Factors associated with hepatitis B knowledge among people of Vietnamese ethnicity in Australia

ABSTRACT

Despite high hepatitis B (HBV) prevalence among people of Vietnamese ethnicity in Australia and elsewhere, there is limited research on levels of HBV knowledge and factors associated with such knowledge. The aim of this study was to examine HBV knowledge and associated demographic and attitudinal factors among people of Vietnamese ethnicity in Australia. People of Vietnamese ethnicity (n = 966) were recruited through community events and social media groups to complete online surveys measuring HBV knowledge, attitudes towards HBV, levels of mistrust in Western medicine, and demographic characteristics. Findings of this study indicate that levels of knowledge are mixed, with gaps in knowledge related to transmission and treatment of the virus. Those with greater knowledge of HBV tended to be older, have higher levels of formal education, have been tested for HBV, and know someone living with HBV. Those with lower levels of knowledge tended to have more negative attitudes towards the virus and greater levels of mistrust in Western medicine. Given that health literacy is connected to effective communication from health providers, we suggest that there is a need for the development of health promotion and education resources targeted at people of Vietnamese ethnicity and translated into Vietnamese. We propose that such resources be developed in consultation with Vietnamese communities and health providers to ensure that they are culturally appropriate and sensitive to people of Vietnamese ethnicity living in Australia.

KEYWORDS:

• Hepatitis B
• stigma
• attitudes
• knowledge

Introduction

Hepatitis B virus (HBV) affects an estimated 316 million people globally (GBD 2019 Hepatitis B Collaborators, 2022) and 200,385 people in Australia (MacLachlan et al., 2023). Chronic HBV infection, HBV having persisted for more than 6 months, is the leading cause of hepatocellular carcinoma globally, which is associated with significant mortality (Ringelhan et al., 2017). Many people living with chronic HBV are asymptomatic and as such a significant proportion are not aware of their infection (World Health Organization [WHO], 2022). As a result, many people at high risk of chronic HBV may not access testing, vaccination, and monitoring or treatment (where required), thus increasing the risk of transmission and disease progression (C. Cohen et al., 2011).

In Australia, HBV is largely endemic among migrant communities, with an estimated 69.7% of Australians with chronic HBV having been born overseas, with the most common regions of birth being Northeast Asia and Southeast Asia (Kirby Institute, 2021; MacLachlan & Cowie, 2018; MacLachlan et al., 2023). China (18.3% of people living with chronic HBV) and Vietnam (10.3% of people living with chronic HBV) are the most common countries of birth, together making up more than one-quarter of people living with chronic HBV in Australia (MacLachlan et al., 2023). There is significant cultural and linguistic diversity among people living with or at high risk of HBV in Australia, with Chinese and Vietnamese languages being the most common spoken amongst people living with the virus (Cowie, 2011). As a result, people from culturally and linguistically diverse backgrounds are recognised as a priority population in the national strategy for HBV (Australian Government Department of Health, 2023).

Migrant communities face a range of systemic barriers that may impede their access to testing and care for HBV, including racism, stigma surrounding HBV, language barriers, financial impediments, a lack of culturally competent and appropriate care, and cultural differences in understandings of health and illness (Dahl et al., 2014; Guirgis et al., 2012; Smith-Palmer et al., 2020; Vedio et al., 2017). Migrants may also have poor health literacy and knowledge of HBV, which may impede access to testing and treatment (Jin et al., 2022a; Owiti et al., 2015). It is important to note that ‘effective health literacy is largely to do with effective communication’ (Christie, 2010, p. 40). Thus, rather than focusing on individual deficits in knowledge among migrant communities, health literacy must be considered in the context of whether health systems are facilitating appropriate and effective communication. For instance, research among Chinese migrants living with HBV in Australia has found that perceptions of health provider competency is a core component of trust in Western medicine, which includes perceptions of the providers’ provision of accurate information about HBV (Jin et al., 2022b). Thus, it is possible that trust in Western health providers may contribute to HBV health literacy. Levels of trust, or mistrust, among people of Vietnamese ethnicity in Australia towards health providers has not yet been examined.

Research suggests the level of HBV knowledge among migrant groups in Australia and elsewhere is low to middle range, with significant gaps in knowledge of transmission and prevention, and which may contribute to insufficient preventive and testing practices (Huang et al., 2016; Jin et al., 2022a; Shiau et al., 2012; Vedio et al., 2017; Vu et al., 2012). Low levels of knowledge and misinformation about hepatitis B have also been linked to increased stigma and discrimination among migrant communities (Jin et al., 2022a; Lee et al., 2016; Owiti et al., 2015). There is less research about knowledge of HBV among people of Vietnamese ethnicity. What is available suggests that Vietnamese people living in Vietnam and the U.S. have mixed levels of knowledge about HBV, including misconceptions about transmission through food and water (Dam et al., 2016; Ha et al., 2013; Hang Pham et al., 2019; Hwang et al., 2008; Ma et al., 2007; Taylor et al., 2005). In survey research based in Australia, knowledge of HBV among Vietnamese people has been described as very poor to moderate, with particular gaps in knowledge related to HBV transmission (Cama et al., 2024; O’Connor et al., 2008; Vu et al., 2012). Qualitative research among people of Vietnamese ethnicity in Australia has suggested that knowledge is often gathered from personal observations and experiences and anecdotal stories, which tend to hold greater weight than observations from health providers (Le Gautier, Wallace, A Richmond, et al., 2021).

There is also limited research about predictors of HBV knowledge among Vietnamese people. In the U.S. context, higher education and income, family history of HBV, length of residency in the U.S., and English fluency have been found to be associated with greater levels of HBV knowledge (Chu et al., 2017; Hwang et al., 2008). In one Australian study, researchers found that HBV knowledge among Vietnamese men was predicted by being highly acculturated (i.e. acclimatising to Australian culture), having been tested for HIV, and knowing someone living with HIV, however the authors noted that the study was limited to only asking one question about HBV (O’Connor et al., 2008). The aim of this paper is therefore to address the gap in research regarding HBV knowledge among people of Vietnamese ethnicity in Australia. This paper assesses HBV knowledge among a sample of people of Vietnamese ethnicity living in Australia, as well as demographic and attitudinal factors that predict knowledge, such as attitudes towards people living with HBV and levels of trust in Western medicine.

Methods

Sample and procedure

This research forms part of a broader project monitoring stigma towards priority groups in Australia impacted by blood borne viruses and sexually transmissible infections (Broady et al., 2018). The data presented in this paper are from a component of this research, which surveyed people of Vietnamese ethnicity living in Australia about HBV. Four organisations in four different states assisted with the recruitment of participants for these surveys: LiverWELL (Victoria), Hepatitis NSW (New South Wales), Hepatitis SA (South Australia), and Ethnic Communities Council of QLD (Queensland). These organisations distributed hard copies of the surveys to people at Vietnamese community events, and completed surveys were returned to the researchers at UNSW Sydney. Participants were provided with the survey in either Vietnamese or English, depending on their preference.

Social media was also used to recruit participants, including through advertisements on Facebook groups for the Vietnamese community. Interested participants were directed to a survey website where they could access a Participant Information Statement and complete the survey. Participants could elect to complete the survey in Vietnamese or English. Participants consented to the study by ticking a checkbox at the beginning of the survey and by submitting their responses.

The surveys took approximately 15–20 minutes to complete, and participants were provided with an AUD $15 voucher as reimbursement for participation. A researcher of Vietnamese background entered all hardcopy data into the survey website, which was then combined with the online survey data. This research has ethics approval from the UNSW Human Research Ethics Committee (HC210036).

Measures

HBV knowledge

Thirty items adapted from previous research (Jin et al., 2022a) were included in the survey to measure participants’ knowledge of HBV. The domains assessed were general knowledge of HBV (including vaccination and treatment), transmission of HBV, and prevention of HBV. Example items included ‘There are no effective pharmaceutical medicines available to treat HBV infection’ (False) and ‘There is a vaccination that can prevent HBV infection’ (True). Response options were ‘false’, ‘true’, and ‘unsure’. Items were recoded as ‘correct’ and ‘incorrect’, with unsure responses coded as ‘incorrect’. Items were then summed to form a composite measure of HBV knowledge, whereby higher scores were indicative of greater knowledge.

Attitudes towards HBV

Attitudes towards HBV were assessed using eight items, such as ‘People who have HBV deserve it’ adapted from previous research (Jin, 2022). Participants responded on a five-point Likert scale from ‘strongly disagree to ‘strongly agree. After reverse scoring two items, all items were summed to form a measure of attitudes towards HBV (α = .75), where higher scores indicated more negative or discriminatory attitudes towards people living with HBV.

Mistrust in Western medicine

Six items were included in the survey to assess participants’ levels of mistrust in Western medicine. Example items included ‘I am suspicious of information about HBV from Western-trained doctors and healthcare workers’ and ‘I believe that using pharmaceutical medicine to treat HBV has more negative side effects than using traditional Chinese medicine’. Participants responded on a five-point Likert scale from ‘strongly disagree’ to strongly agree’. Positively worded items were reverse scored, and items were then summed to form a measure of mistrust in Western medicine (α = 0.86), where higher scores indicated greater mistrust in Western medicine.

Demographic characteristics

A range of demographic questions were included in the survey, including age, gender, education, marital status, language spoken at home, state of residence, testing for HBV, and personally knowing someone living with HBV. The following variables were recoded as binary variables for the purposes of the analyses reported in this paper: gender (man, woman), education (up to Year 12, undergraduate/postgraduate university and diploma/trade certificate), testing for HBV (yes, no), and personally knowing someone living with HBV (yes, no). Due to small numbers reporting gender diversity, responses for ‘non-binary’, ‘different term’, and ‘prefer not to answer’ were excluded from analyses.

Data analyses

Data were analysed using IBM SPSS Statistics software version 26. Descriptive statistics were used to describe demographic and attitudinal characteristics of the sample. Demographic differences between participants who completed the survey online compared to offline (hardcopy) were measured using an independent samples t test for age and chi-square tests for categorical variables. Multiple linear regression was conducted to assess which variables predicted HBV knowledge. Entered into the model as independent variables were age, gender, education, ever tested for HBV, knowing someone living with HBV, attitudes towards HBV, and mistrust in Western medicine. There were two outliers on knowledge, which were removed from the analyses. All other assumptions of multiple regression were met.

Results

The sample consisted of 966 Vietnamese adults living in Australia, of whom 68.6% completed the survey online and 31.4% completed the survey on hardcopy. The majority (77%) of participants were born in Vietnam, with 22.6% born in Australia and 0.4% born in another country. The average age of the sample was 36 years, and more than half (56.9%) identified as women. The sample was highly educated, with 52% of the sample having undergraduate or postgraduate qualifications. Nearly two-thirds of the sample reported being vaccinated against HBV (62.8%). Reported testing rates for HBV were quite high, with 64.3% of the sample reporting that they had ever been tested for the virus. Thirty-three participants (3.5%) reported that they have HBV. More than a third (36.4%) reported that they personally knew someone living with HBV. Additional demographic data are reported in Table 1. There were some key demographic differences between participants who completed the survey online compared to offline or hardcopy. Online participants were younger (Mean 30.70 online vs 49.49 offline; t_(343.80) = −20.61, p < .001.) and more likely to have a university degree or trade certificate (82.1% online, 52.4% offline; p < .001), have ever been tested for HBV (78.5% online vs 64.9% offline; p < .001), and have ever been vaccinated for HBV (74.4% online vs 36.6% offline, p < .001).

Table 1. Demographic characteristics of the samples.

	Vietnamese sample N = 966
Age Mean (SD), Range	36.44 (13.21), 18–90
Gender identity
Man/male	397 (41.5)
Woman/female	544 (56.9)
Non-binary	1 (0.1)
Different term	1 (0.1)
Prefer not to answer	13 (1.4)
Highest level of education
Years 1–6	11 (1.2)
Years 7–10	51 (5.4)
Years 11–12	195 (20.5)
Diploma/Trade certificate	202 (21.2)
Undergraduate university	334 (35.0)
Postgraduate university	160 (16.8)
Marital status
No relationship	280 (29.4)
Married	533 (55.9)
De facto/steady partner	85 (8.9)
Separated/divorced	28 (2.9)
Widowed	11 (1.2)
Other	1 (0.1)
Prefer not to answer	16 (1.7)
Country of birth
Australia	218 (22.6)
Vietnam	742 (77.0)
Other	4 (0.4)
Language most frequently spoken at home
English	318 (33.3)
Vietnamese	630 (66.0)
Other	1 (0.1)
Not sure	1 (0.1)
Prefer not to answer	4 (0.4)
State of residence
Australian Capital Territory	8 (0.8)
New South Wales	169 (17.6)
Northern Territory	11 (1.1)
Queensland	161 (16.8)
South Australia	181 (18.9)
Tasmania	28 (2.9)
Victoria	393 (40.9)
Western Australia	9 (0.9)
Vaccinated for HBV	597 (62.8)
Ever tested for HBV	614 (64.3)
HBV positive	33 (3.5)
Know someone living with HBV	347 (36.4)

The mean score for knowledge of HBV was 15.13 (SD = 5.66, Range 0–30), indicating that knowledge of HBV was mixed. Participants were aware that HBV can only be identified by a blood test (81.1%), that there is a vaccination available to prevent HBV (85.2%), that chronic HBV can develop into cirrhosis and liver cancer (84.1%), and that HBV can be prevented by avoiding blood-to-blood contact (89.0%). Notably, however, only a small number of participants correctly identified that there are effective pharmaceutical medicines available to treat HBV (26.6%). Furthermore, many participants incorrectly believed that HBV was caused by drinking too much alcohol (78.4%) and from contaminated food/water or utensils (78.2%), and many also incorrectly believed that HBV can be prevented by maintaining good hygiene (e.g. washing hands frequently, general cleanliness) (86.0%), making sure food or water are not contaminated with hepatitis (79.4%), exercising (77.1%), and by avoiding sharing eating utensils with a person infected with HBV (75.6%).

Overall, the sample had mixed attitudes towards people living with the virus (M = 21.01 SD = 5.73, Range 1–36). Nearly two-thirds of the sample believed that people who have HBV should not be isolated from family and friends (64.8%) and that people living with HBV should not be ashamed of their illness (65.9%). However, more than half (52.8%) supported screening or testing for HBV for job applications to prevent transmission to other employees, more than two-thirds of participants indicated that they would not have a romantic relationship with someone living with HBV (41.3%), and one-third (33.5%) reported that they would avoid close contact with people living with HBV.

Participants had mixed levels of trust in Western medicine (M = 14.61 (SD = 5.03, Range 1–30). Positively, 63.0% of participants said that they were willing to speak with Western-trained doctors and healthcare workers about their health and disease treatment, with 17.8% remaining neutral. However, 25.9% of participants believed that Western-trained doctors and healthcare workers do not understand Vietnamese/Asian perspectives on health and disease treatments, and 25.1% remained neutral. Furthermore, although only 15.3% of participants indicated that they were suspicious of information about HBV from Western-trained doctors and healthcare workers, 21.1% remained neutral to this statement.

Multiple linear regression (see Table 2) was conducted to determine which of the demographic and attitudinal variables predicted HBV knowledge among the sample. The model was statistically significant, F_(7,769) = 55.01, p < 0.001, R² = 32.8% suggesting a medium effect size (J. Cohen, 1988). Significant predictors of HBV knowledge were age, education, testing for HBV, knowing someone living with HBV, attitudes towards HBV, and mistrust in Western medicine. In other words, participants who were older, more highly educated, who had ever been tested for HBV, and who knew someone living with HBV were more likely to have greater knowledge of the virus. On the other hand, those with more negative attitudes towards HBV and who had greater mistrust in Western medicine tended to have lower knowledge of the virus. Gender was not a significant predictor of HBV knowledge.

Table 2. Multiple linear regression predicting knowledge of HBV.

	B	95% CI for B		SE B	β
		Lower	Upper
Constant	21.25***	19.00	23.50	1.15
Age	.06***	.03	.09	.02	.12
Gender	−.22	−.87	.43	.33	−.02
Education	1.21**	.39	2.04	.42	.09
Ever tested for HBV	1.66***	.89	2.42	.39	.13
Know someone living with HBV	1.10**	.41	1.78	.35	.10
Attitudes towards HBV	−.41***	−.48	−.34	.03	−.42
Mistrust in Western medicine	−.11**	−.19	−.04	.04	−.11

*** p < 0.001 ** p < 0.01 * p < 0.05.

B = unstandardised regression coefficient; CI = confidence interval; SE B = standard error of the coefficient; β = standardised coefficient.

Discussion

This paper examined levels of knowledge and associated factors among people of Vietnamese ethnicity living in Australia. Among this sample of Vietnamese people, knowledge of HBV was mixed. Participants were largely aware, for example, that there is a vaccine to prevent the virus and that HBV can be identified through a blood test. However, there were some significant knowledge gaps, particularly with respect to how HBV is transmitted. For instance, participants commonly held misconceptions that HBV could be transmitted through drinking too much alcohol and through contaminated food, water, or utensils. These knowledge gaps are consistent with those found in previous research among Vietnamese migrants living in the US and in Vietnam (Dam et al., 2016; Ha et al., 2013; Hang Pham et al., 2019; Hwang et al., 2008; Ma et al., 2007; Taylor et al., 2005). Also consistent with previous research (Chu et al., 2017; Jin et al., 2022a) was the finding that greater levels of education predicted higher levels of HBV knowledge.

Attitudes towards HBV in this study were mixed, with some concerning negative attitudes towards people living with HBV. More than half of participants supported screening for HBV for job applications to prevent transmission to other employees and more than two-thirds of participants reported that they would not have a romantic relationship with someone who has HBV. This research demonstrates that negative attitudes were associated with lower levels of knowledge about HBV. Improving knowledge of HBV among the Vietnamese community could have positive flow on effects in reducing stigmatising attitudes towards the virus and those affected by it. This is crucial given that stigma has significant negative physical and mental health outcomes (Smith-Palmer et al., 2020), and can act as a barrier to screening (Li et al., 2012; Sriphanlop et al., 2014) and ongoing health care among migrant populations (Blanas et al., 2015; Guirgis et al., 2012). This finding demonstrates the need for interventions to improve knowledge of HBV and reduce discriminatory attitudes towards people living with the virus (e.g. Broady et al., 2021).

Trust in health providers may be associated with beneficial health behaviours such as screening and medication adherence, as well as greater quality of life, and fewer symptoms (Birkhäuer et al., 2017). The findings of this research suggest that Vietnamese participants who were more mistrustful of Western medicine had lower levels of knowledge of HBV. Research suggests that migrant communities may prefer alternative or traditional medicine and approaches to health care and may be hesitant to disclose their use of such medicines as they may be overlooked and condemned by Western practitioners (Agu, 2020; Agu et al., 2019). Le Gautier, Wallace, Richmond, et al (2021a, 2021b). found a disconnect between biomedical interpretations of hepatitis B and those adopted by the Vietnamese migrants living in Australia who were strongly influenced by cultural, social, and economic influences, including concepts of balance and harmony in maintaining one’s health and the use of traditional medicines. In a qualitative study among Chinese migrants living with HBV in Australia, Jin and colleagues (2022b) found that trust in health providers was influenced by a range of factors, including differences in health and illness beliefs. When considered alongside previous research, our findings indicate that mistrust might mean that these participants were not receptive to health messaging around HBV from Western health professionals, resulting in lower levels of knowledge.

There is also evidence among Chinese migrants living with HBV in Australia that inadequate information about HBV is linked to perceptions of competence of health providers, which is a core element of trust in Western medicine (Jin et al., 2022b). One of the barriers to testing and care for HBV is the lack of culturally competent and appropriate care, including in language resources (Dahl et al., 2014; Guirgis et al., 2012; Smith-Palmer et al., 2020). This would also contribute to a lack of knowledge around HBV among migrant populations. A study conducted in Australia found that 70% of 433 Vietnamese participants would prefer information about HBV to be delivered in Vietnamese, 20% both in Vietnamese and English, and only 10% in just English (Vu et al., 2012). Thus, health professionals and researchers must identify ways to disseminate accurate health information in ways that are acceptable and culturally appropriate to migrant groups. This might include collaborating with providers of alternative and traditional medicine where possible, and must include resources in a range of languages, with a particular focus on addressing misconceptions around transmission of the virus.

This study is limited by the use of a cross-sectional survey. Furthermore, convenience sampling was used, and hard copy recruitment at community events only occurred in four states, thus the sample is not generalisable to or representative of the broader Vietnamese community living in Australia. This sample was also highly educated, with around half of participants having undergraduate or postgraduate university qualifications. Given education was significant in the regression model, this may have over inflated levels of HBV knowledge. Efforts were made to recruit a diverse sample of participants, including through hard copy recruitment at Vietnamese community events. However, a large portion of the recruitment did occur through social media, and thus the sample is not representative of the Vietnamese community living in Australia. There were also some demographic differences between participants recruited online compared to offline (hardcopy), with online participants being younger, and more likely to be highly educated, be tested for HBV, and be vaccinated for HBV. Further research is needed to explore why such differences may be present.

This study has implications for the development of health promotion and education resources targeted at people of Vietnamese ethnicity living in Australia. Specifically, such resources must be translated into Vietnamese and must address misconceptions about transmission and treatment for HBV. Such resources may need to be targeted at those who are younger, who have lower levels of formal education, and who have never been tested for HBV. These resources should be developed in consultation with Vietnamese communities and health providers to ensure that they are culturally appropriate and sensitive and align with best practices in stigma reduction.

Authors contributions

Data was collected by HMKV DJ, and KOEW who also assisted with translation of materials. EC analysed the data and wrote the first draft of the manuscript along with LB. All authors contributed to the interpretation and writing of the final manuscript.

Ethics approval and consent to participate

This research has ethics approval from the UNSW Human Research Ethics Committee. All participants were provided with a Participant Information Sheet. Participants indicated their consent through a question at the beginning of the survey, and by returning the survey.

Acknowledgments

This project was funded by a grant from the Australian Government Department of Health. For more information on this project, please see http://bit.ly/stigma_indicators

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data are presented in aggregate form within the manuscript. Individual-level data contain potentially sensitive information and are not suitable for public repository due to ethical restrictions. Data are available in deidentified form upon reasonable request and pending ethics approval.

Additional information

Funding

This project was funded by the Australian Government Department of Health.