Curbing the Hepatitis B Epidemic in Asian American Communities : Engaging Local Hospitals

Background. In the United States, more than 50% of the 1.2 million living with hepatitis B infection are Asian Americans (Centers for Disease Control and Prevention [CDC], 2013). In the city of San Francisco, Asian Americans make up 33% of the population and the city itself has the highest rate of liver cancer in the nation (United States Census Bureau, 2010, California Cancer Registry, 2011). In 2007, to address the risk of hepatitis B and liver cancer, the San Francisco Hep B Free Campaign (SFHBF) drew together a comprehensive coalition of key leaders and organizations from media, health care, government, community and business sectors within and beyond the Asian American community. Methods. Based on 13 key informant interviews with stakeholders, this paper explores how SFHBF incorporated local city hospitals as coalition partners to increase knowledge and screening of hepatitis B among Asian Americans throughout San Francisco. Results. Key findings include the various steps needed to involve hospitals including 1) Identify mission and key stakeholders, 2) Create collaborations among hospitals; 3) Identify benefits to hospitals. Implications. This research makes a unique contribution to the literature on engaging hospitals in community health partnerships. The findings have implications for other public health initiatives that are seeking to engage and involve hospitals as partners and collaborators. © 2013 Californian Journal of Health Promotion. All rights reserved.


Introduction
Hepatitis B is a liver disease caused by the hepatitis B virus.The infection leads to cirrhosis of the liver, liver cancer and liver failure.Worldwide, 60-80% of liver cancer is the result of hepatitis B infection (World Health Organization, 2013).Approximately 350 million people in the world are chronically infected with hepatitis B (Centers for Disease Control and Prevention, 2009).In the United States, nearly 60% of the 1.2 million living with hepatitis B infection are Asian Americans (Centers for Disease Control and Prevention [CDC], 2013).In California, liver cancer ranked as one of the five most commonly diagnosed cancers among Asian Americans (Lin et al., 2013).From 1990 to 2008, liver cancer rates increased for Cambodian American men and women, Filipino American men, Laotian American men, Korean American men, and Vietnamese American men (Lin et al., 2013).Between 1990 and2004, liver cancer was the leading cause of cancer incidence and death for Asian American men in the San Francisco Bay Area (Chang et al., 2007).For Asian American women, liver cancer was identified as the top seven causes of cancer death (Chang et al., 2007).
In 2010, the Institute of Medicine (IOM) issued a report noting that hepatitis B virus infection was not widely recognized as a serious public health problem.As a result, viral hepatitis prevention, control, and surveillance programs have inadequate resources.The report continued by highlighting the importance of public awareness of hepatitis B and better integration of viral hepatitis services (Institute of Medicine, 2010).In recent years, health problems like hepatitis B and C have been left to communities at risk to solve the problem and strategize how to address the complex bio-psycho-social and environmental components affecting them.Communities at risk for hepatitis B have had to develop and implement creative solutions to health care concerns (Bryson, Crosby & Stone, 2006;Lasker, Weiss & Miller, 2001).Often alliances, consortia and coalitions form health partnerships to address these health concerns.However very little has been written on processes involved in the formation of alliances and partnerships within city-wide public health campaigns.This study focuses on the partnerships of the San Francisco Hep B Free campaign in particular hospitals.
The San Francisco Department of Public Health (SFDPH) had been actively involved in efforts to curb hepatitis B since 1997 by making the adult hepatitis B vaccine available throughout the city, free of charge, to clinics treating uninsured, low-income patients.Specifically reaching out to the Asian American community, the health department partnered with a Chinese American health coalition and established vaccination sites at a Chinese Hospital in Chinatown. In 2004-2005, the ALC and SFDPH joined efforts in a pilot project, "3 for Life", which provided low cost screening and vaccinations two Saturdays a month in a predominantly Asian immigrant neighborhood.Over the course of one year, over 1,200 people were screened in a total of 72 clinic hours.The long lines were indicative that there was a need for more work with hepatitis B.Moreover, the project demonstrated the need for screening, vaccination and linkage to care among the local foreign born Chinese population (Chang et al, 2009).The success of these efforts served as a model for SFHBF for continual integration and partnerships.
In 2006, the AsianWeek Foundation (AWF), a non-profit dedicated to developing the Asian Pacific American community, invited the Asian Liver Center (ALC) to its second annual Asian Heritage Street Celebration (AHSC), an arts and crafts fair with 80,000 attendees from the greater Bay Area showcasing diverse Asian cultures.Following this event, key leaders from the three organizations, SFDPH, ALC and AWF, joined efforts as the steering committee to identify resources, address gaps in service and education, develop clear public awareness messages and address system change.They considered the strategy of hepatitis B screening/testing for all Asian Americans in San Francisco, a strategy similar to an HIV prevention strategy proposed in Washington DC to curb HIV rates among its residents.

Building San Francisco Hep B Free Partnerships
AWF organized press conferences at City Hall and in a Chinatown restaurant to create awareness and promote the goal of screening all Asian Americans in San Francisco.The media outreach had two messages ("get tested/get treated") that were delivered by two San Francisco County elected officials.Both of these elected officials shared compelling personal stories-one describing her story as a "carrier" of hepatitis B, and one disclosing that his partner had died of liver disease as a result of hepatitis B. The need for awareness and education was highlighted as these elected officials urged Asian American residents to get tested and treated.One elected official describes this event as a critical moment in understanding her own status of being chronically infected with hepatitis B in which she realized her own personal need for follow up and monitoring.The press conferences were significant as they helped mobilize support for interventions from the Mayor, the San Francisco Health Commission, and multiple healthcare organizations.
Following the press conference, a resolution to screen and vaccinate all Asian Pacific Islander (API) residents in San Francisco, "Hepatitis B Screening Goal" passed unanimously and was subsequently underscored in December, 2006 when the San Francisco Health Commission called for a full endorsement of the city's resolution.The resolutions supported the goal of screening and vaccinating Asian American residents, but did not procure a budget for meeting the objectives.Passage of these two resolutions was instrumental in raising the level of optimism in public officials and community leaders had about the capacity of the city to fight Hepatitis B.
In 2007, community organizing helped SFHBF bring together a comprehensive coalition of key leaders and organizations from media, health care, government, community and business sectors within and beyond the Asian American community.The campaign recruited partners to provide free and low-cost hepatitis B testing and vaccinations to Asian American adults at locations throughout San Francisco.More than 200,000 of the general public in San Francisco was outreached through hepatitis B community events and fairs (Bailey, Shiau, Zola, Fernyak , Fang, So & Chang, 2010).Another 260,000 were outreached through billboards, bus panels, public service announcements and advertisements fairs (Bailey, Shiau, Zola, Fernyak, Fang, So & Chang, 2010).Studies have demonstrated that these efforts have allowed for increased screening fairs (Bailey, Shiau, Zola, Fernyak, Fang, So & Chang, 2010 and for de-stigmatizing hepatitis B among Asian Americans (Yoo, Fang, Zola & Dariotis, 2010).

Public Health Campaign Partnerships
The benefits of public health coalitions/ partnerships have been well-documented (Butterfoss, Goodman, & Wandersman, 1993& Lasker 2001).Coalitions, or community partnerships, represent one of the major innovations that respond directly to local health care needs and enable many agencies to accomplish what a single agency is unable or unwilling to do alone (Roussos & Fawcett, 2000).Partnerships create opportunities for diverse organizations and personnel to leverage funds and skills, combine efforts and capitalize on their complementary strengths and capabilities.Others have documented that it is a cooperative energy, synergy, that is formed out of such public health partnerships that arise out of a shared vision and mission which creates and fuels unique and distinct partnerships that might not have otherwise been formed (Lasker et al., 2001).The SFHBF formative efforts represented a unique synergy, especially with the joint efforts of ALC, SFDPH, AWF, and subsequent collaborative events that created public awareness, and a city-wide resolution which reflected the political will of the Mayor, the Board of Supervisors and the Health Commission.

Public Health Campaign Partnerships:
Engaging Hospitals?Hospitals have not typically taken a major role in public health campaigns with health education, screening, testing and vaccinating, yet SFBHF invited and engaged hospitals in this campaign.There is little in the literature examining the role of hospitals in targeted health promotion campaigns to specific populations.By and large, primary care providers and clinics are the source for preventive care that include screenings, health education and vaccinations while hospitals focus on tertiary care offering high skill-high cost services.Hospitals follow a business model competing for physicians, high end patient care and consumers yet are also compelled to participate in charity and community care through statute, regulation and other legal obligations.Despite the challenges in organizing hospitals, San Francisco Hep B Free (SFHBF) was able to elicit the support and collaboration of almost all the local hospitals, private and public.Although much has been written on the role of partnerships involving public health partners and academic institutions (Minkler & Wallerstein, 2010), very little has been written about the formation and development of public health coalitions involving organizations like hospitals.This paper explores, from the leaders and hospital partners of SFHBF, how SFHBF involved local hospitals as coalition partners in screening, testing, vaccinating and treating Asian Americans for hepatitis B infection and increasing awareness and knowledge among medical providers and the general public in San Francisco.

Methodology
In studying how SFHBF involved local hospitals as coalition partners, key informant interviews were conducted.Semi-structured interviews with open-ended questions were conducted with 13 key informants who were contacted through snowball sampling with referrals provided by SFHBF steering committee.Key informant interviews were chosen as the best approach to elicit opinions and insights from key partnership leaders in the San Francisco Hep B Free campaign.Thirteen key informants were selected to participate because of their involvement as partners in this campaign; they included physicians, nurses, health educators, and hospital administrators representing large organizations such as the Department of Public Health, the Northern California Hospital Council and private hospitals.Of the 13 individuals interviewed for this evaluation, three are founders of SFHBF.
The semi-structured interviews were scheduled for 60 minutes per interview and allowed for a depth of exchange that enabled the participants to describe the initial and ongoing involvement of their organization in SFHBF.A twenty question script was developed to guide the participants in telling their organization's story including their mission and why their organization decided to get involved as well as key activities.The core categories of the questionnaire included key influences in their organization's involvement, successes and challenges associated with their involvement as a partner in SFHBF.All interviews were audio recorded and later transcribed.A qualitative analysis of the transcripts using grounded theory (Corbin & Strauss, 2008) took place to identify frequency of responses, patterns in experiences, common concerns, and unique insights regarding SFHBF involvement.

Results
This section outlines themes identified in the interviews.The SFHBF's chief objectives were Themes that emerged from the interviews identified the key steps needed to engage hospitals in SFHBF (see Table 1).
Step 1: Identify the Mission and Key Stakeholders Key leaders from the three founding organizations acted as the steering committee for the campaign and actively recruited a diverse membership from private and public agencies.
The initial formal kick-off of the campaign utilized a culturally appropriate event to reach the target population by "throwing a banquet".One community partner described how they came to the decision to throw a banquet saying, So how do you organize the Asian community?We didn't organize rallies.We didn't organize demonstrations.We organized a dinner.We had 500 people come out to this dinner and 150 different community groups represented.And that's how we got everybody together, over breaking bread.Asians do things over meals.
In addition, the event attracted politicians who promoted awareness.Most of those interviewed agreed that spokespersons with high visibility and celebrity appeal were instrumental in increasing public awareness and getting people to be screened or to lend support to the campaign.
SFHBF had the goal of eradicating hepatitis B in San Francisco.Hospitals were among the first essential partners identified for the success of the campaign because 1) the enormity of the health issue would require a city-wide effort; 2) one agency could not be expected to meet the goals of screening and vaccinating Asian Americans in San Francisco by itself; 3) creative partnerships were needed; 4) the campaign goals aligned with hospitals' mission to improve community health; 5) hospitals are established resources and have links to the community.Leveraging community networks, SFHBF was able to arrange a presentation to executives at the Hospital Council of Northern California (HCNCC) with an invitation to partner in the city-wide effort to reduce hepatitis B rates among Asian Americans.They also emphasized the California Health Inventory Survey (CHIS) report that estimated that 86% of the API population in San Francisco had health insurance noting the opportunity for new enrollees (CHIS, 2003).
The HCNCC members represented hospitals.
Hospitals were asked to participate in their own unique ways that aligned with their mission and resources.Leaders in the Asian American community met with hospital CEOs individually and collectively to emphasize the importance of this issue to the community.The steering committee emphasized that this effort could result in measurable outcomes since there are effective treatments for preventing and monitoring hepatitis B infection.The initial request was the most general, asking the hospitals simply to declare their support for SF Hep B Free and also appointing a point person at that hospital to lead collaborations with SFHBF.
Examples of tangible requests developed later include sharing costs of outreach, screening and vaccinating, especially for the uninsured, and ensuring that their medical personnel were well educated about chronic hepatitis B and the Asian American community.
Respondents described a variety of motivational factors for initial involvement that included opportunities for community networking, learning opportunities for medical students, curbing the hepatitis epidemic, improving standards of primary care and enhancing their organization's visibility to enroll new clients.Most stated that the mission of the campaign matched or was closely aligned with their own agency's mission.
All partners explained that their organization initially became involved through personally being contacted by Asian American community leaders.Personal communication and networking among hospital executives was pivotal in launching the campaign.A hospital partner articulated his institution's multiple motivations for participating: It's a worthy endeavor, and so that was probably number one.... Second, our CEO is on hospital council…and was interested in a city-wide collaboration, ... third, and very important, was the fact that [name of institution] has a student organization" A hospital partner explained: And all the hospital CEOs were very--felt very much that they needed to be involved.I'll never forget, [name of hospital administrator from private hospital] said, you know, we eliminated polio, we should do the same with hep B.
Other hospital leaders saw that there was a good fit between what their organization was currently doing and the mission of SFHBF.A hospital partner stated: It was something that we felt was a good fit for us.We have a very active community benefit program as part of our nonprofit mission and so this was a good way for us to engage with the broader community and both make in-kind as well as actual monetary granting contributions to our community benefit program.There were multiple ways hospitals found a fit with SFBHF.The diversity of the three steering committee members reflected the diverse interests of SFHBF.The Asian Liver Center represented world-renown medical expertise, but at the same time allayed any competitive tensions as it was not affiliated with any San Francisco hospital.The San Francisco Department of Public Health possessed some regulatory leverage over the hospitals, and also played the key role in offering safety net support.AsianWeek Foundation represented the voice of the community and provided an entry point for the hospitals to interact with the campaign and to interact with each other in a non-competitive setting.
Step 2: Create Collaborations among Hospitals The SFHBF leadership focused on a shared linkage and mission and work to unite multiple different hospitals throughout San Francisco to support SFHBF efforts.The shared linkage and mission help move hospitals move away from the competition they normally experienced.As part of SFHBF efforts, they sought support including the appointment of a lead person at each hospital.These lead persons from each hospital were also invited to participate in monthly Community Action Board meetings that involved collaboration with community groups and to sharing best practices with other hospitals.Involvement at monthly meetings provided hospitals with a way of demonstrating a public commitment to SFHBF.SFHBF leadership also constantly worked at linkages and collaborations individually and personally with each hospital.
They also worked collaboratively on the vision and action plan with hospitals.
A physician from a large hospital network noted that the diversity and caring nature of SFHBF contributed to the community building that was happening among hospitals: We've been able to tap into the caring nature of the healthcare community to do something.I think that's worked really, really well…the lack of any kind of internal politics or in-fighting…that's worked really well.The young folks, these young students that come to the meetings all the time..that was something unexpected for me… Bringing people together is our biggest success.
Another member echoed a similar sentiment: A hospital partner opined that the health department leadership and the steering committee leaders and the non-competition among hospitals allowed for the success of SFHBF: I think the opportunity to be more visible in this campaign as well as other community efforts has helped people appreciate that we have that broader agenda.It's certainly strengthened our working relationships with the Department of Public Health and I think it's helped us overcome some of the competitiveness that exists between the hospitals.I think all of the members of the coalition campaign have set aside what you might argue are market competition interests for the benefit of the whole.
In evaluating partner satisfaction, respondents often cited the steering committee leadership skills in bringing and keeping partners involved in the campaign.Respondents described the collaborative, egalitarian framework that guided the campaign as a contributing factor to sustained partnerships.Most respondents identified the monthly meetings as an important part of the campaign's success.A medical officer from a large university stated that the ability to pull hospitals, clinics, political leaders, business leaders and Asian American community leaders together made the collaborative experience positive and enjoyable.
..bringing us together to pull in one direction at the same time I think was a tremendous success.In my roughly 20 years in San Francisco providing health care, I've never seen or been a part of anything that's been quite this good…or even nearly as good The monthly meetings allowed all hospital members to share what they were doing with steering committee leaders ensuring no hospital gain prominence over others.The synergistic pooling of member and community resources prompted effective planning, assessment and implementation of "do-able" strategies.The interviews revealed that agencies sustained their involvement because they were able to take ownership of a single part of the campaign and were not expected to do all the work of the campaign.All stakeholders believed that the collaboration resulted in shared resources and shared information.One partner noted It's really key to have all the partners take ownership in the projects, rather than someone else's project.Each group goes to their organization/executives who give them money for their projects.So I think the only way you can build sustainability is if people take ownership and take pride in their own programs.
As a result of ensuring partners took ownership, this approach made it easier for all hospitals to participate.
Step 3. Identify Benefits to Hospitals A major theme in engaging hospitals was to identify ways hospitals could donate and contribute to this campaign but also to identify the benefits the hospitals would gain.Hospitals benefitted from their involvement in several different ways including: 1) improving community health and ending a major health disparity; 2) lowering or eliminating long-term health costs for liver transplants and treatment; 3) adding to base of patients with insurance coverage; 4) building connections with hard-toreach immigrant populations, and with community groups that work in limited-Englishproficiency communities; 5) aligning with the community on policy concerns such as hepatitis B and 6) providing tangible solutions to preventing hepatitis B disease and measurable results in increasing testing and vaccination.All respondents were aware that the campaign started with no funding and identified this lack of funds as a challenge to the campaign, but also noted that this factor contributed to the success and sustainability of the campaign because it focused on human capital and incorporating prevention practices into existing systems and institutions.Interviews described the generosity of all partners in contributing resources, time, and money that played a key role in the success of the campaign.In addition, interviewees also noted that hospitals benefited from the cooperative energy, the strong sense of a shared vision and by demonstrating to other coalition partners, as well as the public, their commitment to addressing hepatitis B in the Asian American community.
Each hospital was asked to contribute resources in its own creative way, a key component in sustained involvement.Hospital partners were impressed by the diversity of the campaign's membership and acknowledged that the collaboration was to some extent novel as it linked private and public organizations and a wide scope of participants from medical students to hospital executives, from community organizers to elected officials.Respondents summarized overall impressions: "You don't need money to get something started", "You can engage diverse groups around a common cause" and "It's a replicable model".
Hospitals provided an array of resources and services which included the following: • Hospital and clinic-based hepatitis B testing, vaccination and treatment Hospital participation greatly increased public knowledge and awareness of hepatitis B and the campaign itself.Before partnering with hospitals and others, the campaign's education reach was limited to donation supported media advertising, education through community medical clinics and word of mouth.Hospitals leveraged their own funding, networks and connections to inform the public about hepatitis B and therefore expand the reach of the campaign.Through a pre-existing hospital partnership, SFHBF was able to develop its own partnership with the San Francisco Giants, and each May, during Asian Pacific American Heritage month public service announcements are aired at a designated game.

Discussion
In the last decade, the public health literature has published numerous key studies on partnerships (Bryson, Crosby & Stone, 2006;Lasker, Weiss & Miller, 2001).Much of this literature though is focused on partnership with local community and service providers and local residents and/or consumer and patient organizations and increasing empowerment but not necessarily on incorporating larger entities like hospitals (Bryson, Crosby & Stone, 2006;Lasker, Weiss & Miller, 2001).There is no research on how public health campaigns engage entities like hospitals.Findings from this paper demonstrate the importance of public health campaign partnerships, like SFHBF, including not only affected community members but also local hospitals.This study illustrates that public health collaborations with local hospitals can happen, but must evolve steadily in stages.
Research on community health partnerships has focused in the inability to reach measurable results and difficulties of sustaining partnerships with diverse communities (Mitchell & Shortell, 2000).Little exists on governance of community health partnerships (Mitchell & Shortell, 2000).Like other community health partnerships, SFHBF was able to capture the need for a shared vision.As mentioned in the results, all partners expressed the belief that the shared mission to eradicate hepatitis B accounted for much of SFHBF and their own agency's willingness to join the campaign.Moreover, the collaborative structure allowed involvement at many different levels.A unique feature of this collaboration was the governance of this partnership.Normally collaborations function as top down control with designated leaders (and followers), which formalize participation, roles, expectations and deliverables.However, SFHBF collaboration was much more organic, in which participation was fluid and informal with expectations/deliverables being self-defined.An important lesson is that there needs to be synergy among collaborators.Partners were impressed by the diversity of the campaign's membership and acknowledged that the collaboration was novel as it linked private and public organizations involving a wide scope of participants from medical students to hospital executives, from community organizers to elected officials, from non-profits to corporations.Ultimately, this campaign was successful because it fostered and allowed for synergy -which included factors of individual leadership, personal commitments, organizational missions, timing, and resources.Moreover, hospitals benefited from the shared vision, collaborative energy amongst all partners and in building positive public relations with the Asian American community.The findings from this paper are significant in many different ways.By and large, primary care providers and clinics are the source for preventive care that include screenings, health education and vaccinations while hospitals focus on tertiary care offering high skill-high cost services.The SFHBF campaign did not follow normal organizational boundaries and patterns on partnering simply with primary care providers and clinics.Instead, the campaign realized that hospitals, a major player in the health care services, could participate not only as a partner, but also in building of a public health campaign that would benefit both the local Asian American community and the hospital.In this way, the findings demonstrated that if asked (and sometimes demanded of) players in a campaign can be from the "top."

Limitations
Although this campaign was limited to San Francisco, the organizers of SFHBF have shared their model with other Asian American communities outside of San Francisco.In five years, 15 replication sites in and outside California -including Los Angeles, Orange County, Santa Clara, Alameda, Long Beach, San Mateo, Philadelphia, and Washington DC -have been created across the country and viral hepatitis disease prevention had become part of national U.S. health policy.This study of engaging hospitals to curb hepatitis B in the Asian American community is not necessarily representative of these other sites but provides a model of the partnership that evolved in San Francisco.

Implications
The findings of this paper have several implications on hospital involvement in curbing the epidemic of hepatitis B in the Asian American community.The involvement of hospitals in SF Hep B Free brought an inherent sense of "legitimacy."It became a city wide, all-encompassing private-public health partnership created to defeat a deadly disease.It had the backing of the city's entire medical community -and the legitimacy that came with that.The effect of this legitimacy undoubtedly caused more people to take action, whether it was getting screened, vaccinated and/or treated, getting involved in the campaign or simply talking more openly about the disease.
Hospital participation is significant because hospitals are the highest profile medical organizations in every community due to their history, physical presence, the high value/high impact of their services and resources relative to other health care providers.Expectation of the level of hospital participation should be tempered by the understanding that public health initiatives are not their core services and that steps need to be taken to build partnerships for involvement.Hospital involvement clearly benefited SFHBF and the "win-win" methodology the campaign used to persuade hospitals to get involved allowed both the campaign and hospitals to prosper.The ultimate winners are the infected people who will not develop liver cancer or die prematurely.
You have to have people who are dedicated.You have to have people who are able to work together and willing to work together I think because you have people from [name of hospital] with their big liver program; you have people at [another hospital] with their liver program, and you have people at [another hospital] with their liver program.They're all at the same table.It doesn't seem like they're really competing, but they're offering suggestions.They're working together.