key: cord-0032576-cfbu4tnw
authors: Rajkumar, Vishnupriya; McCausland, Kahlia; Lobo, Roanna
title: A Rapid Review of Interventions to Increase Hepatitis B Testing, Treatment, and Monitoring among Migrants Living in Australia
date: 2022-05-13
journal: Int J Environ Res Public Health
DOI: 10.3390/ijerph19105947
sha: 59eac2dcd286c583089b4b4f8363ad2e164d4782
doc_id: 32576
cord_uid: cfbu4tnw

Chronic hepatitis B (CHB) disproportionately affects migrants with low health literacy and help-seeking behaviour living in high-income countries. Evidence of effective interventions is required to increase hepatitis B (HBV) testing, treatment, and monitoring. Available evidence from Medline, Embase, Scopus, Google, and Google Scholar was identified, collated, and synthesised. Inclusion criteria included grey and peer-reviewed literature published in English between January 2012 and December 2021. Systematic reviews and meta-analyses were excluded. Seventeen peer-reviewed articles met the inclusion criteria. Most interventions were conducted at the individual level and were typically outreach testing initiatives. One study was conducted at a structural level. All studies were successful in encouraging HBV screening uptake, and 10 studies demonstrated effective linkage to care. Two studies showed evidence of monitoring participants post-intervention. Most interventions had more female than male participants. Interventions conducted across community and clinical-based settings had more participants engage in screening and/or linkage to care in community settings. Effective interventions to prevent HBV transmission and CHB-related morbidity and mortality were approaches that utilised linguistic-specific and culturally appropriate resources to successfully engage migrants. Community outreach programmes that educate participants about HBV transmission, screening, and treatment can promote community dialogue and understanding to reduce stigma and discrimination.

Globally, mortality from chronic viral hepatitis (CVH) has surpassed that of human immunodeficiency virus (HIV), malaria, and tuberculosis combined, prompting significant concern [1] . While the burden of disease is mainly carried by low-resource countries in sub-Saharan Africa, South East Asia, and the Western Pacific regions where hepatitis B (HBV) is endemic, the epidemiological spread of HBV to industrialised countries is driven by migration [2] . HBV is the most prevalent blood-borne and sexually transmissible virus in Australia, and when left untreated, chronic hepatitis B (CHB) can lead to serious adverse health outcomes such as liver cirrhosis and cancer [3] . Additionally, deaths attributable to liver cancer have increased faster than deaths caused by any other cancer, with liver cancer being the sixth leading cause of cancer mortality in Australia [4] . HBV in Australia disproportionately affects residents born overseas in HBV-endemic areas, accounting for 61% of infections [5, 6] , and can be attributed to the lack of a universal vaccination programme prior to 2014, mother-to-child (vertical) transmission, and transmission from other close contacts with CHB in the first years of life [1, 5, 6] . The introduction of childhood HBV vaccination programmes both overseas and locally reflect a decreased prevalence in the under-19 age group; however, more than 90% of new cases of CHB in Australia occur income countries: the United Kingdom (UK), Canada, New Zealand (NZ), and the United States (US). The findings are expected to assist efforts to reduce HBV-related morbidity and mortality in Western Australia, and Australia more broadly.

This review was conducted using the recommendations and minimum standards for rapid reviews by the Cochrane Rapid Reviews Methods Group and Preferred Reporting Items for Systemic Reviews and Meta-Analyses extension for Scoping Reviews guidelines (PRISMA-ScR) [23, 25] .

The following search strategy was developed incorporating search terms used in similar reviews and in consultation with a university librarian: ("hepatitis B" OR (hep AND b) OR "hep* B" OR "viral hepatitis") AND (interventions OR process* OR strateg* OR procedure OR screen* OR "mass screen*" OR diagnosis OR testing* OR monitoring OR target* OR care OR treatment) AND (CALD OR migrant* OR "culturally and linguistically diverse" OR transient OR overseas-born OR refugee OR humanitarian) AND (Australia* OR "New South Wales" OR Victoria OR Tasmania OR "West* Australia" OR "South Australia" OR Queensland OR "Australian Capital Territory" OR ACT OR "Northern Territory" OR NT OR "United Kingdom" OR UK OR Canada OR NZ OR "New Zealand" OR US OR USA OR "United States").

To identify potentially relevant studies for inclusion, a comprehensive search of three databases and two search engines (Google and Google Scholar) was conducted. The first ten pages of search results from Google and Google Scholar were screened. The following academic databases were identified to be appropriate: Medline, Embase, and Scopus, as they contain references to journal articles in life sciences with a focus on biomedicine. The search strategy included both grey and peer-reviewed literature (quantitative or qualitative) published between January 2012 and December 2021 and in the English language. Articles characterised as systematic reviews and meta-analyses were ineligible for inclusion. Due to a lack of Australian studies focusing on HBV interventions to increase testing, treatment, and/or monitoring among migrants from CALD backgrounds, eligible studies included those conducted with first-and/or second-generation migrants from CALD backgrounds living in the UK, the US, NZ, and Canada.

This review defined a high-income country as one with a gross national income per capita of USD 12,696 or more [24] . A migrant was defined as "any person who changes his or her country of usual residence" and included migrant workers, international students, refugees, and asylum seekers [26] . A first-generation migrant was defined as foreign-born, and a second-generation migrant was defined as a person who was born and is residing in a country that at least one of their parents entered as a migrant [16] . Second-generation migrants were included in this study as unvaccinated household contacts of CHB-positive individuals are susceptible to HBV infection [6] .

The primary researcher (V.R.) conducted the same searches in each database to ensure a complete, consistent, and comprehensive process. The citations identified through the search strategy were exported into Endnote X9 citation management software. Duplicate citations were removed before exporting the remaining citations into Rayyan, a systematic review management software where further duplicate citations were identified and removed [27, 28] .

In Rayyan, two reviewers (V.R./K.M.) screened the titles and abstracts of the imported citations independently of one another (a double screening approach) to determine eligibility, reducing the risk of bias and promoting the selection of the relevant literature [29] . For the citations that were identified as potentially eligible, or that required further investigation, the full text was retrieved to further assess eligibility and reviewed by V.R. Reasons for excluding studies during the full-text review process were studies reporting current HBV prevalence in migrants, barriers that migrants faced to accessing healthcare, and inclusion of other population groups, such as people who inject drugs. A third reviewer (R.L.) reviewed articles where eligibility was uncertain. The reference lists of the eligible literature were also screened to ensure no relevant studies were missed.

The research team developed a pro forma data extraction table containing the following headings: Author(s), Year of publication, Location of study, Population and sample size, Aim, Methodology, Intervention type, Outcome measures/results, Implications for research, policy, and/or practice. The expanded data extraction table is available in the Appendix A. Two reviewers (V.R./K.M.) extracted data from five articles and then convened to compare the data extracted. This process served to assist the primary reviewer (V.R.) with consistency when extracting data from the remaining papers.

Relevant outcome measures identified from the literature were reported, which focus on aspects of interventions that are successful and unsuccessful, implications for research, policy, and practice, how these results relate to Australia, and strategies to increase HBV testing, treatment, and monitoring.

The screening process was documented and reported using a PRISMA flow diagram [30] (Figure 1 ). The search retrieved 2437 articles. After duplicates were removed, a total of 2206 articles were screened based on their keywords, title, and abstract, and from this, the full texts of 47 articles were assessed for eligibility. After full-text review, a further 30 articles were excluded as they measured HBV prevalence in the target group, or the study included other population groups such as persons injecting drugs. A final sample of 17 studies met the inclusion criteria. The populated data extraction pro forma is available in Table 1 . 

Of the 17 studies, 9 were conducted in the US [32, 33, 35, 38, [40] [41] [42] [43] [44] , 5 in the UK [34, 36, 37, 39, 45] , 2 in Australia [31, 46] , and 1 in Canada [47] . Five studies used mixed methods (qualitative and quantitative) [31, 39, [45] [46] [47] , and the remaining twelve studies used quantitative methods [32] [33] [34] [35] [36] [37] [38] [40] [41] [42] [43] [44] . The sample size of the studies ranged from 54 to 827 in the mixed methods studies [31, 39, [45] [46] [47] , and from 96 to 90,250 participants in the quantitative studies [32] [33] [34] [35] [36] [37] [38] [40] [41] [42] [43] [44] . All studies collected information between 2009 and 2020 [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] . One study did not report ethics approval from a human research ethics committee [42] .

Of the 17 studies, 2 studies examined migrants from South East Asia (SEA) [36, 39] , 3 focused on migrants from North East Asia (NEA) [36, 47, 48] , 3 focused on migrants from both SEA and NEA [37, 42, 49] , 2 focused on migrants from sub-Saharan Africa (SSA) [32, 43] , and the remaining 7 studies were on migrants from a mixture of SEA, NEA, SSA, and other regions [34, 35, 39, 41, 43, 45, 50] . All studies included both male and female participants. Thirteen studies had more female than male participants [32, 33, 35, 36, [38] [39] [40] [41] [42] [44] [45] [46] [47] , and the remaining four studies had more male than female participants [40, 43, 45, 50] . Participants' ages varied among studies, with six including participants over 18 years of age [37, 40, 42, 44, 46, 48] , and the remaining studies including participants under 18 years of age [36, 47, 50] or not stating the lower limit of their participants' age range [34, 35, 38, 39, 41, 43, 45, 49] . A majority of studies included broad migrant communities, with some studies conducted with refugees [35, 43, 50] and asylum seekers [37] . Six studies explicitly stated that 71% to 100% of the participants had a preferred language other than English [35, 36, 39, 42, 48, 49] .

Individual interventions consisted of outreach testing and provider-initiated interventions such as testing and linkage to care (vaccination or referral to primary care or a specialist provider for treatment). Outreach testing refers to locating at-risk populations where they socialize, and provider-initiated interventions are defined as testing and counselling services recommended by health professionals as a standard component of medical care [48, 50] . Of the 17 studies, 13 studies reported individual interventions [31, 33, [35] [36] [37] [38] [40] [41] [42] [43] [44] [45] [46] , and they were categorised by the method(s) used to encourage testing and linkage to care.

Outreach testing was conducted by seven studies in the US [33, 35, [40] [41] [42] [43] [44] , one study in the UK [45] , and one study in Australia [46] . Of these studies, outreach efforts were effective in encouraging testing in all studies, and eight studies identified HBV prevalence in their target populations ranging from 3.0% to 9.6% [33, 35, [40] [41] [42] [43] [44] [45] .

Six studies showed evidence of linkage to care ranging from 28% to 97% of the participants, such as counselling to receive HBV vaccination or referral to a primary care or specialist provider [33, 35, 40, 41, 43, 44] . Three studies reported that males were more likely to test positive for HBV [36, 40, 42] , and one study reported that women were five times more likely to have a previous HBV diagnosis compared to their male counterparts [45] . Navarro et al. [40] reported a discrepancy between serological results and self-declared vaccination history; out of 240 participants thought to have been previously vaccinated, only 60% (n = 145) had serological evidence of this (p < 0.001). No studies conducting outreach testing showed evidence of monitoring participants after they had been linked to care.

All studies used linguistic-specific and culturally appropriate materials such as advertisements in local newspapers and announcements on radio stations in languages used by local migrant communities or bilingual/multilingual patient navigators, including community and religious leaders, to recruit and communicate with their target populations [33, 35, [40] [41] [42] [43] [44] [45] [46] . Seven studies provided education on HBV in conjunction with screening events [33, [41] [42] [43] [44] [45] [46] . Six studies conducted interventions in community-based settings (public schools, places of worship, or community centres) [35, 40, 41, 43, 45, 46] , and three studies conducted interventions across both community (health fairs or faith-based organisations) and clinical-based settings (primary care or emergency departments) [34, 35, 39] .

Of the interventions conducted across community and clinical-based settings, the studies by Chandrasekar et al. [33] and Raines-Milenkov et al. [42] reported that more participants engaged in testing in community settings compared to clinical-based settings, and the former linked more participants tested in community settings to medical care. The study by Dang and Chen Jr. [35] reported that 72% (n = 21) of the participants eligible for vaccination completed the series of doses required for full immunisation. Other studies by Perumalsawmi et al. [41] and Shankar et al. [43] also reported that 37% and 57% of the participants were eligible for HBV vaccination, respectively. However, there was no information on post-intervention vaccination rates in either study, even though Perumalswami et al. [41] offered free HBV vaccines at screening sites. Shankar et al. [43] offered HBV-positive participants cash and travel-cost incentives after the completion of follow-up visits, and Standford et al. [44] offered participants cash incentives after they completed HBV testing. One study used dried blood spot sampling to test for HBV, which offered advantages such as a reduced risk of needle-stick injury, safer transportation of samples, and the ease of storing samples at room temperature [45] . A study by Xiao et al. [46] compared the impact of educational resources on HBV testing uptake. Participants were randomised to receive either standard HBV-related information or education focusing on liver cancer prevention, and at the end of the study, the latter group had an HBV testing uptake four times that of the former [46] .

Provider-initiated testing was conducted by Flanagan et al. [36] and Hargreaves et al. [37] in the UK, Hsu et al. [38] in the US, and Ash et al. [31] in Australia. Three interventions among these studies were effective in encouraging up to 90% of their target population to engage in HBV screening [37, 44, 50] . Ash et al. [31] identified and immunised 6% of uninfected susceptible individuals in their target population but did not find any new cases of CHB. Studies by Flanagan et al. [36] and Hsu et al. [38] linked 80% and 50% of the HBsAg-positive participants to care, respectively. Only one study [38] monitored HBsAg-positive or HBV-non-immune individuals for three months post-intervention.

All studies except for Flanagan et al. [36] used linguistic-specific and culturally appropriate materials to communicate with their target populations. All studies were conducted in a clinical-based setting [37, 44, 45, 50] . Flanagan et al. [36] provided participating general practitioners with education, a financial incentive, clinician support, and electronic prompts when accessing patient records to screen migrants for CVH. Although the intervention was successful compared to the control (20% vs. 2%), it had a lower than expected screening uptake and fell short of the assumption that at least 40% of the eligible participants would be screened. A similar intervention by Hsu et al. [38] that used electronic health record prompts tracked HBV-positive participants for three months post-intervention and vaccinated 25% of susceptible individuals. In a "one stop" screening initiative in a UK hospital emergency department, Hargreaves et al. [37] found that while 61% of patients presenting to the service were reported to be from an ethnic background, it was not possible to ascertain the number of migrants in this group that did not consent to participate in the study. The nurse-led contact tracing system by Ash et al. [31] yielded 420 contacts from 122 CHB-positive index patients and vaccinated 27 susceptible individuals.

Community interventions consisted of group or peer education initiatives. A total of 3 of the 17 studies conducted community interventions to address low levels of HBV knowledge, awareness, and associated stigma [38, 46, 49] . All three studies were effective in encouraging participants to consent to HBV testing, ranging from 19% to 84% of their target populations [38, 46, 49] . In one of the studies, four participants (1%) requested a HBV vaccination within four weeks of attending a community education workshop [47] .

All studies used linguistic-specific and culturally relevant methods to communicate with their target populations [38, 46, 49] . Two studies conducted interventions across community and clinical-based settings [32, 39] , or in community settings only [47] . In addition to screening and linkage to care, the education workshops conducted by Zibrik et al. [47] prompted participants to proactively read information online or in print (60%), talk to their doctor about HBV testing (48%), schedule an appointment with their doctor (7%), or check their vaccination status or that of a family member (6%). Word-of-mouth from participants who watched an educational film in a study by Kelly et al. [39] encouraged an additional 45 participants to engage in CVH screening. Dried blood spot sampling was used to test for HBV, and primary care recruitment was poorer compared to that in the community [39] . Chandrasekar et al. [32] employed a chain-referral sampling method to engage hard-toreach individuals through their natural social networks and found that individuals without healthcare insurance were more comfortable presenting to a community setting. The same study also reported fear of reprisal as a reason that migrants were reluctant to utilise the chain referral system [32] .

Structural interventions included interventions addressing broader social, economic, and political environments. Only 1 of the 17 studies in this review reported the results of a mandatory screening programme conducted in clinical-based settings [34] . The intervention screened a large cohort of UK-bound refugees as part of a mandatory pre-migration resettlement programme, and the testing yield for HBV was notably high at 2.0% (n = 188) and ranged by nationality from 0.6% for Iraq and 13% for South Sudan [34] . This study cited fear of legal implications affecting migrants' rights to resettlement as a barrier to the self-reporting of risk factors for infectious diseases [34] .

All included studies made various recommendations for clinical practice, health education and promotion, research, and policy. Nine studies supported the need for future interventions that address common barriers faced by migrants for HBV testing, diagnosis, and care by utilising culturally tailored education and collaboration with community groups [34, 35, 38, 39, 41, 42, 46, 48, 49] . Two studies highlighted the importance of a targeted approach to screening and linkage to care for at-risk groups such as prevalence linked to patients' country of origin [43, 45] , and Hargraves et al. [37] recommended routine testing for HBV for new entrants from high-incidence countries in both community and clinicalbased settings. Ash et al. [31] , Flanagan et al. [36] , Hsu et al. [38] , and Navarro et al. [40] made recommendations related to improvements in clinical practice such as a nurse-led approach to contact tracing, incentives for clinicians to screen patients, and provider recommendations for testing due to their influence on increasing patient testing and treatment outcomes. One study provided policy recommendations and acknowledged the effectiveness of mandatory screening of refugees as part of a resettlement programme in identifying infectious diseases [34] .

The purpose of this rapid review was to identify, collate, and synthesise the literature pertaining to interventions that aim to increase HBV testing, treatment, and/or monitoring among migrants from CALD backgrounds living in Australia, the UK, Canada, NZ, and the US. In summary, 17 peer-reviewed journal articles published between 2012 and 2021 met the inclusion criteria for review. This review identified three levels of interventions (individual, community, and structural) and two key settings where interventions took place, namely, community, and clinical-based health services (primary care and other clinical health services).

All interventions were successful in encouraging HBV screening uptake among their target group/s of first-and/or second-generation migrants [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] . According to previously defined HBV endemicity levels, a prevalence of less than 2% is considered low, a prevalence of 2-4.99% is lower-intermediate, a prevalence of 5-7.99% is considered higher intermediate, and a prevalence of >8% is high [49] . Twelve studies in this review identified an HBV prevalence of more than 2% in their target populations, confirming the intermediate to high prevalence of HBV in these at-risk groups, highlighting the importance of targeted testing [32] [33] [34] [35] 37, 38, [40] [41] [42] [43] [44] [45] . Three studies in this review reported an HBV prevalence of more than 8%, and the populations in these studies comprised African-born migrants and migrants of Chinese or Vietnamese origin [37, 40, 47] . This finding is consistent with reports stating that the regions with the highest HBV prevalence are SSA and East Asia [7, 51] . Reported discrepancies between self-declared vaccination history and serological results post-testing could be due to recall bias, poor English proficiency and health literacy, confusion between hepatitis B and hepatitis C, lower education level attained, access to care, or a general lack of awareness of prior screening and/or healthcare [52, 53] . This further highlights the importance of complete serological testing in migrants before recommending treatment options [40] .

Ten studies had effective linkage to care [31, 33, 35, 36, 38, 40, 41, 43, 44, 47] . Two studies monitored participants post-intervention [38, 47] . Given that all individuals living with CHB should be regularly monitored and their HBV viral loads assessed annually to monitor disease activity and inform treatment, it was expected that more interventions would have monitored participants linked to care for at least twelve months post-intervention [54] . Given the critical importance of vaccinating susceptible individuals against HBV [6] , it was surprising that none of the studies that recommended vaccination to participants based on serological results [41, 43] provided evidence of vaccination uptake.

Three out of the four studies [35, 38, 39, 46] that conducted their intervention across community and clinical-based settings reported higher engagement of participants in a community setting with regard to HBV screening and/or linkage to care [35, 39, 46] . This was an expected finding as migrant populations from CALD backgrounds often draw on their social networks for support with regard to health-literacy-related tasks such as interacting with health professionals and making health-related decisions [55] . Furthermore, migrants view a community-based screening service favourably as it delivers "services to the people where they are" [18] (p. 7), and participants feel more comfortable in a familiar environment with staff that are likely to have been recruited from the community itself [18] .

Culturally relevant interventions that incorporate appropriate language and culturally sensitive settings are essential when attempting to successfully engage migrants from CALD backgrounds [18] . The screening intervention by Flanagan et al. [36] fell short of its target by more than 50% despite providing electronic health record prompts to general practitioners. One explanation could be that this study did not employ linguistic-specific methods or culturally competent health workers to communicate with their target group. Language barriers have been identified as a pertinent issue for migrants regardless of their level of education or length of residence in a predominantly English-speaking country [18, 55] . A study by Hyun et al. [55] on barriers to HBV health literacy faced by Korean Americans revealed that while some individuals can communicate in simple English during everyday tasks, they encountered difficulty when it came to describing their health concerns or understanding health advice.

The majority of the interventions in this review had more female than male participants. Three studies reported that females were more likely to test positive for HBV [36, 40, 42] , and Vedio et al. [45] highlighted that men were five times more likely to have a previous HBV diagnosis at the time of screening. The findings mentioned above are likely due to gender differences in beliefs about health among migrant communities. Males tend to avoid consciously thinking about their health and define being healthy as not seeking medical help [56] . By contrast, females are more likely to be aware of their family medical history and make associated changes to their lifestyles [56] . Furthermore, females reported help seeking as one of their common behavioural responses for a range of symptoms and bodily changes [56] . The higher HBV prevalence in male migrants may also be attributable to differences in their social and sexual behaviours [57] .

It was difficult to compare the effectiveness of the interventions due to the varying study designs adopted by the studies in this rapid review. Studies that used a randomised controlled trial design had clear differences in outcomes between the control and intervention groups. Conversely, studies that conducted a feasibility trial or observational study measured the uptake of intervention outcomes among their target group. Therefore, future scoping or systematic reviews on this topic could limit the study design to one type in their eligibility criteria to allow comparisons of study effectiveness.

This rapid review had several strengths. Firstly, multiple researchers reviewed the database search results and adopted a team approach to minimise errors and ensure the quality of studies retrieved during the search. This is consistent with the Cochrane Methodological Expectations of Cochrane Intervention Reviews guidelines for rapid reviews [23] . Additionally, this review only used studies published in the last ten years, ensuring that the information collected included current research findings, innovations in care, and recent trends in population outcomes and was in line with the current social and political contexts of care provided. Furthermore, this review only included outcome-driven studies, allowing the authors to assess the effectiveness of the interventions. The three levels of interventions conducted in the two key settings successfully achieved at least one intervention outcome (testing, treatment, and/or monitoring), better guiding future policy development, research, clinical practice, and health promotion initiatives.

Studies from the US accounted for just over half of the studies included in this review. Compared to the other countries analysed in this rapid review with universal health insurance programmes, only the US has a voluntary, private employer-and individualbased system with private insurance as the primary form of health insurance [58] . It is acknowledged that the results from the US studies may reflect the organisation of its health system. For example, individuals that do not have health insurance may be reluctant to participate in interventions due to their inability to pay for healthcare services. This review also excluded grey and peer-reviewed literature not published in English and acknowledges that studies in languages other than English could have provided valuable information to understand successful interventions for migrants from CALD backgrounds. Studies conducted in low-income countries may also have offered a wealth of information to provide additional context to the findings. There was also no risk of bias assessment conducted.

The recommendations of the studies included in this review mainly addressed challenges at the individual level. Emphasis was placed on methods to identify at-risk groups in both community and clinical-based settings and break down language and cultural barriers to improve healthcare engagement. Most of the studies focused on screening and treatment, possibly due to the complexity, time, and resources required for interventions that monitor participants after they are linked to care. The following sections provide implications for research, policy, health promotion, and clinical practice considering the broader literature.

Reasons for the low participation of male migrants were not explored and warrant further investigation, and the limited number of studies that monitored HBV-positive participants post-intervention merits further research to explore patient retention after they are linked to care and the reasons why they may have ceased treatment to prevent associated morbidity and mortality.

Only two studies in this review were conducted in Australia [31, 46] . While there are useful lessons learnt from the other studies in this review, it would be beneficial to test interventions in the Australian healthcare context to increase migrants' participation in HBV screening and clinical management.

Despite the effectiveness of all studies in achieving at least one intervention outcome, each intervention worked at one of three levels of action (individual, community, or structural). A majority (n = 12) of the interventions in this review focused on changing individual behaviours in a one-to-one setting [31, 33, [35] [36] [37] [38] [40] [41] [42] [43] [44] [45] . As individual interventions target short-term behaviour change, there is a growing consensus that prevention programmes for infectious diseases need to address the broader social structural context to bring about sustained behaviour change [16] . This is especially the case for groups that experience inequality, discrimination, and exclusion [16, 59] . Therefore, future interventions should include the simultaneous use of evidence-based individual, community, and structural strategies-an approach that is consistent with the foundations of the Ottawa Charter for Health Promotion [60, 61] .

Primary care providers, including general practitioners and primary care nurses, are critical in identifying risk factors for chronic disease and implementing clinical management with early detection, follow-up, and monitoring of CHB [62, 63] . Furthermore, it is mainly through primary care services that Australian patients are linked to specialist care [54] . Primary care services may vary widely in their provision of interpretation services which can result in patients either relying on family members as interpreters during healthcare appointments, and crucial information being omitted by family members if the consultation involves sensitive topics or specialist terminology, or patients seeking traditional medicine practitioners who speak their preferred language [64] . Therefore, interpreters should be recognised as an essential component of clinical services provided to migrants from CALD backgrounds, and HBV education and awareness materials should be available in multiple languages [11, 44] . In this review, provider-initiated interventions with electronic health record prompts and incentives were successful in encouraging screening and linkage to care [36, 38] . To further boost screening initiatives, medical practitioners and other healthcare workers should receive continuing education to aid in identifying persons at risk and linking them to screening [63] .

Studies within this review stressed the importance of an ongoing need for community outreach programmes that build awareness and educate vulnerable populations about HBV to promote prevention, screening, and treatment. The key features of programmes should correct culturally rooted myths and conceptions about HBV transmission and educate participants on long-term risks and consequences to health [65] . Consultation and collaboration with relevant stakeholders, including community and religious leaders, should be considered to promote community dialogue, and understanding to reduce stigma and discrimination [15, 66] . Additionally, effective health education should incorporate understanding and navigation of the healthcare system to connect patients with primary care resources and encourage patientphysician dialogue [66] . Furthermore, for any education and awareness programme to be effective, it must be culturally tailored to migrants from CALD backgrounds [67] . Therefore, outreach initiatives should involve facilitators from similar cultural backgrounds to participants, and educational resources should be developed in participants' native language(s) [67, 68] .

Currently, there are no pre-arrival immunisation requirements for migrants or refugees entering Australia [69] . Although the Australian Immunisation Handbook advises the targeted catch-up vaccination of all migrants and refugees without valid vaccination documentation, no national system exists to achieve this [69] . Therefore, a universal tool for recording past immunisations is recommended, enabling primary care providers to assess immunisation needs among migrants and refugees [66] .

Another barrier identified by Crawshaw et al. [34] and Chandrasekar et al. [32] to the self-reported history or voluntary screening of STIs identified by migrants is the fear of reprisal or legal implications affecting their rights to resettlement. Accordingly, it should be emphasised that neither mandatory screening nor catch-up vaccination will be used as a process of exclusion for those who test positive [70] .

Global migration has resulted in an increasing number of CHB infections in high-income countries. Although Australia has endorsed the World Health Organization's strategy to eliminate viral hepatitis by 2030 and has set targets to increase testing and linkage to care, effective and coordinated responses for migrants from CALD backgrounds have been slow, with limited reporting of Australian interventions in the literature. To prevent further HBV transmission and CHB-related morbidity and mortality, there is a critical need for public health approaches that consider broader socioeconomic and sociocultural factors associated with migrants from CALD backgrounds. Based on this review, interventions should utilise linguistic-specific and culturally appropriate resources to successfully engage migrants from CALD backgrounds, and community outreach programmes should educate participants to promote community dialogue and understanding to reduce stigma and discrimination. 

The authors would like to thank Vanessa Varis, Health Science Faculty Librarian, for her assistance in developing the search strategy. The authors also wish to acknowledge Daniel Vujcich for his guidance in preparing this scoping review for publication.

The authors declare no conflict of interest. 

To determine whether incentivising and supporting primary-care physicians in areas with a high density of migrants increases the numbers of adult migrants screened for viral hepatitis.

General practices were randomly assigned to an opportunistic screening (control) group or one of four targeted screening (interventional) groups; standard (ie, hospital-based) care and a standard invitation letter; standard care and an enhanced invitation letter; community care and a standard invitation letter; or community care and an enhanced invitation letter. In control screening, general practitioners (GPs) were given a teaching session on viral hepatitis and were asked to test all registered migrants. In the intervention, GPs were paid a nominal sum for setting up searches of records, reimbursed for signed consent forms, and supported by a dedicated clinician. Patients who were eligible for testing and tested positive for viral hepatitis in the intervention groups were eligible to enrol in a second embedded trial of community versus hospital-based care. 

To investigate the delivery of an opportunistic screening model offering new migrants multi-disease screening using a one-stop blood test for latent tuberculosis infection (LTBI) combined with HIV and hepatitis B/C in an emergency department setting.

The PROMOTE study was conducted at St. Mary's Hospital Emergency Department, London, UK, which is a high-migrant area representative of many of the Boroughs across London, and where 49.8% of the resident population was born abroad. Migrant patients meeting the study inclusion criteria were offered combined infection screening in addition to the standard care they received and followed up according to routine care pathways. The screening intervention was a single venesection to test for: (i) LTBI using interferon gamma release assay (QuantiFERON-TB Gold in-tube); (ii) HIV (HIV screening assay); and (iii) hepatitis B surface antigen test (HBsAg) and (iv) hepatitis C antibody test (anti-HCVAb). Participants completed a questionnaire (piloted in this setting) with questions pertaining to time in the UK, nationality, registration with a local primary-care provider, and whether patients had previously been offered any kind of screening since their arrival. They then provided a peripheral venous blood sample, which was obtained by the research nurse. 

To determine the effectiveness of electronic health record (EHR) prompts to increase the ordering of HBV tests among primary care providers (PCPs) within an academic health system.

Providers were randomized to either receive an EHR prompt for HBV testing prior to patients' appointments or usual care. Primary outcomes were the proportion of patients (1) whose physician ordered a HBsAg test and (2) who completed testing. Secondary outcomes were (A) test results and (B) whether the physicians followed up on the results. Providers in the intervention received an electronic prompt 24 hours before their patient's scheduled appointment that identified the patient as a candidate for HBV testing and urged the provider to evaluate the patient for testing. The message, sent by a hepatologist to the provider's EHR inbox, consisted of several components including a description of the Centre for Disease Control's recommendations for HBV testing in at-risk Asian populations, the high prevalence of HBV in Asia, and a list of the appropriate laboratory tests for proper HBV screening. partnered with a non-profit organisation to provide targeted screening for HBV to any African born adult >18 years of age. Before screening, participants were provided with a questionnaire to assess demographics and risk factors. Community members were invited to attend the screening events at no cost through public service announcements on local African radio stations, flyers at community venues, announcements by community and religious leaders, and word of mouth by the patient navigator at community events. A trained phlebotomist collected a blood sample on-site for serological testing for each patient. A culturally targeted, multilingual (English-, Arabic-, and French-speaking) professional patient navigator attempted to contact persons with their results via telephone 1 week after their screening. Upon completion of their visit, all persons were provided a round-trip public transportation fare card to cover travel costs and a $20 incentive for attending the visit. To explore approaches to increase HBV testing in Australia's Chinese community and inform evaluation planning, specifically to i) assess the feasibility and acceptability of HBV educational programs, and ii) compare HBV testing uptake in people receiving a tailored education resource focussing on liver cancer prevention compared with a standard HBV education package.

People of Chinese ethnicity and unsure of their HBV infection or immunity status were recruited from 10 community sites. Participants were randomised to receive an education package (comprised of a leaflet and in-person one-on-one educational session) with a focus on either 1) standard HBV-related information, or 2) liver cancer prevention. Participants completed a baseline questionnaire prior to receiving the intervention and were followed up at 6 months for a questionnaire and an opt-in semi-structured interview.

Educational and outreach intervention; Individual; Communitybased organisations.

HBV testing uptake, intervention acceptability and feasibility of the study.

54 participants received an education package; baseline and follow-up data from 33 (61%) were available.

The study procedures of recruitment and retention were feasible; the acceptability of the education program was moderate with improved HBV-related knowledge observed. 4 participants self-reported being tested: 1 (1/15, 7%) in the standard HBV information group and 3 (3/18, 17%) in the liver cancer prevention information group.

A larger study is required to determine if a liver cancer prevention message would improve HBV testing uptake in the Chinese community than a standard HBV education message. Support from healthcare providers, community-based testing programs, and public health education programs are likely needed to motivate diagnostic testing among Chinese people at risk of HBV infection. 

To describe different types of viral hepatitis and the severity of infection. Emphasize HBV prevention including screening, vaccination and risk reduction strategies. Outline symptoms and transmission routes of HBV.

Describe HBV treatment and pathway for care; identify community resources and supports for people living with HBV Promote a healthy lifestyle to prevent the progression of liver disease.

Culturally tailored HBV education workshops were delivered over 12 months. Data from pre-and post-workshop surveys and 2-week and 1-month follow-up interviews were collected and analysed to evaluate knowledge gaps and challenges around HBV prevention and screening. Barriers, health care service gaps and facilitators identified in the interviews were coded and analysed.

Culturally tailored education workshops; Community; Community (community centres, immigration settlement service centres, organised health events and religious/cultural gathering places).

Selfreported action related to HBV prevention and management.

Data were collected from 827 participants who attended workshops. 633 participants took part in the 2-week and 1-month follow-up interviews conducted via telephone. Of these, 55% took specific action related to HBV prevention or management such as proactively sought out/read information (online or in print) on HBV; talked to their doctor/health professional about HBV testing/care; got tested for HBV following the workshop; scheduled an appointment to see their doctor/health professional; checked their vaccination status or that of a family member; got vaccinated against HBV.

Study findings support the need for culturally tailored HBV public education and outreach programs to further advance HBV immunization and awareness in British Columbia. Addressing barriers and developing targeted programmatic strategies identified in this study will promote more effective HBV education programming and improve uptake of HBV screening and vaccination in British Columbia's immigrant populations.

Combating Hepatitis B and C to Reach Elimination by 2030

Improving care of migrants is key for viral hepatitis elimination in Europe

National Surveillance for Hepatitis B Indicators: Measuring the Progress towards the Targets of the National Hepatitis B Strategy-Annual

Deaths from liver cancer continue to rise in Australia: Is elimination by 2030 possible?

Australian Government Department of Health. Third National Hepatitis B Strategy

Recognising the role of infection: Preventing liver cancer in special populations

World Health Organization. Global Health Sector Strategy on Viral Hepatitis 2016-2021: Towards Ending Viral Hepatitis

Barriers faced by migrants in accessing healthcare for viral hepatitis infection

In my culture, we don't know anything about that": Sexual and reproductive health of migrant and refugee women

Interventions to increase migrants' care-seeking behaviour for stigmatised conditions: A scoping review

Addressing cultural diversity: The hepatitis B clinical specialist perspective

Hepatitis B knowledge and associated factors among people with chronic hepatitis B

The global impact of the COVID-19 pandemic on the prevention, diagnosis and treatment of hepatitis B virus (HBV) infection

Differences in cancer incidence by country of birth in New South Wales 1991 to 2001: Healthy migrants, ascertainment bias or salmon swimming upstream?

Community-based prevention of hepatitis-B-related liver cancer: Australian insights

World Health Organization

A typology of actions to tackle social inequalities in health

Engaging new migrants in infectious disease screening: A qualitative semi-structured interview study of UK migrant community health-care leads

Structural interventions to reduce and eliminate health disparities

Structural interventions for HIV prevention among women who use drugs: A global perspective

Interventions to optimise the care continuum for chronic viral hepatitis: A systematic review and meta-analyses

What works in inclusion health: Overview of effective interventions for marginalised and excluded populations

PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation

World Bank Country and Lending Groups

Cochrane Rapid Reviews Methods Group offers evidence-informed guidance to conduct rapid reviews

International Organization for Migration. Key Migration Terms

Rayyan-A web and mobile app for systematic reviews

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Single screening versus conventional double screening for study selection in systematic reviews: A methodological systematic review

Study flow diagrams in Cochrane systematic review updates: An adapted PRISMA flow diagram

Hepatitis B contact tracing: What works?

A novel strategy to increase identification of african-born people with chronic hepatitis B virus infection in the Chicago Metropolitan area

A comparison of effectiveness of hepatitis B screening and linkage to care among foreign-born populations in clinical and nonclinical settings

Infectious disease testing of UK-bound refugees: A population-based, cross-sectional study

Increasing hepatitis B testing and linkage to care of foreign-born Asians

Case finding and therapy for chronic viral hepatitis in primary care (HepFREE): A cluster-randomised controlled trial

Delivering multidisease screening to migrants for latent TB and blood-borne viruses in an emergency department setting: A feasibility study

Electronic messages increase hepatitis B screening in at-risk Asian American Patients: A randomized controlled trial

Improving uptake of hepatitis B and hepatitis C testing in South Asian migrants in community and faith settings using educational interventions-A prospective descriptive study

Lower than expected hepatitis B virus infection prevalence among first generation Koreans in the U.S.: Results of HBV screening in the Southern California Inland Empire

Hepatitis Outreach Network: A practical strategy for hepatitis screening with linkage to care in foreign-born communities

Hepatitis B virus awareness, infection, and screening multiethnic community intervention for foreign-born populations

A novel collaborative community-based hepatitis B screening and linkage to care program for African immigrants

Community-engaged strategies to promote hepatitis B testing and linkage to care in immigrants of Florida

Hepatitis B: Report of prevalence and access to healthcare among Chinese residents in Sheffield UK

Assessing the feasibility, acceptability and impacts of an education program on hepatitis B testing uptake among ethnic Chinese in Australia: Results of a randomised controlled pilot study

Let's Talk About B: Barriers to hepatitis B screening and vaccination among Asian and South Asian immigrants in British Columbia

Provider-initiated hiv testing and counseling in low-and middle-income countries: A systematic review

Estimations of worldwide prevalence of chronic hepatitis B virus infection: A systematic review of data published between

Outreach strategies for the promotion of HIV testing and care: Closing the gap between health services and female sex workers in Benin

Understanding the barriers to uptake of antenatal vaccination by women from culturally and linguistically diverse backgrounds: A cross-sectional study

Migrant Blood-Borne Virus and Sexual Health Survey 2020-2021: Queensland Results

The cascade of care for Australians living with chronic hepatitis B: Measuring access to diagnosis, management and treatment

Sociocultural barriers to hepatitis B health literacy in an immigrant population: A focus group study in Korean Americans

Gender differences in beliefs about health: A comparative qualitative study with Ghanaian and Indian migrants living in the United Kingdom

Prevalence of hepatitis B and knowledge about hepatitis B among migrant workers in Shandong Province, China: A cross-sectional study

Health care spending in the United States and other high-income countries

Findings from Encontros: A multi-level STI/HIV intervention to increase condom use, reduce STI, and change the social environment among sex workers in Brazil

Investigating combination HIV prevention: Isolated interventions or complex system

World Health Organization. Ottawa Charter for Health Promotion

Hepatitis B testing and diagnosis experiences of patients and primary care professionals in Australia

Managing chronic hepatitis B: The role of the GP

Informing the design of a national screening and treatment programme for chronic viral hepatitis in primary care: Qualitative study of at-risk immigrant communities and healthcare professionals

Hepatitis B screening in Asian and Pacific Islanders: New guidelines, old barriers

Improving access to immunisation for migrants and refugees: Recommendations from a stakeholder workshop

Hepatitis B awareness and knowledge in Asian communities in British Columbia

Improving access to health care for chronic hepatitis B among migrant Chinese populations: A systematic mixed methods review of barriers and enablers

Australian Immunisation Handbook: Vaccination for Migrants, Refugees and People Seeking Asylum in Australia

Screening for infectious diseases among newly arrived migrants in EU/EEA countries-Varying practices but consensus on the utility of screening