Abstract

Background:

Immigrants are the largest subgroup living with chronic hepatitis B (HBV) infection in the United States (US). Close monitoring is recommended for all patients with chronic HBV regardless of disease activity. It is not well understood how immigration factors and social determinants of health (SDOH) impact downstream adherence to HBV monitoring among immigrants.

Methods:

We conducted a multicenter multilingual survey study among foreign-born adults with chronic HBV at three sites in California and Washington D.C. between 7/2021-2/2023. Participants were surveyed regarding 1) immigration factors such as birth country, time in the US, and citizenship status 2) acculturation including the Vancouver Index of Acculturation and language preferences 3) SDOH such as education, income, employment, and insurance and 4) clinical factors such as specialty care, treatment status, and evidence of end-stage liver disease. Primary outcome was optimal adherence to monitoring, defined as % of time with at least annual testing of HBV DNA, ALT, and ultrasound (if indicated for cancer surveillance per AASLD guidelines) while under care. Outcomes data were retrospectively collected through electronic medical records. Stepwise backwards logistic regression was used to examine factors associated with outcome.

Results:

217 participants (median 57 years, 55% male) completed the survey from 27 birth countries, with highest representation from China (30%), Vietnam (16%), and South Korea (10%). 6% were from Latin America. A minority (29%) were recently immigrated within the past 20 years and 63% were US citizens. Nearly all participants (92%) reported seeing a specialist for HBV, with 74% currently on treatment. 119 participants (55%) had optimal adherence to monitoring over median 4 years (2-7) under care. Immigration factors, degree of acculturation and language were not associated with adherence. Factors associated with more optimal adherence on multivariate testing included younger age (OR 0.96, 95% CI 0.93-0.99), on treatment (vs not: OR 2.7, 1.2-5.9), currently employed (vs not; OR 2.2, 1.0-5.0), and higher education (college vs high school; OR 3.6, 1.4-9.0; graduate degree vs high school: OR 3.2, 1.1-9.6).

Conclusion:

SDOH rather than immigration-related factors influenced likelihood of adherence to guideline-recommended monitoring of chronic HBV infection among immigrants. Efforts to improve monitoring should target socially disadvantaged foreign-born.