What was the research about?
Infection with hepatitis B and C viruses increases the risk of liver disease and liver cancer. Treatment can slow hepatitis B and cure hepatitis C. But many people don’t know they have the viruses. Asian Americans have a high risk for both viruses and get liver cancer three times as often as white people.
In this study, the research team compared two ways to increase screening for these viruses among Asian Americans. The first was to give doctors a list of patients who need screening. All doctors in the study got this list. The second was to give patients a mobile app that teaches them about hepatitis and prepares them to ask their doctors about screening. In this study, half the patients used the hepatitis app while waiting for their doctors’ visit. The other patients used an app with general health information.
What were the results?
Compared with patients who used the general health app, those who used the hepatitis app were more likely to
- Report talking to their doctors about hepatitis B and C.
- Say their doctors recommended getting tested.
- Get a test for hepatitis B or C.
Doctors were more likely to order tests for hepatitis B or C for patients who used the hepatitis app than for those who used the general health app.
Using the hepatitis app didn’t change how much people knew about the viruses or whether they said they were aware of hepatitis.
Who was in the study?
The study included 189 primary care doctors and 452 patients. All patients were Asian American, and 80 percent were born outside the United States. The average age of patients was 57, and 64 percent were women.
What did the research team do?
The research team developed an app that would teach patients about hepatitis B and C and ask patients about their risk for the viruses. The app included printed information that patients could take to their doctors. Patients could view the app in English, Cantonese, Mandarin, and Vietnamese.
All doctors in the study got a list of patients who hadn’t had hepatitis B tests. The research team then assigned doctors to one of the two groups by chance. Patients of doctors in the first group got the hepatitis app on a tablet when they came for a clinic visit. Patients in the other group got the general health app. The team followed up with patients directly after their appointments to find out if they had talked to their doctors about hepatitis testing and if their doctors had recommended or ordered testing. Three months later, the research team asked whether the patients had a referral for testing or were tested. The team also surveyed patients about their knowledge of hepatitis.
Local hepatitis organizations, Asian health groups, patients, clinic staff, and doctors helped plan the research and develop the hepatitis app.
What were the limits of the study?
Patients in this study said that even before using the app, they felt comfortable asking their doctors about hepatitis. Results might differ for people who don’t feel that way. The study took place in one city with a large Asian American population. Results may differ in other parts of the country. Doctors in this study see an average of 17 patients per week. Results may differ for doctors who see more patients.
Future research could focus on testing similar apps for other health problems and different patient populations.
How can people use the results?
Doctors’ offices can consider using a mobile app like the one in this study to increase screening for hepatitis among Asian American patients.
To compare two strategies to increase screening among Asian Americans at risk for hepatitis B and C
|Design||Randomized controlled trial|
|Population||452 Asian American patients receiving care from 189 primary care providers|
Primary: hepatitis B test ordered and completed
Secondary: hepatitis C test ordered and completed; patient-reported discussion with provider about hepatitis B and C, patient-reported request for hepatitis B or C screening
|Timeframe||3-month follow-up for primary outcomes|
This randomized controlled trial compared two strategies to increase hepatitis B and C screening among Asian Americans: a mobile app with information about hepatitis B and C for patients plus provider notification versus provider notification alone. Researchers randomized 189 primary care providers and their Asian American patients who were eligible for hepatitis B screening to the intervention or control group. Every six months, the research team sent providers in both groups lists of patients who were eligible for hepatitis B screening but were not yet screened. Patients in both groups received access to an app in the waiting room before a clinic visit. For the intervention group, the research team created an app that taught patients about hepatitis B and C, screened patients for risk factors, and produced a printed recommendation for care that patients could share with their doctors. The app was available in English, Cantonese, Mandarin, and Vietnamese. In the control group, patients received a general health app in the same languages.
The study included 452 Asian American patients eligible for hepatitis B screening. Of these, 80% were foreign born, and 56% spoke English well or fluently. The average age was 57, and 64% were female.
Immediately after the clinic visits, researchers reviewed patients’ knowledge of hepatitis B and C and whether patients had asked their doctors about screening. After three months, researchers asked patients whether their providers referred them for hepatitis B and, if appropriate, hepatitis C testing. Using electronic medical records data, researchers reviewed which patients had testing ordered and completed.
Local hepatitis organizations, Asian health groups, patients, clinic staff, and physicians helped plan the research and develop the hepatitis app.
Compared with patients who used the general health app, patients who used the hepatitis app were more likely to
- Complete screening tests for hepatitis B (38% versus 8%, p<0.001) and, if appropriate, hepatitis C (30% versus 6%, p<0.001) within three months of the visit.
- Discuss hepatitis B (70% versus 17%, p<0.001) or C (63% versus 13%, p<0.001) with their primary care providers.
- Say their providers recommended screening for hepatitis B (51% versus 13%, p<0.001) or C (38% versus 10%, p<0.001).
Primary care providers were more likely to order screening tests for hepatitis B and C, when appropriate, for patients who used the hepatitis app than for those who used the general health app (44% versus 10%, p<0.001 and 39% versus 10%, p<0.001).
At the end of the study, there were no differences between the groups in reported awareness of hepatitis B and C; awareness increased in both groups from before to after their clinic visits.
The study took place in one large city with a high proportion of Asian American doctors and patients. Results might differ in other locations. Providers in this study saw an average of 17 patients per week. Results may differ for providers who saw more patients. Patients in this study reported before the intervention that they felt comfortable asking their doctors about hepatitis. Results might also differ among patients who feel otherwise.
Conclusions and Relevance
Asian American patients who used a multilingual mobile app about hepatitis immediately before a scheduled clinic visit and who received a printed recommendation to share with their primary care providers were more likely to discuss hepatitis screening, get a referral, and complete screening than patients who used a general health app.
Future Research Needs
Future research could examine the effectiveness of multilingual app-based education with other populations to increase other recommended healthy behaviors.
Final Research Report
View this project's final research report.
Results of This Project
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Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. Those comments and responses included the following:
- The reviewers asked for clarification about the researchers’ use of the term, Asian populations, because it lacked specificity. The researchers responded that this was a common criticism of intervention studies, which sometimes included a so-called Asian subgroup without taking into account the cultural, geographical, and linguistic differences within this designation. The researchers stated that their intervention was applicable to the 66 percent of Asian Americans who were fluent in English, as well as the 12 percent who were not English proficient but were fluent in Chinese or Vietnamese. The researchers expanded their description of patient eligibility, results, and limitations to address the intervention’s applicability to Asian American populations.
- The reviewers expressed concern that the lack of an upper age limit meant patients in their 80s and 90s received inappropriate screening for hepatitis and that inclusion of these patients could bias the sample. The researchers explained that they lacked an upper age limit based on stakeholder recommendations. The researchers also noted that the app they developed was more user-friendly because of the wider user base they needed to accommodate.
Conflict of Interest Disclosures
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