The Role of Culturally Appropriate Mediated Communication Strategies to Reduce Hepatitis B and Liver Cancer Disparities

Abstract

Asian, Pacific Islander, African, and Caribbean communities in the U.S. are heavily impacted by chronic hepatitis B (HBV) and hepatocellular carcinoma (HCC). Educating these groups about the link between the two diseases is imperative to improve screening rates and health outcomes. This study aims to identify and incorporate preferred mediated communication methods into community-specific educational campaigns which emphasize the connection between the conditions, to promote uptake of prevention and management behaviors for HBV and HCC. Fifteen focus groups and two key informant interviews were conducted with Micronesian, Chinese, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, and Francophone West African communities. Data were analyzed using thematic coding and analysis. Findings demonstrate that all communities preferred materials be offered in both English and native languages and requested that materials highlight the connection between HBV and HCC. Delivery channel preferences and messaging themes varied by group. This study provides insight into community-specific preferences for learning about HBV and HCC. The findings can be used to design culturally and linguistically tailored, multi-platform, health education campaigns to facilitate improved HBV screening and vaccination rates and increase knowledge about HCC risk among highly impacted communities in the U.S.

Chronic hepatitis B infection is a leading cause of liver cancer. In the U.S., foreign-born populations bear the heaviest burden, accounting for 69.1% of infections (Roberts et al., 2021). However, hepatitis B screening and vaccination, health behaviors that are key to liver cancer prevention, remain low among U.S. foreign-born communities (Hu et al., 2013; Ogunwobi et al., 2019; Sriphanlop et al., 2014; Win et al., 2023). Low awareness and knowledge of hepatitis B and liver cancer play a role in this, and effective health education is necessary to improve screening and vaccination rates, and to ensure uptake of the recent Centers for Disease Control and Prevention recommendations for universal adult hepatitis B vaccination (Weng et al., 2022) and screening (Conners et al., 2023).

The use of mediated communication channels is a cost-effective method for educating diverse audiences about the health concerns by which they are directly impacted (Adesina et al., 2020; Pourkarim et al., 2022; Schiavo, 2013). Mediated communication utilizes print, digital, and audio platforms to circulate messages (Cronin & Sood, 2018). National and global public health efforts have frequently employed mediated strategies for this purpose and have been proven to facilitate behavior change and reach expansive audiences (Adesina et al., 2020; Pourkarim et al., 2022).

Previous health education programs focusing on hepatitis B virus (HBV) and hepatocellular carcinoma (HCC) that used mediated strategies have effectively reached immigrant populations by delivering information through social media, newspapers, and photo novels. However, such campaigns have historically addressed the conditions as separate diseases and have not underscored HBV’s causative relationship to HCC (Hong et al., 2022; Lee et al., 2013; Shiau et al., 2012). Initiatives attempting to highlight this relationship have not been informed by insights from multiple diverse communities nor designed to meet the needs of priority audiences (Prevent Cancer Foundation, n.d..).

This presents an opportunity to employ mediated strategies to disseminate educational content about the link between HBV and HCC, to increase awareness and lower the disease burden among those most affected. A campaign that focuses on diverse Asian and Pacific Islander (API), African, and Caribbean communities in the U.S. can be instrumental in increasing uptake of prevention behaviors and linkage to appropriate care.

This study aimed to identify mediated communication preferences within various foreign-born groups living in the U.S. The findings can help establish a foundation upon which to build an effective, culturally tailored health communication campaign that clearly outlines the relationship between hepatitis B and liver cancer.

Materials and Methods

Data Collection

A total of fifteen focus groups and two key informant interviews were conducted virtually from April to September 2021.

At the start of the project, an advisory committee was assembled, composed of 14 members from the API, African, and Caribbean communities. The committee included public health professionals, healthcare providers, people with lived experience of HBV, and representatives of community-based organizations. Committee members had extensive knowledge of HBV and/or HCC and participated in focus groups themselves, providing insight into the challenges of addressing these diseases in highly impacted communities.

A focus group guide was developed in collaboration with the advisory committee to ensure cultural relevance. This guide was translated into different languages by a certified translation company (Elite TransLingo) and reviewed by bi-lingual researchers before use. The guide helped to ensure consistent data collection to allow for accurate comparisons during analysis.

Researchers used a purposive sampling strategy and were assisted by committee members in identifying community leaders and members to facilitate and participate in the focus groups, ensuring that the sample population was robust and diverse.

Focus group participants included foreign-born people from API, Haitian, and African communities. Sociodemographic information was collected prior to the focus group discussion. Focus groups were held with the API and African and Caribbean advisory committee members, as well as Micronesian, Hmong, Nigerian, Ghanaian, Vietnamese, Korean, Somali, Ethiopian, Filipino, Haitian, Francophone West African, and two Chinese (Mandarin and Cantonese-speaking) communities. Two additional key informant interviews were conducted with committee members. Focus groups were held over Zoom. Each focus group consisted of between seven and 12 participants. The sessions were recorded and conducted by trained interviewers in either English or another preferred language, determined by the focus group leader. Languages other than English that were used included Cantonese, Haitian Creole, Yoruba, French, Amharic, Vietnamese, Marshallese, and Korean. Audio recordings were transcribed and if needed, translated into English. Transcriptions and translations were completed professionally by DataGain Services.

Method for Protecting Confidentiality: All focus groups were conducted anonymously, and no identifying information was collected. Verbal consent and authorization to record the focus group and analyze data was collected from all participants. The voluntary nature of participating in and contributing to any portion of the discussion was made explicit at the beginning of each session. IRB approval was obtained before the initiation of this study (Heartland IRB Project No. 329–062421).

Data Analysis

NVivo 20 software was used for thematic coding and analysis of qualitative data. The research team developed a codebook a priori that was revised during the coding process as new themes and subthemes emerged. Each transcript was assigned a primary and secondary coder. Transcripts were coded independently and then, to ensure inter-coder reliability, primary and secondary coders discussed each transcript to resolve discrepancies. The final kappa coefficient was 0.78, indicating high inter-coder reliability.

Results

Participant Characteristics

A total of 101 people participated in the focus groups. Study participants represented diverse cultures (Table 1) and varied in their spoken language preferences (Table 2).

Table 1. Demographic characteristics of focus group participants, 2021

			Residence N (%)		Born in U.S. N (%)
	Overall N (%)	Mean age in years^1	Urban	Suburban	No	Yes	Mean length of Time in U.S. in years
	101 (100)	52	84 (83.3)	16 (16.7)	92 (91.3)	8 (8.7)	25.3
Community Group
Chinese (Cantonese)	6	66.5	6 (100)	-	6 (100)	-	38.5
Chinese (Mandarin)	6	37	3 (50)	3 (50)	5 (83)	1 (17)	22
Filipinx	8	65	8 (100)	-	8 (100)	-	39.5
Hmong	6	36	3 (50)	3 (50)	1 (17)	5 (83)	23
Korean	9	55	9 (100)	-	9 (100)	-	19
Micronesian	5	45	5 (100)	-	5 (100)	-	24
Vietnamese	10	58	10 (100)	-	10 (100)	-	26
Ethiopian	6	54	3 (50)	3 (50)	6 (100)	-	32
Nigerian	9	62.5	9 (100)	-	9 (100)	-	35
Nigerian and Ghanian	6	53	2 (33)	4 (67)	6 (100)	-	18
West African	13	49	13 (100)	-	13 (100)	-	12
Somali	8	41.5	8 (100)	-	7 (87.5)	1 (12.5)	20
Haitian	9	58	9 (100)	-	9 (100)	-	20

¹Participant age was not asked directly in any focus group. Instead, age was determined by accounting for age upon arrival in the United States and length of time spent in the United States.

A total of 101 people participated in the focus groups. Most participants were foreign-born and spent an average of 25 years in the United States.

Table 2. Spoken language preferences by community group, 2021

	Language Preference
Community Group	Prefer English N (%)	Prefer a Language other than English N (%)	Prefer a combination (English & Another Language) N (%)
Chinese (Mandarin)	6 (100%)	-	-
Nigerian & Ghanaian (D.C.)	1 (16.67%)	1 (16.67%)	4 (66.67%)
Filipinx	4 (50%)	1 (12.5%)	3 (37.5%)
Chinese (Cantonese)	2 (33%)	4 (67%)	-
Micronesian	-	2 (40%)	3 (60%)
Hmong	5 (83%)	-	1 (17%)
Korean	-	9 (100%)	-
Nigerian (Chicago)	1 (11%)	3 (33%)	5 (56%)
West African	3 (23%)	10 (77%)	-
Ethiopian	2 (33%)	3 (50%)	1 (17%)
Somali	1 (12.5%)	4 (50%)	3 (37.5%)
Vietnamese	-	10 (100%)	-
Haitian	1 (11%)	8 (89%)	-
TOTAL	26 (28.71%)	55 (48.86%)	20 (22.44%)

Most participants preferred speaking a language other than English, others preferred speaking English, and some preferred speaking a combination of both English and another language.

Using a Likert-scale, with one being not at all comfortable and five being extremely comfortable, the average comfort level with arranging a doctor’s appointment among participants was 4.2. This was used as a proxy for comfort navigating the U.S. healthcare system. Perceived severity of HBV and HCC was 4.2 and 4.8, respectively (Table 3).

Table 3. Comfort arranging doctor’s appointment and perceived severity of hepatitis B and liver cancer, by community group, 2021

Community Group	Comfort Level Arranging Doctor’s Appt* Mean (SD)	Perception of hepatitis B Severity Mean (SD)	Perception of Liver Cancer Severity Mean (SD)
Chinese (Mandarin)	5 (0)	4 (1)	5 (0)
Nigerian and Ghanaian (D.C.)	4.4 (1.1)	4 (1.1)	5 (0)
Filipinx	5 (0)	5 (0.5)	5 (0.35)
Chinese (Cantonese)	4 (0.9)	5 (0.5)	5 (0)
Micronesian	5 (0.9)	4 (0.5)	5 (0)
Hmong	5 (0.4)	3 (1.3)	5 (0)
Korean	2 (1.33)	4 (0.66)	5 (0.44)
Nigerian (Chicago)	4 (1.33)	5 (1.33)	5 (1.33)
West African	4 (1.4)	4 (1.3)	4 (1.5)
Ethiopian	5 (0)	4 (0.5)	5 (0.4)
Somali	5 (0.9)	5 (0.38)	4.5 (0.38)
Vietnamese	3 (0.99)	3 (1.2)	4 (1.3)
Haitian	3 (1.4)	4 (1.1)	5 (0.33)
TOTAL	4.18 (0.988)	4.15 (0.688)	4.81 (0.38)

Using a Likert-scale, with 1 being not at all comfortable and 5 being extremely comfortable, the average comfort level with arranging a doctor’s appointment among participants was 4.2. This was used as a proxy for comfort navigating the U.S. healthcare system. On a similar Likert scale, the average perceived severity of hepatitis B and liver cancer among participants was 4.2 and 4.8, respectively.

Emphasizing the Link Between HBV and Liver Cancer

All communities agreed that materials must clearly explain the connection between HBV and HCC. When asked, one key informant emphasized that messaging should explain how HBV can increase the risk for HCC, as this would likely increase peoples’ willingness to get screened for both diseases. One Filipino participant shared, “I think that’s the confusion so it’s really important to know the occurrence of hepatitis B, and how it progresses into … liver cancer.” A Francophone West African participant communicated, “As soon as people understand that cancer is the result of untreated hepatitis B, when information is passed on, education is passed on, [and people] go get tested.” Hmong and Haitian participants voiced similar sentiments. A member of the Nigerian group believed that people’s motivation to get screened would increase as they learned about the connection, particularly because they take cancer “more seriously” than other diseases.

Furthermore, informing the community about the benefits of screening and management of HBV is necessary, as these behaviors will reduce the risk of progression to cancer. One Chinese-Mandarin participant summarized this:

If you have a really convincing statistic to make me think that doing it is worth it, like “if you get it [hepatitis B treatment], you have a 90% chance of not getting liver cancer,” I’d be like, “Oh, that’s pretty good.”

Preferred Messaging Themes

Balancing Hope and Fear

Overall, all focus groups preferred informational messages to be hopeful. An API advisory committee member shared that messages should “…focus more on the positive like, ‘If you catch [it] early, you save lives.’ … I feel like if you try to explain more, you actually make it even worse.” One key informant discussed how messages that use “open optimism” and include “resources [that] are available and affordable” are more appropriate than fear-based messages. A person in the Nigerian group provided insight into how positive framing can prompt uptake of prevention behaviors within their community:

You give them hope that even though you have this disease, if it’s managed, then there’s hope that you’re not going to die, that’s what the hope is.… the whole thing here is giving people hope, in the message to say, if you get screened, and tested, you will know your status. And if you are positive, there’s a way to manage it to live.

Conversely, some communities preferred a combination of hopeful and fearful messages. One Chinese-Mandarin participant expressed the importance of educating the community so they are aware of the “dangers” HBV might cause, coupled with “concrete steps” to help people not only overcome their fear of hepatitis, but also to “make people feel they have some sense of control” over their health.

A Vietnamese participant discussed how accommodating individuals’ communication preferences is challenging, as, “Everyone has their own knowledge. Some said they are scared of death, others said it’s more dangerous to find out the disease and don’t want to do test.” One Korean community member shared this sentiment, stating how the use of “both a warning and a hopeful message” can effectively promote behavior change.

Discussing Quality of Life

Multiple groups discussed the importance of messages that focus on quality of life. A member of the Korean community advised to go “beyond simply promoting the prevention of hepatitis and liver cancer … it would be better to produce and distribute information related to the quality of life.” One Haitian participant provided an analogy that alludes to the future benefits of knowing one’s hepatitis status: “We have a saying in Haiti ‘chimen bouton se chimen maligne’ which means when you have a little wound if left untreated it can turn into worse.”

Personal testimonials were also mentioned as a way to show how people’s lives have been affected by HBV or HCC. A Somali participant voiced how people “Want to hear the stories, so they might relate to them … they can be learning something from that.” One Micronesian participant also explained how testimonials can reassure people of their potential to live a long and healthy life with HBV:

Nowadays programs … like to include heroes, where these are survivors or people who are currently having the disease, so people who have hepatitis B can show an example of how to live life with hepatitis B and be successful at it.

Demonstrating Respect

Participants discussed how informational messages on screening and care should be respectful to the audience. One key informant offered:

If you sound condescending, or you are trying to throw what you are presenting in [their] face … then you start having problems. Because a lot of … Africans don’t let go of those things… It must be done from a place of respect and be sensitive to the African culture.

Other people discussed the need to respect social and cultural norms when presenting information about the sexual transmission of HBV. One Somali participant shared how messages regarding transmission could be misunderstood:

You may avoid … talking about how the disease is transmitted, for example, sexual intercourse. As you know, most people, all the generations … are people who practice faith, Islam. And once you tell them, “Oh, it’s transmitted in that kind.” They will tell you, “Well, we don’t. We are very close … my partner and I, so I’m not worried about being exposed to external intercourse.”

Respect when conveying community-specific risk of HBV and liver cancer was regularly mentioned, although there were differences in opinion across communities. Vietnamese, Nigerian, Hmong and Micronesian participants shared that when explaining the risk to their communities, such information should be grouped with that of other highly impacted communities. A Francophone West African community member explained:

Rather than pointing the finger at Africans, we are all citizens of the world … a campaign should inform humans about the need to be tested and encourage people … that stigmatizes less. Don’t give the impression that only Africans are doing this.

One key informant had a similar opinion: “I think any words that point blame … any phrasing that says ‘this is your fault’ should definitely be avoided.” A member of the Haitian group agreed that materials should “List a number of countries, so that you’re not singling out a country” when informing audiences of their communities’ HBV risk.

In contrast, another Francophone West African participant said, “I think that when we say that this disease is affecting more and more West Africans, we should not hide the reality … Unfortunately, it is much more widespread among us.” In the Chinese-Mandarin group, one person remarked, “For the main messaging that … anyone could get hepatitis B, or that it’s something that’s a bit more prevalent among our community, among Chinese, or Chinese-Americans.” An Ethiopian participant shared similar thoughts, “We are already one community and it is not singling us out by race or religion. So, if it says all of us who came from Ethiopia are at high risk, I don’t think it will have stigma.”

Interestingly, another Ethiopian participant countered this statement: “The stigma that it only comes from drinking would now be replaced with the expression that the country where we came from has an impact.” This highlights the challenge surrounding communicating a group’s risk without further stigmatizing them.

Incorporating Family

Incorporating the responsibility to one’s family to maintain health in campaign messaging was considered extremely important. A Vietnamese participant articulated, “Messages that are family-based are crucial. Taking care of themselves is a responsibility for taking care of their family.” Similarly, one key informant believed:

To Africans, family is everything and so, if you want to be there for your family, then you need to get tested. If you need to take your pills, then you need to take your pills because if you don’t, then you won’t be there for your family. … family is one big thing that Africans cannot do away with.

A Hmong participant stated that messages should use “the overarching beliefs of the Hmong families, blessings, group-oriented. I think those are the themes that we’d promote, them being able to learn more information and come get tested.”

Identified Mediated Communication Preferences

Language

In this study, language preference seems to be dependent upon birthplace and age. Across every community, younger generations used English more, while older participants preferred to consume information in their native languages. One Francophone West African member succinctly stated, “In-language materials are important, as is age-specific messaging.” Participants agreed that ideally, materials should be available both in English and the community’s native language to effectively engage diverse age groups. As for ways to incorporate in-language media, one Vietnamese participant suggested having a television show with “A doctor talking specifically about hep B or liver cancer and giving updated information. Info provided should be in both languages” especially for older populations since “Older folks trust doctors a lot.” People from Somalia, Haiti, the Hmong community, Nigeria and the Philippines expressed similar ideas. In general, people agreed that materials should be professionally translated to incorporate colloquialisms and the natural way of speaking, to accurately capture information in an accessible manner.

Visual Aids

Visual aids, specifically videos and images, were routinely cited as an impactful way to disseminate messages. A Korean participant described this impact:

I attended a hepatitis seminar and I have seen an image of how the liver changes depending on the progress of hepatitis … I was not aware of the effects of diseases such as hepatitis, cirrhosis, and liver cancer, but I was able to understand the characteristics of each disease through accurate images.

A Haitian group member shared, “Sometimes when you are talking about something and it is supported with pictures, it makes people have consciousness about the matter.” One key informant explained how providing people with visual representations, such as videos of testing procedures, can reduce apprehension around screening. These perspectives on the use of visual aids were echoed across multiple groups.

Print Materials

Generally, print materials were considered helpful in specific settings, but enthusiasm varied between communities. One Hmong participant shared, “I like those pamphlets. When I go to the office and I’m sitting or waiting, I usually just grab one and read and look through it, and then take it home with me.” A key informant thought that while placing printed materials in healthcare settings can be beneficial, using multiple channels, such as radio ads, may be more effective at reaching more people.

Other settings, such as salons, have increased audience engagement with printed materials, as discussed by an African and Caribbean advisory committee member: “We have an educational slide deck that is printed that they can flip through to learn about hepatitis B facts while sitting and getting their hair braided … it’s been really, really effective.”

However, these views were not shared across other communities. One Haitian participant stated, “Not all the people like to read. Sometimes people go to doctors and see the papers there and are not even interested in reading them.” An Ethiopian member shared this view. Similarly, a Micronesian participant expressed, “A piece of paper has no value to our community, and this is why: It’s not because we don’t think it’s valuable … we didn’t really have information everywhere in our house, we learn by speaking to each other.”

Social Media

The importance of social media in communicating statistics, personal testimonials, and video materials related to HBV and HCC was strongly emphasized. The choice of social media platform varied based on the community and the audience’s age. An API advisory committee member suggested, “I think using YouTube, the message should be a simulation of how to talk to your doctor about getting tested for hep B.” YouTube was also popular within the Hmong and Chinese-Mandarin communities. Facebook was specifically cited by two groups as a popular social networking site. Regarding age, one Vietnamese participant said, “I think Facebook is only useful for middle-aged, and young people.” Key informants, along with Filipino and Haitian participants, recommended engaging with younger generations via TikTok. While most groups endorsed the use of various social media platforms, one key informant felt differently, “Not really a big fan of social media and I won’t be surprised a lot of my African community members are not either.”

Despite consensus that the Internet and social media are effective and practical information-sharing tools, participants described digital literacy challenges within communities. This barrier was voiced during the Vietnamese community focus group: “Older people don’t know about Facebook and Internet.” A Chinese-Mandarin participant brought up how older people “are less tech savvy” which makes it “challenging” for them to access information online.

Radio

There was consensus among all communities regarding the radio’s potential to expand the reach of a health communication campaign. A Vietnamese participant remarked, “Radio is very popular. I think that we should promote on radio … have talk shows about benefits of vaccination and the danger of hepatitis B … I think radio is highly effective.” One key informant shared, “Radio, it’s our main way of informing one another [in the Marshall Islands].” People in the Hmong, Francophone West African, Korean, and Filipino communities also regarded radio communication highly. One Haitian participant stated, “The people listen to radios a lot and they believe in some voices. They say if it is on that radio and that person said it, they believe it.”

Table 4 represents the organic responses of participants but does not serve as a complete representation of all preferred and utilized mediated communication channels within each group.

Table 4. Communication channel preferences by community group, 2021

	Mediated Communication Channel
	Visual Aids	Printed Materials	Social Media	Radio
Community Group
Chinese (Cantonese)
Chinese (Mandarin)			Yes: YouTube No: older people have difficulty
Filipinx			Yes: TikTok	Yes
Hmong		Yes	Yes: YouTube	Yes
Korean	Yes			Yes
Micronesian		No	No	Yes
Vietnamese			Yes: Facebook	Yes
Ethiopian		No
Nigerian
DC West African
Francophone West African				Yes
Somali			Yes: Facebook
Haitian	Yes	No	Yes: TikTok	Yes

This table represents the organic responses of participants but does not serve as a complete representation of all preferred and utilized mediated communication channels within each group.

Discussion

This study’s exploration of mediated communication preferences across different immigrant communities in the U.S. demonstrates the need for culturally tailored HBV and HCC health education campaigns that employ a variety of messaging strategies and channels. By actively engaging community leaders and members of different foreign-born groups, this study offers insight into different populations’ health communication needs and delivery preferences (Bolutayo et al., 2018), and expands upon existing literature with examples of how to design future programmatic and health communication efforts to have cultural and linguistic relevance.

Identified Messaging Strategies and Themes

Employing the audience’s native language, particularly for older generations, is an essential component of culturally appropriate interventions (Joo, 2014; Joo & Liu, 2020; Porteny et al., 2020). Multiple communities concurred with previous research, that materials should be created both in English and in identified native languages, as in-language resources are considered reliable and enhance audience comprehension (S. Hyun et al., 2018). Study participants confirmed prior findings that educational materials must be professionally translated by someone who speaks the language and should be pilot-tested and reviewed by community members (Bolutayo et al., 2018; Lee et al., 2013). This study found that messaging strategies must also be attuned to community-specific cultural nuances. For example, when informing certain audiences about HBV and HCC, it is of particular importance to find ways to portray sexual transmission in a non-descriptive manner, and to present gender-specific information to men and women separately (Pourkarim et al., 2022; Taylor et al., 2013). Additionally, one way to reduce stigmatization when informing people of their HBV and HCC risk is to group impacted populations together, to avoid placing blame on a specific community, while simultaneously providing relevant information respective to each group (Parvanta & Bass, 2018).

Engaging an audience’s emotions can increase their acceptance of information and their likelihood of following health recommendations. Focus groups agreed that messages should remain positive and explain how to manage an HBV diagnosis to reduce the risk of HCC. Many people fear the potential disruption to their lives that an HBV diagnosis might bring. Participants mentioned that emphasizing how testing and vaccination are routine practices that effectively reduce HBV burden can help decrease associated stigma, as people learn that these behaviors are commonplace and do not indicate the end of one’s life. Emotional content that highlights the lived experience of HBV, such as personal testimonials, may enhance the audience’s acceptance of the content as they see first-hand how one’s quality of life does not have to diminish because of HBV (C. S. Hyun et al., 2019). Additionally, family-focused messaging underscores the connection between personal and family health and can lead to greater acceptance of the need for prevention and management of HBV and HCC.

While most communities preferred messages of hope, some expressed the potential utility of incorporating hopeful and fearful tones, as using facts to instill fear can increase one’s alertness and motivation to manage their HBV and practice HCC prevention behaviors. This notion is supported by a previous study, which found that framing HBV screening as a liver cancer prevention strategy increased the study population’s testing rates and awareness of the disease connection (Xiao et al., 2021). Despite the potential of fear-based strategies to instigate behavior change, most communities in this study agreed that death should not be mentioned in campaign materials. Therefore, content must present the facts about each condition and reinforce their connection by explaining that leaving HBV undiagnosed and unmanaged increases one’s risk of HCC, and emphasizing how prevention and management behaviors can reduce this risk (Parvanta & Bass, 2018).

All campaign materials should be solution-oriented and provide concrete ways to manage health. Audiences are empowered when they are provided the tools to protect themselves against severe HBV-related outcomes, such as connection with local testing facilities or referral to online resources (Parvanta & Bass, 2018).

Identified Mediated Communication Channels

Combining print and visual materials can enhance audiences’ overall understanding and internalization of health information (Lubetkin et al., 2015). Health information can be presented through visual media in many ways, including pamphlets, photo novels, and narrative videos; such content has been shown to heighten trust, acceptance, and engagement among community members when they can identify with the people and stories featured in materials (S. Hyun et al., 2021; Kile, 2022; Lee et al., 2013; Talal et al., 2022). In the present study, Korean, Haitian and Somali communities all agreed that written information should be supported by videos to enhance audience comprehension. Providing visual representations, including video or illustrative graphics, of the written copy can enhance the audience’s understanding of HBV’s connection to liver cancer, what to expect of testing and vaccination processes, and how to reduce the risk of disease transmission and progression (Parvanta & Bass, 2018).

Social media has been found to be a powerful tool for increasing the flow of information between public health organizations and priority populations (Koskan et al., 2014). While using social media for disseminating information was widely supported across all focus groups, each community preferred different platforms, although Facebook and YouTube were the most popular channels. Previously, Facebook has been found to effectively promote behavior change, such as HIV testing, medication adherence and cancer prevention, within various populations (Hong et al., 2021; Russomanno et al., 2019). Campaigns can post in-language videos on YouTube to disseminate health information, such as tips for conversing with healthcare providers, which decrease health literacy and English proficiency challenges faced by immigrant groups (Cudjoe et al., 2021; Hong et al., 2021; Khalili et al., 2023).

Additionally, combining social media-based strategies with messaging through traditional media sources, such as radio, can expand a campaign’s reach (Pourkarim et al., 2022). Ethnic radio outlets are vital components of health communication campaigns. In this study, participants agreed on the effectiveness of in-language radio shows, as they reach a broader audience, and are considered reliable sources of health information (S. Hyun et al., 2018).

Not only do tailored communication campaigns improve access to health information (Chee et al., 2017; Hong et al., 2022), they also increase peoples’ self-efficacy in practicing health behaviors and improving their overall health (Hong et al., 2022; Lee et al., 2013; Maglalang et al., 2017). When people can learn about HBV and HCC through avenues that are considerate of their safety, social values, and language preferences, and that empower them with actionable steps to take control of their health, they may be more likely to engage in safe health practices and encourage others to do the same (Maglalang et al., 2017).

Limitations and Lessons Learned

This study has several limitations and lessons learned. The results from this study are not generalizable to the broader population due to the small sample size and demographic make-up of each focus group. However, the results are still transferable to other similar populations. Despite employing a purposive sampling strategy for participant recruitment, selection bias may pose a threat to the study’s internal validity, as demographic diversity may have been limited within each community group. As the focus groups were conducted virtually, potential participants who have low digital literacy or do not have access to the required technology may have been excluded.

Social desirability bias may also impact the validity of the study results, as the focus group setting may have prompted sharing behaviors that may have differed from those exhibited in individual interviews. Some participants were clinicians or providers who had preexisting knowledge about hepatitis B and liver cancer, which could have impacted the natural course of group discussions. In this study, one focus group conversation was subject to leading questions and prompts posed by a facilitator, so participants’ answers may not have been authentic.

This study may be subject to challenges with translation. Focus groups that were conducted in a language other than English were professionally transcribed and translated; however, there may have been some incorrect translations of phrases or jargon.

This study found that the focus groups themselves were often a source of HBV awareness and knowledge for participants. In the future, a small educational session following each group or the provision of a fact sheet or other resource for participants would be beneficial. Additionally, an assessment of knowledge before and after exposure to educational materials could help to better ascertain the utility of the materials, as would a comparison of knowledge between study participants and non-participants of the same communities. In light of this, the researchers will plan to include such an assessment in tandem with the dissemination of the communication campaign that was informed by, and is following, this study. This will be an effective tool for capturing the impact of newly acquired knowledge on behavior. The researchers recognize that, while not comprehensive or sufficient on their own, effective educational resources can be critical components of a robust and comprehensive intervention to assuage health disparities.

Conclusion

This study elucidated community-specific mediated communication preferences for learning about hepatitis B and liver cancer. Culturally tailored health education campaigns can play a strategic role in helping communities understand the link between hepatitis B and liver cancer, to more effectively increase rates of hepatitis B screening and vaccination among highly impacted groups in the U.S. Findings from this study can be used to design multi-platform, culturally and linguistically appropriate health education campaigns to facilitate improved hepatitis B awareness, testing, and prevention rates among impacted communities in the U.S.

Acknowledgments

The authors would like to thank the advisory committee for their guidance and expertise; the focus group leaders for their expertise and assistance; and all who participated in this study.

Disclosure Statement

The Hepatitis B Foundation receives public health program and research grants from BMS, GSK, Gilead Sciences and VBI Vaccines. Chari Cohen serves on a patient/advocacy advisory committee for GSK and Gilead Sciences, with funds being distributed to the Hepatitis B Foundation. Beatrice Zovich has also served on an advisory committee for Gilead for which she was financially compensated.

Data Availability Statement

The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author.

Additional information

Funding

This work was supported by the Bristol Myers Squibb under Grant #65080979, Addressing Liver Cancer Disparities Among Asian American, Pacific Islander and African Immigrant Communities in the U.S.; and through general operating funds of the Hepatitis B Foundation. This study received ethics approval through Heartland IRB (HIRB project No. 329-062421).