Sometimes the best way to get a message across is to be as direct as possible. For Dr. Gloria Coronado and a team of researchers from the Hutchinson Center's Public Health Sciences Division, being candid has the potential to prevent the rapidly rising incidence of the hepatitis B virus (HBV) in populations where English is being learned as a second language.
In the process of creating English as a Second Language (ESL) curriculum to deliver vital information about this often sexually transmitted disease without violating cultural taboos, the researchers met with Chinese-American students in the ESL program at the Chinese Information and Service Center in Seattle and asked, "What's the best way to talk about the risks associated with sexual contact with untested partners?" Advice from the students: "Just tell us what we need to know."
Coronado is developing curriculum that does just that in collaboration with colleagues Drs. Vicky Taylor and Beti Thompson, Elizabeth Acorda and H. Hoai Do. The paper describing their pilot project appeared in the Dec. 15, 2005, issue of the journal Cancer.
Coronado has also been assisting Taylor on a larger, similar initiative in Vancouver, B.C., which addresses several Asian immigrant populations collectively.
HBV causes more than 80 percent of all cancers originating in the liver and can also lead to cirrhosis of the liver and liver failure. It is endemic to many parts of the world including Southeast Asia and Sub-Saharan Africa. When communities from affected areas become established in North America, they bring HBV with them. Today, Asian- and Pacific-Islander Americans make up more than half of the 1.3 million to 1.5 million known HBV carriers in the United States.
Coronado and colleagues focused their pilot curriculum project on the Chinese-American community for several reasons. "Since we considered including a glossary (in English and Chinese) to accompany the curriculum, we wanted to work with an organization that taught ESL to a population that spoke a single language," Coronado said. "Colleagues of mine had a previous successful working relationship with the Chinese Information and Service Center, and we discovered that they had ESL classes that enrolled only Chinese Americans."
The goals of the new curriculum are straightforward: to improve knowledge about the risk factors for HBV and to encourage at-risk individuals to get a blood test to find out if they've been infected. Chronic carriers can learn how to avoid transmitting the virus. Anyone found to be uninfected is a candidate for the HBV vaccine, which is a series of three separate vaccinations. The Centers for Disease Control recommends the vaccine for all children by 18 months of age.
The virus does not treat all victims equally. When adults are exposed to HBV, they may experience symptoms such as fatigue, loss of appetite, nausea, abdominal pain and jaundice as their immune systems confront the virus. But the strong response is ultimately beneficial — 95 percent of adult victims recover completely and gain immunity to the virus.
For children, the situation is reversed. Their immature immune systems cannot resist the virus, so they rarely show symptoms. But children are much more likely to develop chronic HBV; in fact, the youngest victims — children born to infected mothers — are almost 100 percent certain to develop chronic HBV. This is harmful for them because chronic HBV is responsible for more than 80 percent of all cancers originating in the liver and can lead to cirrhosis of the liver and liver failure. But it is also harmful for their communities, because chronic HBV carriers grow up to pass the disease on to sexual partners and to family members through direct blood contact, which can occur quite casually — by sharing contaminated razors or toothbrushes, for example.
The interesting part about developing the curriculum, Coronado said, has been discovering what works best. "By conducting focus groups with both instructors and students, we learn about exercises and activities that work well in the classroom," she said. "Then we incorporate these strategies in the curriculum."
A session may start with the teacher presenting an illustration of a Chinese man receiving a vaccination for hepatitis B and asking the students to contribute to the story. The teacher then asks open questions, such as "What do you think is happening?" to prompt response. When the story is completed, the teacher reads it back to the class. The session may continue with a "warm up" period during which teachers ask students if they have heard of hepatitis B and, if so, what they know about it.
After the class, separate sets of student and instructor groups meet to review the curriculum and fine-tune the messages and strategies. The target audience for the curriculum is beginner and lower intermediate ESL classes — adult students who have sufficient English-language proficiency to comprehend an English curriculum on hepatitis B. Coronado said the team is now ready to deliver the curriculum to more classrooms. The Asian American Network for Cancer Awareness, Research and Training funded the pilot project in Seattle. The study should be complete by spring 2006, at which point the curriculum will be available to ESL classrooms everywhere.
In her work as an epidemiologist, Coronado looks for factors that heighten a particular population's susceptibility to some types of cancer. Such factors range from pesticides that farm workers unknowingly track into their homes to cultural taboos that cause people to shy away from invasive diagnostic tests. As a Mexican American with roots in Eastern Washington, Coronado said she takes satisfaction in contributing to the health and well-being of the Latino community. She said it is equally fulfilling to transfer insights, skills and approaches that work well with one immigrant community to others.
"We have been surprised to discover that we can be direct about the ways that hepatitis B is transmitted," Coronado said. "But we have also learned that it is important to emphasize that non-Chinese are also at risk for hepatitis B and to avoid giving the impression of singling out Chinese immigrants."
As for the receptiveness of students to the curriculum, Coronado said, the key is bringing home the relevance of this disease to the students' lives. "ESL students want to learn about practical things like going to the bank, taking the bus or ordering food at a restaurant. The challenge is making HBV relevant to them. I think we can do this by pointing out the strong link between this disease and liver cancer. It's also critical to communicate that there is a vaccine available. But it all starts with getting a blood test." It can also start with curriculum that provides information to raise awareness of the need.