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Leslie D. Hsu, MS, William DeJong, PhD, Renee Hsia, AB, Michael Chang, BS, Marvin Ryou, BA and Ellen Yeh, BA

Leslie D. Hsu is with the Office of Disease Prevention and Health Promotion, US Department of Health and Human Services, Washington, DC. William DeJong is with the Boston University School of Public Health, Boston, Mass. All of the authors have worked with the Hepatitis B Initiative. Renee Hsia, Michael Chang, and Marvin Ryou are students at Harvard Medical School, Boston, Mass; and Ellen Yeh is a student at Harvard College, Boston, Mass.

Correspondence: Requests for reprints should be sent to William DeJong, PhD, Department of Social and Behavioral Sciences, Boston University School of Public Health, 715 Albany St, Boston, MA 02118 (e-mail: wdejong{at}bu.edu).

	ABSTRACT

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Increasing hepatitis B vaccination rates for Asian Americans and Pacific Islanders is a priority. Laws requiring vaccination prior to school enrollment have helped, yet many youths remain unvaccinated.

The Hepatitis B Initiative (HBI), launched in 1997 and operated by public health and medical school students, provides free screenings and vaccinations to Boston’s Asian American/Pacific Islander community, with a focus on youths.

By October 2002, 997 HBI patients from Boston’s Chinatown had received free hepatitis B screenings. Of these, 384 patients (39%) were deemed susceptible to the hepatitis B virus and provided with free vaccination.

	INTRODUCTION

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ASIAN AMERICANS AND Pacific Islanders are up to 13 times more likely to die from liver cancer than Whites; the risk is 6 times higher for Chinese Americans, 8 times higher for Korean Americans, and 13 times higher for Vietnamese Americans.¹ Fully 80% of liver cancer among Asian Americans/Pacific Islanders is caused by hepatitis B virus infection. Although Asian Americans/Pacific Islanders represent only 4% of the population, they account for 50% of the 1.25 million chronic hepatitis B cases in the United States.²

Higher immunization rates could reduce these numbers.³ Laws requiring vaccination prior to school enrollment have helped, but many youths remain unvaccinated. Because high school students and young adults are at highest risk for hepatitis B virus infection, the National Task Force on Hepatitis B: Focus on Asians and Pacific Islanders has stated that "catch-up" vaccinations for Asian American/Pacific Islander children should be a priority.²

Wishing to address this need, students from the Harvard School of Public Health and the Harvard Medical School founded the Hepatitis B Initiative (HBI) in 1997. Relying on student volunteers, the HBI provides free hepatitis B screenings and vaccinations to Boston’s Asian American/Pacific Islander community, with a focus on youths. Student volunteers now come from such undergraduate and graduate schools as Boston University, Brown University, Cornell University, Harvard University, the Massachusetts Institute of Technology, Tufts University, and Wellesley College.

From January to December 1997, HBI volunteers conducted extensive interviews with community, medical, and government leaders, met with faculty advisors, conducted surveys of Asian American/Pacific Islander youths at local health fairs, researched model vaccination programs, and identified key business, government, and foundation contacts for resource development. The HBI’s leadership used this information to refine the program’s objectives and operations.

In January 1998, the HBI launched an awareness campaign in Boston’s Chinatown to introduce the free services being offered (Figure 1). Developed with community participation, the campaign included storefront posters and pamphlets in Chinese, Vietnamese, and English (Figure 2); information kits for local newspapers and schools; talks at neighborhood council meetings; skits performed at health fairs; and appearances on local radio talk shows. Additional activities included staffing information tables at community festivals; sponsoring a raffle; conducting youth workshops to develop educational photonovellas⁴; and hosting a "guerrilla media" event at which youths made sidewalk chalk drawings to promote hepatitis B awareness.

View larger version (185K): [in this window] [in a new window]   FIGURE 1—— Hepatitis B Initiative (HBI) coordinators Sandy Wong (left) and Delia Kong (right) set up an information table in Boston’s Chinatown with posters and banners advertising the HBI’s clinic services.

View larger version (65K): [in this window] [in a new window]   FIGURE 2—— Front (top) and back (bottom) of the Hepatitis B Initiative brochure in Chinese (also available in English and Vietnamese).

The HBI’s services are organized to meet the needs of Chinatown’s residents, including many recent immigrants. Clinic walk-in times are set to accommodate restaurant workers who work evening and weekend hours. Student volunteers guide patients through the process, and bilingual services are provided. Intake is set up to minimize paperwork; the required forms are available in multiple languages. Local businesses provide incentives for clinic visitors such as T-shirts and gift certificates.

	DISCUSSION AND EVALUATION

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By the end of October 2002, 997 HBI patients had received free screenings for hepatitis B virus. Of these, 384 patients (39%) were deemed susceptible to hepatitis B virus and offered free vaccination; 371 of these patients (97%) received the first vaccine. By the end of November 2002, 305 of 363 eligible patients (84%) received the second shot and 199 of 334 eligible patients (59%) received the third shot. (Note that some patients became eligible for subsequent shots after November 2002).

At intake, patients reported how they had learned about the HBI. Cited most often was word of mouth from family and friends (40%), but the HBI’s outreach campaign (16%), newspapers (15%), and referrals from health centers (15%) were also key sources.

In 1998, the HBI was awarded funding by the Centers for Medicare and Medicaid Services as an Asian American/Pacific Islander initiative of the US Department of Health and Human Services. In 1999, the HBI received the Adult Immunization Achievement Award from the Centers for Disease Control and Prevention. In 2000, the surgeon general’s Web site featured the HBI as a model program for eliminating health disparities (http://www.surgeongeneral.gov/tour/hbi.htm).

Initially, the HBI was launched on the strength of donations. Over time, the annual budget expanded to over $25 000, with funding from the Centers for Medicare and Medicaid Services. To help ensure continuity, the HBI secured a central office in late 1999 and established an advisory board of community, government, and academic leaders. The HBI’s former student directors remain active as project advisors.

The HBI’s experience provides several key lessons for student-run public health programs. First, a program like the HBI cannot succeed without strong and committed student leadership. To engineer smoother changes in student leadership, the HBI has a formal transition period for new leaders so that they can work alongside the current leadership to learn about their roles.

Second, annual student recruitment and training are essential to renewing the program. Each year, there are 4 to 10 student leaders and about 50 volunteers. The HBI provides students with direct experience in program management, vaccination clinic management, coalition building, and communications. The HBI has created detailed protocols for volunteer recruiting and training sessions.

Third, community leaders may worry that a student-run program will be transient, or that students are seeking personal gain (e.g., résumé building). The HBI’s leadership worked hard to dispel these concerns, but the only real answer was to develop a track record of continuous service.

Perhaps the most important lesson is this: With dedicated leadership in place, a student-run program can create an opportunity to bring together institutional partners who might not otherwise coordinate their efforts. Through its efforts, the HBI created a screening and vaccination service for Boston’s Chinatown that otherwise would not have been available. Additional information about the HBI, as well as copies of brochures and other materials, can be found at the project Web site (http://www.hepbinitiative.org).

	NEXT STEPS

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The HBI continues to face organizational challenges owing to annual turnover in student leadership. With only a 1-year term, student leaders must learn fairly quickly how to set realistic goals and timelines and how to delegate responsibilities. To facilitate the leadership transition, the HBI is working to create better systems for preserving organizational and personal contacts, communicating lessons learned, and planning long-term goals.

As the HBI works to meet these and other challenges, the program is expanding to reach the Asian American/Pacific Islander community beyond Boston’s Chinatown.

	HIGHLIGHTS

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• The National Task Force on Hepatitis B: Focus on Asians and Pacific Islanders has stated that "catch-up" vaccinations for children of Asian American and Pacific Islander descent should be a priority.
  
• Boston-area public health and medical students established and operate the Hepatitis B Initiative (HBI), an award-winning program that unites public and private organizations in a coordinated effort to reduce hepatitis B viral infection, especially among Asian American/Pacific Islander youths.
  
• With dedicated leadership in place, a student-run program can present the opportunity to bring together institutional partners who might not otherwise coordinate their efforts and thereby help close an important gap in public health services.
  

	Acknowledgments

 
We thank the following HBI institutional partners for their generous support: Beth Israel Deaconess Medical Center, Centers for Medicare and Medicaid Services, Merck and Co Inc, Sharewood Project, and South Cove Community Health Center.

We are grateful to cofounder Michael K. Tran and the many student leaders and volunteers who have contributed to the HBI, as well as to members of the HBI’s advisory board for their invaluable advice. We extend special thanks to Dr Lachlan Forrow of The Schweitzer Fellowship; Dr Gary Euler of the National Immunization Program, Centers for Disease Control and Prevention; and Beverly Wing of the Chinatown Coalition. Finally, we thank members of the Boston Chinatown community for opening their hearts to us.

	Footnotes

 
Contributors

L. D. Hsu and W. DeJong wrote the first and final drafts of this report. R. Hsia, M. Chang, M. Ryou, and E. Yeh collaborated on the data analysis and edited several versions of the manuscript.

Peer Reviewed

Accepted for publication January 17, 2003.

	References

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1. Miller BA, Kolonel LN, Bernstein L, et al. Racial/Ethnic Patterns of Cancer in the United States, 1988–1992. Bethesda, Md: National Cancer Institute; 1996. NIH publication 96-4104.

2. Euler GL. The epidemiology of hepatitis B vaccination catch-up among AAPI children in the United States. Asian Am Pacific Isl J Health.2001;9: 154–161.

3. Immunization Practices Advisory Committee. Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep.1991; 40(RR-13):1–19.[Medline]

4. Rudd RE, Comings JP. Learner developed materials: an empowering product. Health Educ Q.1994;21:313–327.[ISI][Medline]

This Article Abstract Figures Only Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via ISI Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Hsu, L. D. Articles by Yeh, E. Search for Related Content PubMed PubMed Citation Articles by Hsu, L. D. Articles by Yeh, E. Related Collections Adolescent Health Other Health Service Delivery Hepatitis Public Health Workers Asians