures

The current study used the data collected from the baseline survey of the larger trial. Baseline data drove was conducted from April 2019 to March 2020 through a face-to-face survey, which took approximately xxx min to complete. The survey questionnaire was adult in English, translated into Mandarin, Cantonese, and Vietnamese, and dorsum-translated into English by bilingual community health educators on the enquiry team. The back-translated version was compared with the English version to verify that the questions were properly translated. Participants completed the survey in their preferred language. During the survey, trained bilingual customs health educators provided linguistic communication back up to address questions from the participants. The study was canonical past the Western Institutional Review Lath (WIRB) (protocol #: 20190122). All participants read and signed informed consent forms to participate in the study and received a $25 incentive for completing the baseline survey.

2.iii. Measures

The primary outcomes were HBV monitoring measures, including doctor visits for CHB and HBV blood testing in the by vi months. Doctor visits for HBV were measured with one question "Did yous meet a doc to cheque your hepatitis B infection status during the past six months?" The answers were dichotomous (yeah or no). HBV blood testing was measured with the question "Accept you had blood tests (e.g., HBV Deoxyribonucleic acid, Liver part, Alpha-fetoprotein) in the past vi months?" The answers were dichotomous (yes or no). For both questions, "I don't know" was coded every bit "no".

HBV-related cognition was examined with a 10-item scale that previously was validated in Asian Americans with CHB [46]. Specifically, participants answered "Fake", "True", or "Don't know" to ten HBV noesis statements, such as "People will feel sick if they are infected with hepatitis B" and "Regular monitoring and treatment can reduce liver impairment caused past chronic hepatitis B". 1 betoken was assigned to correct answers and zero points to wrong answers. We computed the accumulated HBV knowledge score past summing the points from all 10 items. The final knowledge score ranged from 0 to x, with a college numeric value indicating a higher level of HBV-related cognition.

CHB-Management motivation was accessed with 10 items on a five-point Likert scale (from 1, "strongly agree", to five, "strongly disagree"). Examples of the items include "I don't like taking my HBV medications because they remind me that I am HBV+" and "My healthcare provider doesn't requite me enough back up when it comes to taking my medications as prescribed". The total motivation score was the summation of the responses to the 10 items. The score ranged from 5 to 50, with a higher numeric value indicating a higher level of motivation related to CHB management.

CHB-Management self-efficacy was measured with 13 items adapted from the medical adherence self-efficacy score (MASES) [47], request participants how confident they were in taking HBV medications under various situations. The answers ranged from 0 "not at all" to 3 "extremely sure", which were summed up to compute the last self-efficacy score. The cocky-efficacy score ranged from 0 to 26, with a college numeric value indicating a greater confidence in taking HBV medications as recommended past doctors.

Socioeconomic factors, specifically, participants' age in years, gender, ethnicity, U.Southward. residency length, marital condition, education levels, employment condition, annual household income, wellness insurance coverage, and English-speaking proficiency were included as predictors of HBV management outcomes.

2.4. Statistical Analysis

Nosotros conducted a descriptive assay of the sociodemographic characteristics and the psychosocial factors of the analysis sample. We also conducted chi-foursquare tests and t-tests to examine associations between sociodemographic/psychosocial factors and CHB management behaviors (doctor'southward visit and claret test). Nosotros then fitted two multilevel mixed-effects generalized linear models (GLMs) to identify the pregnant predictors of the outcomes while bookkeeping for the sample clustering by recruitment site and state. All data analyses were conducted using Stata 16 [48]. A p value that was smaller than 0.05 was considered statistically significant.

3. Results

Table 1 presents the sociodemographic characteristics and psychosocial factors of the participants, as well as their association with CHB monitoring, specifically doctor'south visit in the by six months. Bivariate analyses showed that being Chinese (vs. Vietnamese), having a high school or lower education (vs. college or above), having health insurance, and having a regular dr. were significantly associated with higher rates of having visited a doctor for CHB in the past six months. In addition, having a higher HBV-related knowledge score, a college CHB-management motivation score, and a higher CHB-managed self-efficacy were significantly associated with higher rates of having visited a doctor for CHB in the by 6 months.

Table 2 presents the sociodemographic characteristics and psychosocial factors of the participants, as well equally their association with having had blood tests for their CHB infection in the by six months. Bivariate analyses showed similar associations with those in Table 1. Specifically, being Chinese (vs. Vietnamese), having a high school or lower education (vs. college or above), having health insurance, and having a regular physician were significantly associated with higher rates of having had blood tested for CHB in the by six months. In addition, having a higher HBV-related knowledge score, a higher CHB-direction motivation score, and a higher CHB-managed self-efficacy were significantly associated with higher rates of blood testing for CHB in the past six months. Other characteristics, including household income, were non significantly associated with the outcome.

Tabular array 3 presents the results of the multivariate logistic regression on a doctor'southward visit and blood testing in the past 6 months. Having a regular doc (OR = iii.81, p < 0.05) was significantly associated with a higher likelihood of having visited a doctor for CHB, while Chinese ethnicity (vs Vietnamese), having a high school or lower degree (vs. college caste or above), and having health insurance were significant predictors of having had claret tests washed in the by six months. With regard to psychosocial factors, higher HBV-related noesis and higher CHB-direction motivation were significantly associated with a higher likelihood of both outcomes—having had a doctor'south visit and blood tests in the past six months. CHB-management self-efficacy was not a pregnant predictor for either outcome.

4. Discussion

The present study examined factors associated with CHB monitoring adherence amidst Chinese and Vietnamese Americans living with CHB. More specifically, we examined adherence within the framework of the IMB model to meliorate understand the touch of cognitive, emotional, and behavioral factors on the pursuit of healthy behaviors. The results of our analyses indicate that HBV knowledge and CHB-management motivation are significant predictors of having a doctor's visit in the by six months for both Chinese and Vietnamese American study participants. We further found that HBV knowledge and CHB-management motivation are positively associated with the likelihood of having had blood tests for HBV in the past half dozen months in these populations.

Previous studies take found that low levels of noesis and lack of awareness most hepatitis and the risk of liver cancer are important predictors of suboptimal hepatitis monitoring in different subgroups of Asian Americans [33,34,35,36]. Our data support these associations, specifically in that a higher HBV-related knowledge score was significantly associated with college rates of having visited a doc for CHB in the past six months and with higher rates of blood testing for CHB in the terminal half-dozen months. Enquiry has besides suggested that adherence to CHB monitoring can exist predicted by motivation and psychosocial factors (east.g., self-confidence and self-efficacy) [29,37,38]. Our findings also support these observations, with higher CHB-management motivation score and higher CHB-managed self-efficacy existence significantly associated with higher rates of having visited a doctor and undergoing blood testing for CHB in the terminal half-dozen months.

In addition, our findings confirmed the meaning roles of having wellness insurance and having a regular md in CHB monitoring found in previous studies [29,31]. Specifically, we found three-fold differences in the odds of having an office visit and having claret tests done for their CHB conditions past insurance condition and whether they had a regular doc. More efforts are needed in outreach, education, and service to Asian Americans without health insurance or a regular source of intendance.

Household income was non significantly associated with CHB monitoring in bi-variate analysis. Previous research has generated conflicting findings in the human relationship between household income level and healthcare utilization amidst Asian Americans [49,50]. Our findings suggest that private level education and healthcare access potentially played bigger roles in influencing CHB monitoring behaviors than did household income.

A key force of the present study is the employ of the IMB model, which incorporates components of rational beliefs theory and social cognitive theory. The IMB model proposes that engaging in a salubrious behavior requires authentic noesis of the beliefs, personal and social motivation to perform the behavior, and individual cocky-efficacy and confidence to execute the behavior [40]. To the all-time of our knowledge, the present study is the first to apply the IMB model to CHB monitoring adherence. Some other major strength of our study is the baseline data, which was fatigued from a randomized control trial on long-term CHB monitoring and antiviral treatment adherence in a unique written report population, encompassing Chinese and Vietnamese Americans, from the Greater Philadelphia Area and New York City.

The findings of this study serve every bit important baseline data for the large-scale randomized command trial intervention. The culturally tailored, multilevel components that we take designed and implemented are aimed to accost the barriers that Asian Americans with CHB experience on the healthcare organization level, provider level, customs level, and individual level. The multilevel approach is critical in the empowerment of this vulnerable population, especially in the contexts of structural racism, anti-Asian discrimination, and other difficulties exacerbated by the COVID-nineteen pandemic [51,52]. More efforts are needed in creating structural level interventions to facilitate policy and systemic change to improve admission to intendance for the underprivileged and medically underserved populations [52].

five. Conclusions

In determination, we examined factors associated with CHB monitoring adherence amid Asian Americans living with CHB, using the IMB model as a guide. Our primary finding, that higher HBV-related knowledge and greater CHB-management motivation are significantly associated with conveying out CHB-monitoring behaviors, supports observations from previous studies and offers new insight into cognitive, emotional, and behavioral skills factors that influence healthy behaviors amidst Chinese and Vietnamese Americans. Moreover, our findings could have important implications for the development of novel evidence-based interventions for CHB monitoring and liver cancer prevention in the Asian American customs.

Author Contributions

Conceptualization, 1000.X.Thousand., L.Z., Y.T. and M.Q.W.; Data Curation, L.Z., K.Q.West. and E.H.; Formal assay, E.H. and L.Z.; Investigation, L.Z., Due west.Fifty., C.J. and One thousand.T.North.; Methodology, G.X.Thousand., L.Z. and West.L.; Project administration, L.Z., W.L. and Y.T.; Resources, G.X.M.; Software, M.X.Chiliad., Due east.H. and Thou.Q.Westward.; Supervision, Yard.X.M. and Y.T.; Validation, G.X.One thousand.; Visualization, L.Z., W.L., Y.T. and M.X.Thousand.; Writing—original draft, 50.Z., West.L., J.T. and C.J.; Writing—review and editing, L.Z., W.L., J.T., Grand.-C.Y. and One thousand.X.M. All authors have read and agreed to the published version of the manuscript.

Funding

This study supported by TUFCCC/HC Regional Comprehensive Cancer Health Disparity Partnership, Accolade Number U54 CA221704 (five) from the National Cancer Found of National Institutes of Wellness (NCI/NIH).

Institutional Review Board Statement

The written report has been approved by the Western Institutional Review Board (protocol #: 20190122).

Informed Consent Argument

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this written report are available on request from the corresponding writer.

Acknowledgments

The authors would similar to admit Sarit Golub and Chibuzo Enemchukwu from Hunter College for their contribution in study blueprint, intervention, and measurement development.

Conflicts of Interest

The authors declare no conflict of interest.

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Table 1. Sociodemographic and psychosocial factors among participants who had visited doctors in the past six months for their CHB and those who did not.

Tabular array 1. Sociodemographic and psychosocial factors among participants who had visited doctors in the past six months for their CHB and those who did not.

Visited Doctor for CHB
(n = 132)		 No Visit
(n = 246)		 χ ii ( d f ) o r t ( d f ) , p
Sociodemographic characteristics n (%) or hateful (sd)
Age 54.26 (13.92) 52.75 (13.30) −1.03 (376), 0.thirty
Gender 0.49 (1), 0.48
         Female 71 (36.threescore%%) 123 (63.twoscore%)
         Male 61 (33.15%) 123 (66.85%)
Ethnicity 9.76 (one), 0.002
         Chinese 115 (38.98%) 180 (61.02%)
         Vietnamese 17 (20.48%) 66 (79.52%)
Marital status one.95 (1), 0.xvi
         Currently married/cohabitating 111 (36.39%) 194 (63.61%)
         Other 19 (27.54%) 50 (72.46%)
Born in the U.s. 0.50 (i), 0.48
         No 131 (35.12%) 242 (64.88%)
         Yes 1 (20.00%) four (fourscore.00%)
Years lived in the US 1.l (i), 0.22
         <10 years 13 (27.66%) 34 (72.34%)
         ≥x years 116 (36.83%) 199 (63.17%)
Educational attainment 7.25 (1), 0.01
         ≤high school 103 (39.31%) 159 (60.69%)
         ≥college 29 (25.00%) 87 (75.00%)
Employment condition i.58 (ii), 0.45
         Employed 78 (33.33%) 156 (66.67%)
         Unemployed 9 (32.xiv%) 19 (67.86%)
         Not in labor force 44 (40.00%) 66 (60.00%)
Almanac household income <0.001 (1), 0.99
         0–$19,999 67 (34.90%) 125 (65.10%)
         ≥$20,000 65 (34.95%) 121 (65.05%)
Having health insurance 12.15 (one), <0.001
         No viii (14.29%) 48 (85.71%)
         Yes 123 (38.32%) 198 (61.68%)
Having a regular doctor 12.83 (1), <0.001
         No 6 (12.24%) 43 (87.76%)
         Yes 116 (38.54%) 185 (61.46%)
Psychosocial factors
HBV-related cognition 5.92 (2.11) 5.29 (ii.54) −two.38 (360), 0.02
CHB management motivation 28.eighty (7.04) 26.02 (6.73) −3.69 (359), <0.001
CHB management self-efficacy 6.02 (half-dozen.41) iii.62 (6.42) −3.36 (353), <0.001

Tabular array two. Sociodemographic and psychosocial factors among participants who had blood tests washed in the past six months and those who did not.

Table 2. Sociodemographic and psychosocial factors among participants who had blood tests done in the past six months and those who did non.

Had Blood Tests Done
(northward = 177)		 No Tests
(n = 188)		 χ 2 ( d f ) o r t ( d f ) , p
Sociodemographic characteristics n (%) or mean (sd)
Age 52.66 (xiii.59) 53.97 (xiii.32) 0.93 (363), 0.35
Gender 0.34 (1), 0.56
        Female 93 (50.00%) 93 (l.00%)
        Male person 84 (46.93%) 95 (53.07%)
Ethnicity 40.threescore (i), <0.001
        Chinese 163 (57.39%) 121 (42.61%)
        Vietnamese 14 (17.28%) 67 (82.72%)
Marital status one.72 (ane), 0.19
        Currently married/cohabitating 147 (50.00%) 147 (50.00%)
        Other 28 (41.18%) 40 (58.82%)
Born in the US one.65 (1), 0.20
        No 176 (48.89%) 184 (51.11%)
        Aye 1 (20.00%) 4 (80.00%)
Years lived in the US 3.37 (1), 0.07
        <10 years 17 (36.96%) 29 (63.04%)
        ≥x years 156 (51.49%) 147 (48.51%)
Educational attainment 7.82 (1), 0.01
        ≤high school 135 (53.36%) 118 (46.64%)
        ≥college 42 (37.50%) 70 (62.50%)
Employment status 5.54 (2), 0.06
        Employed 105 (46.67%) 120 (53.33%)
        Unemployed nine (33.33%) 18 (66.67%)
        Not in labor force 61 (56.48%) 47 (43.52%)
Annual household income .02 (1), 0.89
        0–$19,999 90 (48.13%) 97 (51.87%)
        ≥$20,000 87 (48.88%) 91 (51.12%)
Having health insurance 10.75 (i), 0.001
        No xv (27.78%) 39 (72.22%)
        Yep 161 (51.94%) 149 (48.06%)
Having a regular physician 17.11 (1), <0.001
        No ten (21.28%) 37 (78.72%)
        Yes 156 (53.79%) 134 (46.21%)
Psychosocial factors
HBV-related knowledge 5.76 (2.04) 5.24 (2.70) −2.02 (348), 0.04
CHB management motivation 29.47 (7.37) 24.77 (5.83) −6.64 (347), <0.001
CHB management self-efficacy half dozen.44 (vii.12) 2.70 (v.40) −5.50 (341), <0.001

Tabular array iii. Multivariate logistic regression results on doctor visit and blood test.

Tabular array three. Multivariate logistic regression results on dr. visit and blood examination.

Had Visited Doc for CHB Had Claret Tests Washed
predictors OR (95% CI)
Female gender (ref: male) ane.23 (0.68–2.23) i.44 (.74–2.78)
Vietnamese ethnicity (ref: Chinese) 0.62 (0.22–1.73) 0.03 (0.01–10) ***
College degree or above (ref: <= loftier school) 0.50 (0.22–1.12) 0.37 (0.xv–xc) *
Lived in the United states for x+ years (ref: < ten yrs) ane.03 (0.forty–2.65) i.35 (0.51–iii.61)
Having health insurance (ref: no) 2.99 (0.67–v.93) four.34 (1.24–xv.27) *
Having a regular physician (ref: no) 3.81 (1.21–12.01) * 2.91 (0.86–nine.89)
Speaking English language well/very well (ref: no/poor) 0.87 (0.twoscore–1.xc) ane.41 (0.60–iii.32)
HBV-related knowledge 1.24 (1.07–one.45) ** 1.29 (1.10–1.51) **
CHB-management motivation 1.06 (1.01–1.11) * 1.12 (1.06–one.nineteen) ***
CHB-direction self-efficacy i.03 (0.98–1.09) i.02 (0.96–1.09)
Abiding 0.004 *** 0.001 ***
due north 313 301
Log likelihood −144.63 −126.59
Wald χ 2 (df), p 33.77 (10), <0.001 64.89 (10), <0.001

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