Cultural Comic Books for Educating Asian Americans about Hepatitis B

There’s the story of a young Chinese American couple planning on getting married, but on the day of the proposal the bride-to-be confesses to her fiance that she has hepatitis B. Then there’s the one about a Korean immigrant family in which the father, who prefers traditional Asian medicine over Western medicine, discovers that his brother has liver cancer. Lastly, there’s the story of a Vietnamese American nail salon owner whose husband is diagnosed with hepatitis B, which was probably contracted by sharing razors with an infected roommate in college. No, these are are not vignettes from an Asian American film about coincidence.* These are cautionary tales used in cultural, comic book-like photonovels that were developed to raise hepatitis B awareness among Asian Americans–the racial/ethnic group with the greatest risk of contracting hepatitis B.

chinese couple

“I have something important to tell you. Actually, i have chronic hepatitis B infection.”
“What? Why didn’t you tell me earlier?”

Hepatitis B is an infectious liver disease caused by the hepatitis B virus and is spread through contact with bodily fluids such as blood, semen, or vaginal fluids. It can also be passed from mother to child during childbirth. Contracting the virus can lead to either acute infection with symptoms that include liver inflammation, jaundice, fever, and nausea lasting several weeks or chronic infection, which may not present with symptoms but is a leading cause of life-threatening conditions such as cirrhosis (scarring of the liver) and liver cancer. Hepatitis B, however, is treatable and preventable through limiting exposure (i.e. not sharing needles, safe sex, etc.) and vaccinations.

ChronicHepatitisB_350px (1)

(image from CDC website)

Asian Americans, particularly recent immigrants, are especially vulnerable to hepatitis B infection because hepatitis B is endemic in many countries from which Asian Americans originate and Asian Americans have low rates of hepatitis B screening and vaccination. As a result, according to the CDC, of the estimated 1 million Americans with chronic hepatitis B about half are from the Asian/Pacific Islander (API) communities. For comparison, Asian Americans make up roughly 5% of the US population. Nearly 1 in 12 Asian Americans are chronically infected with hepatitis B, but many are unaware of their status. This further poses a public health risk since infected individuals can unknowingly spread the virus.

The low rates of hepatitis B screening and vaccination in the Asian American community may be due to a combination of barriers such as hepatitis B awareness, fluency in English, access to healthcare, and cultural beliefs and norms surrounding disease and medicine. To overcome some of these obstacles culturally-appropriate photonovels can be used to increase the effectiveness of a public health message. These are educational materials that use images of ethnic characters, cultural issues, and language to tell a story that is highly relatable to a target community. Photonovels, for instance, have been used with success to educate immigrant Latino communities on various health issues. The effectiveness of photonovels, however, have not been addressed for diverse Asian American communities which have do not have a unifying language such as Spanish for Latino communities.

korean family

“I’ve been feeling so drained these days, but now I’m much better, owing to my stone bed.”
“I should make you feel better. It cost us more than $2000!”

Faced with this obstacle, Sunmin Lee and her colleagues at the University of Maryland School of Public Health and Johns Hopkins Bloomberg School of Public Health developed three photonovels in Korean, Chinese, and Vietnamese languages with the help of focus groups from those communities. These focus groups aided in incorporating not only characters and simplified language into the photonovels, but also identifiable cultural norms such as the stigma of having a disease, misconceptions of traditional medicine and Western medicine, and the idea of luck and misfortune that surrounds disease.


Summary of the storylines for each photonovel. Click for larger image. (Lee S. et al., 2013)

These photonovels were used as one component of a 90-minute hepatitis B educational program consisting of a video, slideshow presentation, and a Q&A session aimed at increasing hepatitis B screening rates to decrease the incidence of liver cancer among Asian American communities. A follow-up survey of participants was conducted a month after the educational program was delivered to evaluate the photonovel. A clear majority (nearly 90%) of survey respondents agreed or strongly agreed that the photonovels presented useful and easy-to-understand information on hepatitis B screening for liver cancer prevention. A similar majority of respondents also found that the stories were written by someone who was familiar with their respective communities (~77%) and a good teaching tool (over 80%). Perhaps most importantly, the authors of the study found that individuals who had never been screened for hepatitis B or were unaware of their infection status and who had evaluated the photonovels positively were more likely to indicate that they felt capable of and intended to undergo hepatitis B screening.

Furthermore, when the authors analyzed the responses based on income and education they found that individuals with less education and on the lower end of the income scale were more likely to evaluate the photonovels positively. Interestingly, when broken down by specific communities, Vietnamese respondents were most favorable overall towards the photonovels compared to their Korean and Chinese counterparts. Vietnamese participants also tended to be less highly educated, so the authors speculate that educational materials such as photonovels that rely on pictures more than text might be an effective strategy for this demographic. However, since the photonovels were all different it could be the case that the Vietnamese photonovel just happened to be better developed than the Korean or Chinese  photonovels and, therefore, more effective for the Vietnamese community.

vietnamese couple

“…Oh, by the way, honey, why were you mad at Aunt Mai?”
“She kept talking about liver infection and cancer! That’s so unlucky!”

The study, however, is not without its limitations. To start, it is a relatively small study of 347 survey respondents. The authors also caution that since their target population was not easily reached, participants were recruited through community organizations rather than through a random selection process. As such, the groups analyzed may not be representative of Asian American communities in the US. Additionally, the photonovels were one component of a larger educational program. Exposure to the 90-minute presentation may have primed the participants to read and understand the photonovels. It would be good to know how effective the photonovels are independent of the presentation as well as how it compares to educational materials that are more text-dependent or written in English. Lastly, to determine if this campaign effectively translates into higher hepatitis B screening rates, it would be essential to know how many of the participants ultimately underwent hepatitis B screening. As it stands, the survey only asked if the participicants felt capable of undergoing a hepatitis B screening and what their likelihood of undergoing a screening.

Despite its shortcomings, the positive reaction of the Korean, Chinese, and Vietnamese participants to the photonovels is encouraging. The study, although small, suggests that culturally appropriate photonovels may be an effective strategy for increasing hepatitis B awareness and lowering the liver cancer rates in the rapidly growing Asian American community. In fact, the Vietnamese photonovel won the Health Education Materials Contest Award in the Printed Category at 2011 American Public Health Association Meeting.**  The study’s methods in consulting focus groups also provides a template for designing future public health education campaigns targeting other immigrant and at-risk populations.

In the meantime, if you’re Asian American don’t let the stigma of having a disease, traditional medicine, or the taboo of discussing illness stop you from getting screened for hepatitis B. Your liver might thank you for it later.

The photonovels are available as pdf here.

*Speaking of coincidence, May is Asian-Pacific American Heritage Month and Hepatitis Awareness Month.

** Post updated 5/26/13.


Lee S., Yoon H., Chen L. & Juon H.S. (2013). Culturally Appropriate Photonovel Development and Process Evaluation for Hepatitis B Prevention in Chinese, Korean, and Vietnamese American Communities., Health education & behavior : the official publication of the Society for Public Health Education, PMID:

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3 Responses to Cultural Comic Books for Educating Asian Americans about Hepatitis B

  1. Marc says:

    I’m curious what your take is about these “comics” as a highly educated Vietnamese man yourself who doesn’t necessarily fall into the demographic polled. Does the use of a stereotypical Vietnamese salon owner scenario bother you? Or does the fact that the ad goes over well within the Vietnamese community polled mean that the ad’s effective message outweighs any borderline stereotyping?

    • Viet Le says:

      Hi Marc, thanks for the question. When I originally started writing this post I had considered touching on the issue of using stereotypes in public health education, but ultimately decided against it.

      It doesn’t bother me because the context (health education) and audience (Asian American immigrants) is much different than when stereotypes are used in the media and entertainment. In those cases, Asian (American) characters are often shallow depictions defined by their stereotypes. I read the Vietnamese photonovel scenario less as a stereotype and more as a snapshot of the immigrant experience for Vietnamese Americans who happen to be nail salon owners. This was aided by the fact that the language and cultural issues the photonovel touches on are genuine and easily recognizable so that targeted readers can easily envision themselves in the story. So, although I am not the demographic targeted I still could relate to the story. The fact is there are members of my extended family who are recent immigrants to the US and either work in nail salons or are nail salon owners themselves. Furthermore, the characterization of disease as misfortune is something that I have witnessed in conversations within my community. In fact, even the topics of traditional medicine and the stigma of having disease featured in the Korean and Chinese American stories crossover into Vietnamese culture as well.

      I suppose you could worry that the depictions are of Asians being ignorant or that all Asians are infected with hepatitis (as one person on Twitter was worried about), but again, here I think you have to think about the target audience.

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