According to data from the World Health Organization (WHO), 257 million people worldwide have chronic infection with hepatitis B virus. However, in 2015 only 9% of the total were diagnosed, since most of them are asymptomatic. In this context, Drassanes-Vall d’Hebron International Health Unit has developed a community strategy based on the use of an educational tool to improve knowledge about the disease and access to diagnosis for immigrant people in Barcelona. The study that allowed defining the action plan is now, within the framework of World Hepatitis Day, published in the Spanish Journal of Public Health (Revista Española de Salud Pública).
In Europe, hepatitis B has an average prevalence of 1.6%, but this percentage increases to 8% if we take into account the immigrant population from endemic areas, such as Africa and the Western Pacific. However, the fact that most people are asymptomatic makes the diagnosis difficult and causes the infection to become chronic. For this reason, early diagnosis is key to reducing new infections, avoiding complications and reducing mortality.
With the aim of improving awareness of hepatitis B, as well as accessibility to diagnosis, Vall d’Hebron has created an educational tool, known as HEPARJOC, aimed at immigrants, who often have difficulties accessing healthcare services. For this reason, researchers have started from a multidisciplinary approach, in which the population that they want to reach has been involved. “In order to reach patients who are not diagnosed, we have to go out to look for them. It is essential that health professionals work together with the community”, highlights Hakima Ouaarab, nurse and coordinator of the team of health community agents at Drassanes-Vall d’Hebron International Health Unit, in Preventive Medicine Department at Vall d’Hebron. “This perspective with community participation gives more strength and value to the results obtained, both from the study itself and from the educational tool”, adds Dr. Jordi Gómez I Prat, head of the Public and Community Health Team (ESPIC) of the same Unit.
Multidisciplinary teams for the creation of HEPARJOC
The creation of the educational tool was based on a previous qualitative study, carried out between 2015 and 2018, based on meetings with different professional profiles and people working in the field of immigration and hepatitis, as well as adult immigrants from Sub-Saharan Africa living in Barcelona. Collaboration with the immigrant community was key to knowing their previous knowledge about hepatitis B and their experience. They also contributed with their vision and proposed strategies to sensitize the rest of the immigrant population about the disease.
The main problem that was detected was the lack of knowledge, both of the hepatitis symptoms, its modes of transmission and prevention measures, as well as the available diagnostic tests and treatments. In addition, the groups contributed ideas on possible methods to raise awareness among the population about hepatitis B. “Everyone agreed on the need to create visual and interactive educational materials (such as games or videos), and not informative talks or workshops”, explains Hakima Ouaarab.
Based on the conclusions of this study, it was decided to create a dynamic educational tool to improve awareness and accessibility to the diagnosis of hepatitis B. The tool, called HEPARJOC, consists of five didactic games that allow learning terms related to hepatitis, knowing the causes, the global distribution and its transmission routes. At the end, a video is played to encourage people to take the test to find out if they are infected with the hepatitis virus.
Once created, pilot tests were carried out in different community spaces, with immigrants from Sub-Saharan Africa and other countries. The eight workshops that were organized had the participation of a total of 56 people and included a questionnaire before and after the workshop that confirmed that the tool improved knowledge about hepatitis. After the workshop, an opportunity was offered to schedule an appointment to screen for hepatitis. Thus, 23 people (41%) were tested. “This could be a key strategy to improve knowledge and promote screening for hepatitis among immigrant groups from countries where it is an endemic disease. Thus, the underdiagnosis that currently exists in hepatitis B would be reduced”, details Dr. Gómez i Prat.
A tool as a base for future studies
HEPARJOC has already been used in some immigrant populations in Barcelona and it is expected that in the coming months it will be extended to other parts of Catalonia to improve the diagnosis of hepatitis B and also hepatitis C.
These studies include a project that was carried out in collaboration with Germans Trias I Pujol Hospital and Research Institute, the Center for Epidemiological Studies on Sexually Transmitted Diseases and AIDS in Catalonia (CEEISCAT) and the HIV, STI and HV prevention, control and care program (PCAVIHV) from the Public Health Agency of Catalonia (ASPCAT), based on a pilot with population of Pakistan, which demonstrated the usefulness of the tool to improve access to the diagnosis and treatment of hepatitis C. In the same way, it aims to reach populations of immigrants who come from countries endemic for hepatitis C living in different parts of the Catalan territory.