Healthcare Provider-Led Education Among Most Effective Strategies for HBV Testing

New research is providing novel insight into the most effective strategies for increasing hepatitis B virus (HBV) testing uptake to aid elimination efforts.¹

Findings from the systematic review and meta-analysis call attention to the value of healthcare provider-led education, decentralized testing, and leveraging framework-driven mechanisms for promoting HBV testing in primary and community care settings, providing actionable insights into real-world effectiveness and implementation challenges to guide future testing programs toward achieving elimination goals.¹

The World Health Organization estimates 254 million people were living with chronic hepatitis B infection in 2022, with 1.2 million new infections occurring each year. As of 2022, 13% of all people estimated to be living with hepatitis B were aware of their infection. Of those living with chronic hepatitis B, 3% (7 million) were receiving treatment, underscoring the need for implementation strategies to expand chronic hepatitis B testing and subsequent treatment and elimination.^1,2

“Various strategies have been tested and implemented to optimize the general CHB care cascade,” Thanh Kim, MD, MSPH, of Johns Hopkins School of Medicine and the department of epidemiology at Pham Ngoc Thach University of Medicine in Vietnam, and colleagues wrote.¹ “However, a notable knowledge gap persists in understanding the effectiveness of implementation strategies aimed explicitly at CHB testing in the context of primary and community care settings. Importantly, further synthesis of strategy specifications (i.e., components or mechanisms) and their implementation outcomes appears necessary to strengthen the contextualization of meta-analytic effectiveness findings.”

To determine the effectiveness of community-based and primary care-based implementation strategies for promoting chronic HBV testing, investigators conducted a systematic review and meta-analysis searching Scopus, Embase, PubMed, and CINAHL databases up to June 5, 2024, for randomized controlled trials investigating primary- and community-care-based implementation strategies promoting testing. Studies considered most relevant to the following preliminary criteria were identified:

• Conducted on populations who were recommended for chronic HBV testing
• Conducted in primary care and community care settings
• Using community-based and primary care-based implementation strategies
• The primary outcome was HBsAg testing uptake in patients (self-reporting or confirmed diagnosis by chart validation or proof of testing) and the secondary outcome was the uptake of tests for diagnosing hepatitis B immunity and linkage to care
• Randomized controlled trials and cluster randomized trials

The outcome measure was the proportion of chronic hepatitis B testing among those who were recommended for testing. The effect measure of effectiveness was the risk difference (RD), representing the absolute incremental increase in the proportion tested.¹

Investigators employed the Behavior Change Wheel (BCW) framework to characterize components within implementation strategies into strategy functions and sources of behavior to be included in qualitative and quantitative analyses, facilitating a deeper understanding of the mechanisms behind each implementation strategy.¹

Of an initial 8652 results identified by investigators, 25 studies with 130,598 participants were included in the review after removing duplicates and screening titles and abstracts. After full-text screening, 19 studies with 34,925 participants were included in 5 meta-analyses and 2 meta-regression because their implementation strategies and outcomes could be directly compared to ≥ 1 other included study.¹

Investigators noted 10 (40%) studies were conducted at primary care clinics, 12 (48%) were clustered randomized trials, and 10 (40%) reported implementation outcomes such as fidelity, adoption, contamination, or cost-effectiveness. Additionally, they pointed out none of the included studies were conducted in low- or middle-income countries.¹

In the community care setting, most implementation strategies involved education and persuasion as strategy functions (84% and 76%, respectively) and psychological capability and reflective motivation as targeted sources of behavior (84% and 84%, respectively). In the primary care setting, environmental restructuring to increase physical opportunity had a central role (100% and 90%, respectively).¹

Community-Based Strategies

A total of 10 studies involving 7451 participants investigated the effectiveness of a lay health workers-led education strategy in which lay health workers without clinical training provided chronic hepatitis B- or liver cancer-related education in the community. When pooled together in the meta-analysis, this strategy showed a 27.9% (95% CI, 3.4 to 52.4%) increase in chronic HBV testing uptake with large heterogeneity (I2 = 99.3%) compared with control arms.¹

Additionally, 2 studies with 1308 participants tested an approach in which educational HBV content was crowdsourced and delivered on social media. Meta-analysis results showed a minimal increase in HBV testing by 3.1% (95% CI, −2.2 to 8.4%, I2 = 0.0%).¹

Primary-Care Based Strategies

Investigators also described 4 studies involving 24,254 patients that assessed the effectiveness of electronic reminders for promoting chronic HBV testing uptake in primary care clinic settings. The pooled RD was 8.4% (95% CI, 3.7 to 13.1%) with large heterogeneity (I2 = 95.0%).¹

Another 2 trials involving 1912 participants applied a model in which HCPs provided HBV education and decentralized testing. Meta-analysis results showed a pooled RD of 62.5% (95% CI, 53.1 to 71.9%) with minimal heterogeneity (I2 = 27.5%).¹

Multicomponent Strategies

Investigators conducted mixed-effect meta-regression analyses to determine the association between the number of implementation strategy mechanisms and the effectiveness in promoting HBV testing uptake. They noted this analysis was only performed for the community-based lay health workers-led strategy.¹

Results showed the number of targeted sources of behavior had a dose-response relationship with testing uptake, with a 23.8% (95% CI, 14.6 to 33.0; R2 = 84.6%) increase in effectiveness per additional source of behavior targeted. Investigators called attention to a 17.9% (95% CI 1.6–34.1%, R2 = 59.2) increase in effectiveness for every additional function included in the implementation strategy.¹

Limitations, Implications

Investigators outlined multiple limitations to these findings, including the unintentional exclusion of studies from low- and middle-income countries due to language barriers and an overall lack of published studies from these areas; the large heterogeneity in some strategies; and the potential lack of generalization.¹

“Taken together, the findings of the study provide valuable insights for policymakers, healthcare providers, and researchers involved in CHB elimination efforts,” investigators concluded.¹

References

1. Van Kim T, Ngoc Doan Pham T, Phan P, et al. Effectiveness and implementation of decentralized, community- and primary care-based strategies in promoting hepatitis B testing uptake: a systematic review and meta-analysis. eClinicalMedicine. doi:10.1016/j.eclinm.2024.102818
2. World Health Organization. Hepatitis B. Newsroom. April 9, 2024. Accessed September 26, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b