Numerous studies have reported that lack of linguistic skills and insurance are barriers for people of color and immigrants in accessing care, and that they are at risk for under-immunization. About 5%-15% of Asian Pacific Islander Americans (APIA) have been infected with HBV; infection rates and liver cancer rates among APIA are much high than those among the general population in the U.S. Although HBV infection can be prevented with vaccination, teen and adult APIA have poor hepatitis B vaccination rates.

In Colorado, the APIA population is 95,213 (2.2%), with 90% of the APIA population living in the Denver or Colorado Springs metropolitan areas. There are about 16,395 Korean Americans (KAs) living in Colorado. Each APIA ethnic group requires an unique approach to overcome language and cultural barriers. The goal of our project was to provide a culturally and linguistically relevant community-partnered HBV knowledge, screening, and vaccination program in collaboration with Korean churches.

We identified two Korean churches, one United Methodist and one Catholic, as convenient and culturally acceptable project sites for the local KA community (one study showed that 77% of KAs were Christian and 68% participated in religious activities at least once a month). The research team and church advisory coalition members developed a plan to offer free HBV testing and vaccination at these two sites.

Each participant initially signed a consent form covering multiple research procedures including survey data collection, qualitative interview, blood tests, and vaccination. The consent process was explained by bilingual Korean American researchers and both Korean and English consent forms were available.

SURVEY
The first step was the health survey. This involved a face-to-face interview before and after Sunday worship. Only one person from each household participated in the survey, not each individual participant. Variables to be measured were demographic and cultural characteristics, knowledge of hepatitis B infection and liver cancer, healthcare access, vaccination status, and a needs assessment for future community health programs. Some of the survey results: (N=111)

Survey data/evidence revealed a low level of knowledge regarding HBV infection, liver cancer, and vaccination. Several factors have been identified as obstacles to health care and vaccination including language barriers, lack of health insurance, and inability to use the U.S. medical system.

SCREENING
All 178 adult participants received hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (HBsAb) tests at no charge. Additional testing was done when appropriate. Results:

Participants received a letter regarding the findings of their hepatitis B screening tests as well as information about receiving the hepatitis B vaccine series, if appropriate.

There was a high incidence of past and current HBV infection among KAs in this study. It is imperative to provide vaccination to the susceptible KAs who are at high risk of infection.

One lesson learned was that we should have included telephone counseling as part of the project. Many participants were confused about their results and called the PI for help in understanding the medical terms.

VACCINATION
All susceptible participants were offered free hepatitis B vaccination at the church sites, before and after worship services. To enhance compliance, participants were given a short personalized phone reminder 2-3 days before the scheduled date. The priest or minister also made a special announcement during Sunday worship for vaccination follow-ups one week before the date.

Prior to administration of vaccine, each participant was screened using the Immunization Action Coalition's (IAC) "Screening Questionnaire for Adult Immunization" (www.immunize.org/catg.d/p4065scr.pdf) or "Screening Questionnaire for Child and Teen Immunization." (http://www.immunize.org/catg.d/p4060scr.pdf). Participants were asked to bring their vaccine records to the appointment and vaccine was given to all susceptible persons (whose screening had shown them negative for both HBsAg and HBsAb) who had no medical contraindication. Participants were given a Korean language VIS for hepatitis B vaccine (available from IAC at www.immunize.org/vis/ko_hpb01.pdf).

Prescreening was cost-effective for the population in the project. Without screening, we would have vaccinated all 178 participants at a cost of $225 each (total of $39,050). Screening cost $50 for each of the 178 participants ($8,900) and vaccination of only the 72 susceptibles cost $16,200, for a total cost of $25,100. This saved $13,950, as well as provided better information to this at-risk population about their true HBV status. CDC's guideline for cost effectiveness is to screen before vaccinating if the group is likely to have 20% or more who are immune or infected (in this project, it was 61%).

We found vaccination at a community setting to be feasible and safe. Issues included 1) ordering the vaccine, 2) liability insurance for the physician who orders the vaccines and the nurses who deliver the vaccines, 3) delivery, storage, and transportation of the vaccine, 4) participant reminders, 5) consent process, 6) administration of vaccine, 7) protocol for emergency procedures, and 8) participants vaccination records. This study proved that a church has potential for use as a site for community-based participatory approaches for immigrants with limited English proficiency who lack health insurance and/or have other barriers to healthcare access.