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Purpose: Strengthening healthcare professionals' (HCPs) communication is an evidence-based approach to increasing human papillomavirus (HPV) vaccine uptake among adolescents. To better target future interventions, we sought to synthesize evidence on HCP subgroups who most need to improve their HPV vaccine recommendation quality., Methods: We searched five databases for quantitative studies published from 2012 to 2022 on HPV vaccine recommendation quality, including recommendation consistency and strength, for United States adolescents. Two coders independently abstracted data from each eligible study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We summarized variation in recommendation quality by clinical and HCP characteristics., Results: The 28 eligible studies indicated that relatively low proportions of HCPs used higher-quality recommendation practices (median: 61% across 30 measures) and that recommendation quality varied across HCP subgroups. The most consistent findings were that more pediatric HCPs used higher-quality recommendations than family medicine HCPs (8 of 11 studies, 2-60 percentage point difference) and that HPV-related knowledge was associated with higher recommendation quality (four of seven studies). Most studies observed no differences in recommendation quality by clinical role (e.g., provider vs. nurse) or HCP demographics (e.g., gender, age, race/ethnicity)., Discussion: Studies suggest a substantial need to improve HCPs' recommendation quality, with opportunities for targeting future interventions., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Adolescent human papillomavirus (HPV) vaccine uptake in the United States dropped during the COVID-19 pandemic due to a decrease in well visits. This study sought to identify opportunities for primary care professionals (PCPs) to get adolescent vaccination back on track., Methods: In early 2021, we recruited 1,047 PCPs (71% physicians) who provided adolescent vaccines in the United States from an existing panel. Participants completed an online survey about changes in adolescent HPV vaccine uptake and actions taken to promote vaccination during the pandemic, as well as intentions to engage in activities to increase adolescent vaccination in the next 3 months., Results: A substantial proportion of PCPs (43%) reported that HPV vaccine uptake decreased in the first year of the pandemic; few (7%) PCPs reported an increase in uptake. PCPs reporting increased uptake were more likely to have used nurse-only vaccination visits, held drop-in and drive-through vaccination clinics, and used telehealth visits to recommend vaccination (all p < .05). Nearly two-thirds (62%) of all PCPs planned to promote adolescent vaccine uptake in the next 3 months. Planning was more common among PCPs who believed HPV vaccine uptake at their clinics increased during the pandemic, who saw more than 10 adolescent patients per week, who had ever reviewed their clinic's vaccination rates, and were nurses (all p < .05)., Discussion: Many PCPs saw HPV vaccination drop during the pandemic. Several interventions could help clinics get HPV vaccination back on track, including increasing the availability of nurse-only vaccination visits and vaccination-only clinics., (Copyright © 2023 Society for Adolescent Health and Medicine. All rights reserved.)

Competing Interests: Declaration of interests The Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA is cohosted by the Yale Institute for Global Health and the Baylor College of Medicine. All authors are Commissioners. PJH is a developer of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E, a commercial vaccine manufacturer for scale-up, production, testing, and licensure. NTB reports personal fees from WHO, Centers for Disease Control and Prevention, Sanofi, and Merck outside of the submitted work. RMC reports receiving research grant funding from Novo Nordisk Foundation (Denmark), outside of the submitted work. RL reports grants from Pfizer, GlaxoSmithKline, Sanofi Pasteur, and Merck, and personal fees from BIO, outside of the submitted work. YAM is a member of a Data Safety Monitoring Board for Pfizer and is a site Principal Investigator for a Pfizer vaccine trial, outside the submitted work. MMM reports personal fees from law firms representing retail pharmacies, generic drug companies, and a health insurer that have sued branded drug companies for marketing and antitrust law violations, outside of the submitted work, and serves as an adviser to Verily Life Sciences on a mobile app designed to facilitate safe return to work and school during COVID-19. DJO reports grants from the US National Institutes of Health, outside the submitted work. DAS reports personal fees from Pfizer, Janssen, and Moderna, is on advisory boards and receives compensation from these companies for time attending meetings, and reports grants from Merck, outside of the submitted work. All other authors declare no competing interests.

Competing Interests: Declaration of interests PJH is a developer of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E, a commercial vaccine manufacturer for scale-up, production, testing, and licensure. NTB reports personal fees from WHO, CDC, and Merck, outside the submitted work. RMC reports receiving research grant funding from Novo Nordisk Foundation (Denmark), outside the submitted work. RL reports grants from Pfizer, GlaxoSmithKline, Sanofi Pasteur, and Merck, and personal fees from BIO, outside the submitted work. YAM is a member of a data safety monitoring board for Pfizer and a site principal investigator for a Pfizer vaccine trial, outside the submitted work. MMM reports personal fees from law firms representing retail pharmacies and generic drug companies that have sued other drug companies for antitrust law violations, outside the submitted work, and serves as an adviser to Verily Life Sciences on an app designed to facilitate safe return to work and school during the COVID-19 pandemic. DJO reports grants from the US National Institutes of Health, outside the submitted work. DAS reports grants from Merck and personal fees from Pfizer and Janssen, outside the submitted work. All other authors declare no competing interests.

Competing Interests: Declaration of interests PJH is a developer of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E, a commercial vaccine manufacturer for scale-up, production, testing, and licensure. NTB reports personal fees from WHO, US national Centers for Disease Control and Prevention, and Merck outside the submitted work. RMC received research grant funding from Novo Nordisk Foundation, outside the submitted work. RL reports grants from Pfizer, GlaxoSmithKline, Sanofi Pasteur, and Merck, and personal fees from BIO and the Infectious Disease Prevention Network, outside the submitted work. YAM is a member of a data safety monitoring board for Pfizer and a site Principal Investigator for a Pfizer vaccine trial, outside the submitted work. MMM reports personal fees from law firms representing retail pharmacies and generic drug companies that have sued other drug companies for antitrust law violations, outside the submitted work, and served as an advisor to Verily Life Sciences on an app designed to facilitate safe return to work and school during the COVID-19 epidemic. DJO reports grants from the US National Institutes of Health, outside the submitted work. DAS reports grants from Merck and personal fees from Pfizer and Janssen, outside the submitted work. The other authors declare no competing interests.

Background: Community pharmacists are often the most accessible health professional in rural areas, which makes them well positioned to increase vaccine access in their communities. This study sought to document rural pharmacists' ability to and interest in administering coronavirus disease 2019 (COVID-19) vaccinations., Methods: A sample of community pharmacists participating in a rural community pharmacy practice-based research network in the United States completed an online survey that assessed (1) demographic characteristics, (2) previous COVID-19 vaccine training, and (3) ability to administer COVID-19 vaccines. Data were collected between late December 2020 and mid-February 2021. Descriptive statistics and correlations were calculated., Results: A total of 69 of 106 pharmacists completed the survey (response rate = 65%). Approximately half of pharmacists were ready (52%) or actively taking steps (39%) to provide COVID-19 vaccines in the next 6 months. Pharmacies had a median of 2 staff members who were authorized to administer COVID-19 vaccines. Almost half (46%) estimated they could administer more than 30 vaccinations per day. Most pharmacies could store vaccines at standard refrigeration (90%) and freezing (83%) levels needed for thawed and premixed vaccines, respectively. Most pharmacists planned to access COVID-19 vaccines through an agreement with a state or local public health entity (48%) or by ordering through group purchasing organizations (46%). Only 23% of pharmacists had received any COVID-19 vaccine training, and only 48% very much wanted to get the vaccine themselves. Several variables, including pharmacy type and pharmacists' vaccine attitudes and previous COVID-19 training, were significantly associated (P < 0.05) with the anticipated number of COVID-19 vaccines pharmacies could administer daily., Conclusion: Even early in the nation's COVID-19 vaccine rollout, most rural pharmacies were interested in and preparing to administer COVID-19 vaccines. Few rural pharmacists had received COVID-19 training, and many expressed some hesitancy to receive the vaccine themselves. The number of vaccines pharmacists could administer varied with pharmacy and pharmacist characteristics., (Copyright © 2022 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objective: Several US health organizations, including the American Academy of Pediatrics, now encourage primary care professionals to recommend human papillomavirus (HPV) vaccination before the traditionally targeted ages of 11 to 12 years as a strategy to increase vaccination timeliness. To understand the feasibility of this approach, we sought to evaluate primary care professionals' current recommendation timing and willingness to recommend HPV vaccination at age 9., Methods: A national sample of 1047 primary care professionals completed our online survey in 2021. Respondents were physicians (71%), advanced practitioners (17%), and nurses (12%)., Results: About one-fifth (21%) of primary care professionals reported that they already routinely recommend HPV vaccination at ages 9 to 10. Among the remaining 822 respondents, over half (61%) reported being somewhat or more willing to start recommending at age 9. Willingness was higher among those working in family medicine versus pediatrics (adjusted odds ratio [aOR]: 1.40, 95% confidence interval [CI] 1.03, 1.92), but lower among those with ≥20 years of practice experience versus ≤9 years (aOR: 0.65, 95% CI 0.44, 0.96). Many primary care professionals believed age 9 recommendations would have the advantage of protecting adolescents before HPV exposure (67%) or increasing vaccination timeliness (55%). The most commonly perceived disadvantage was that parents are not ready to talk about HPV vaccination at age 9 (73%)., Conclusion: Over two-thirds of primary care professionals in our national sample reported they recommend HPV vaccination at ages 9 to 10 or are somewhat or more willing to do so. Training may be needed to help primary care professionals address perceived parental hesitancy toward age 9 recommendations., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Since the first case of COVID-19 was identified in the USA in January, 2020, over 46 million people in the country have tested positive for SARS-CoV-2 infection. Several COVID-19 vaccines have received emergency use authorisations from the US Food and Drug Administration, with the Pfizer-BioNTech vaccine receiving full approval on Aug 23, 2021. When paired with masking, physical distancing, and ventilation, COVID-19 vaccines are the best intervention to sustainably control the pandemic. However, surveys have consistently found that a sizeable minority of US residents do not plan to get a COVID-19 vaccine. The most severe consequence of an inadequate uptake of COVID-19 vaccines has been sustained community transmission (including of the delta [B.1.617.2] variant, a surge of which began in July, 2021). Exacerbating the direct impact of the virus, a low uptake of COVID-19 vaccines will prolong the social and economic repercussions of the pandemic on families and communities, especially low-income and minority ethnic groups, into 2022, or even longer. The scale and challenges of the COVID-19 vaccination campaign are unprecedented. Therefore, through a series of recommendations, we present a coordinated, evidence-based education, communication, and behavioural intervention strategy that is likely to improve the success of COVID-19 vaccine programmes across the USA., Competing Interests: Declaration of interests The Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA is co-hosted by the Yale Institute for Global Health (New Haven, CT) and the Baylor College of Medicine (Houston, TX). PJH is a developer of a COVID-19 vaccine construct that was licensed by the Baylor College of Medicine to Biological E, a commercial vaccine manufacturer, for scale-up, production, testing, and licensing. NTB reports personal fees from WHO, Centers for Disease Control and Prevention, and Merck, outside the submitted work. RMC reports research grant funding from the Novo Nordisk Foundation outside the submitted work. RL reports grants from Pfizer, GlaxoSmithKline, Sanofi Pasteur, and Merck; and personal fees from Biotechnology Innovation Organization, outside the submitted work. YAM is a member of a Data Safety Monitoring Board for Pfizer and a site principal investigator for a Pfizer vaccine trial unrelated to the submitted work. MMM reports personal fees from law firms representing retail pharmacies and generic drug companies that have sued other drug companies for anti-trust law violations, outside the submitted work. DJO reports grants from the US National Institutes of Health outside the submitted work. DRR reports that herself, her spouse, and her children own stocks in GlaxoSmithKline, a vaccine manufacturer. DRR also reports serving in an unpaid volunteer capacity on Moderna's ethics allocation committee. DAS reports grants from Merck and personal fees from Pfizer, outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The World Health Organization and global partners sought to identify existing measures of confidence in childhood vaccines, as part of a broader effort to measure the range of behavioural and social drivers of vaccination. We identified 14 confidence measures applicable to childhood vaccination in general, all published between 2010 and 2019. The measures examined 1-5 constructs and included a mean of 12 items. Validation studies commonly examined factor structure, internal consistency reliability, and criterion-related validity. Fewer studies examined convergent and discriminant validity, test-retest reliability, or used cognitive interviewing. Most measures were developed and validated only in high-income countries. These findings highlight the need for a childhood vaccine confidence measure validated for use in diverse global contexts., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Behavioral science offers several ideas about what it takes to get people to vaccinate. Colleagues and I previously reviewed the evidence for these propositions and put forward what has become known as the Increasing Vaccination Model. To make the model more accessible to practitioners, the current paper summarizes the main insights from the earlier work. First, observational studies show clearly that thoughts and feelings are correlated with vaccine uptake. Such constructs include perceived risk of harm from infectious disease and confidence in vaccine safety and efficacy. However, interventions have not generally shown that changing thoughts and feelings increases vaccine uptake. Second, social processes are promising in observational studies. Such constructs include social norms, altruism, and sharing through social media. More research is needed in this promising area before it will be possible to conclude whether social processes are effective intervention targets. Third, interventions that directly change behavior-without trying to change what people think or feel or their social experience-are reliably effective ways to increase vaccine uptake. Such interventions include reminders, defaults, and vaccine requirements. Finally, the most potent intervention for increasing vaccine uptake is a health care provider recommendation, but it is still unclear whether such recommendations are effective because they increase confidence, set a social norm, or reflect a direct behavior change technique. The paper ends by describing use of the model by a World Health Organization working group as it considers opportunities to address low vaccination uptake globally., (Copyright © 2021 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: We sought to establish which human papillomavirus (HPV) vaccine communication approaches by pediatricians were associated with same-day HPV vaccination of 11- to 12-year-olds by evaluating audio recordings of visits., Methods: Verilogue, a market research company maintaining a panel of primary care pediatricians, provided audio recordings and transcriptions of well-child visits for 11- to 12-year-old patients from January through June 2013. Seventy-five transcripts from 19 pediatricians were coded for use of presumptive language (i.e., words conveying assumption of vaccine delivery), offer of delay, recommendation strength, and information provision. Using logistic regression, we evaluated the association between pediatrician communication approaches and agreement to same-day HPV vaccination. Generalized estimating equations accounted for clustering of patients within pediatricians., Results: Same-day agreement to HPV vaccination occurred in 29% of encounters. Pediatricians in the sample often provided parents with inconsistent, mixed messages and sometimes offered information about HPV or HPV vaccination that was inaccurate. Pediatricians used presumptive language in only 11 of 75 encounters; when used, presumptive language was associated with higher odds of accepting HPV vaccine (73% vs. 22%; odds ratio = 8.96; 95% confidence interval = 2.32-34.70). Pediatricians offered or recommended delay in most encounters (65%). HPV vaccine acceptance occurred far more often when pediatricians did not mention delaying vaccination (82% vs. 6%; odds ratio = 80.84; 95% confidence interval = 15.72-415.67). Same-day vaccination was not associated with strength of recommendation or pediatrician reference to vaccinating their own children., Conclusions: Our findings highlight the need to develop and evaluate physician-focused trainings on using presumptive language for same-day HPV vaccination., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation among adults. However, little is known regarding adolescents' responses to pictorial warnings, particularly in real-world settings., Methods: Participants were 112 adolescent children, ages 13-17, whose parents received either text-only warnings on the side of their cigarette packs or pictorial warnings on the top half of the front and back of their cigarette packs for 4 weeks as part of a trial. We measured adolescents' recall and recognition of these warnings, negative emotional reactions to the warnings, perceived effectiveness of the warnings, social interactions about the warnings, and smoking risk beliefs., Results: Adolescents accurately recalled pictorial warnings more often than text-only warnings (82% vs. 19%, p < .001). Recognition of warnings was also higher for pictorial than text-only warnings (82% vs. 34%, p < .001). Pictorial warnings drew greater attention (p < .001), elicited greater negative emotional reactions (p < .05), and sparked more social interactions (p < .01) than text-only warnings., Conclusions: Pictorial warnings on cigarette packs may have important effects on adolescent children of smokers. Future research should further investigate the impact of such messages on adolescents' susceptibility to smoking initiation and interest in quitting smoking, particularly as the United States and other countries work to implement pictorial warning regulations., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To validate a brief measure of vaccination confidence using a large, nationally representative sample of parents., Methods: We analyzed weighted data from 9018 parents who completed the 2010 National Immunization Survey-Teen, an annual, population-based telephone survey. Parents reported on the immunization history of a 13- to 17-year-old child in their households for vaccines including tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal, and human papillomavirus vaccines. For each vaccine, separate logistic regression models assessed associations between parents' mean scores on the 8-item Vaccination Confidence Scale and vaccine refusal, vaccine delay, and vaccination status. We repeated analyses for the scale's 4-item short form., Results: One quarter of parents (24%) reported refusal of any vaccine, with refusal of specific vaccines ranging from 21% for human papillomavirus to 2% for Tdap. Using the full 8-item scale, vaccination confidence was negatively associated with measures of vaccine refusal and positively associated with measures of vaccination status. For example, refusal of any vaccine was more common among parents whose scale scores were medium (odds ratio, 2.08; 95% confidence interval, 1.75-2.47) or low (odds ratio, 4.61; 95% confidence interval, 3.51-6.05) versus high. For the 4-item short form, scores were also consistently associated with vaccine refusal and vaccination status. Vaccination confidence was inconsistently associated with vaccine delay., Conclusions: The Vaccination Confidence Scale shows promise as a tool for identifying parents at risk for refusing adolescent vaccines. The scale's short form appears to offer comparable performance., (Copyright © 2016 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Electronic cigarette (e-cigarette) use now surpasses the use of conventional cigarettes among U.S. adolescents. Given the important role of physicians in preventing adolescent risk behaviors, we sought to understand how physicians communicate about e-cigarettes when counseling adolescent patients and their parents. We also explored physicians' support for regulations aimed at discouraging adolescents' e-cigarette use., Methods: A national U.S. sample of 776 pediatricians and family medicine physicians who provide primary care to adolescent patients completed an online survey in Spring 2014., Results: Many physicians (41%) would, if asked, tell their patients that e-cigarettes are less harmful than cigarettes, and a substantial minority (24%) would recommend e-cigarettes to adolescents for smoking cessation. Most physicians reported routinely screening adolescent patients for cigarette smoking but few routinely screened for e-cigarette use (86% vs. 14%; p < .001). Routine counseling was similarly more common for avoiding cigarette smoking than for avoiding e-cigarette use (79% vs. 18%; p < .001). Support for government regulation of e-cigarettes was high, with 91% of physicians endorsing policies that prevent minors from buying e-cigarettes., Conclusions: Physicians infrequently screen or counsel their adolescent patients about e-cigarette use, although e-cigarettes often come up during visits. Additional efforts by physicians could help prevent future use by adolescents. Recommending e-cigarettes as a smoking cessation aid to adolescent patients is inadvisable given the lack of evidence for efficacy in that population. As federal regulation of e-cigarettes remains in limbo, pediatricians and family medicine physicians can offer a powerful voice for informing regulations aimed at reducing use by adolescents., (Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Schools are increasingly a part of vaccine provision, because of laws mandating provision of information by schools about vaccination, school entry requirements, and mass vaccination campaigns. We examined preferences for programmatic aspects of voluntary school mass vaccination programs (i.e., "vaccination days")., Methods: We analyzed data from a national sample of United States parents of adolescent males ages 11-19 years (n = 308) and their sons (n = 216), who completed an online survey in November 2011., Results: Sons believed that adolescents should be able to get vaccinated without parental consent at a younger age than parents did (p < .001) and were more willing to participate in vaccination days without a parent present (p = .04). Parents perceived school vaccination days to be a more convenient way to get their sons recommended vaccines if they were younger parents, had older adolescent sons, supported laws letting schools share vaccination records with health care providers, or had sons who were previously immunized at school (all p < .05). Parents of older sons were less likely to want their sons' vaccination records sent home (odds ratio [OR] = .47; 95% confidence interval [CI], .29-.77) or to their sons' physicians (OR = .61; 95% CI, .37-.98) compared with parents of younger sons, but more likely to prefer their sons' records be entered in an immunization registry (OR = 1.66; 95% CI, 1.05-2.63)., Conclusions: Sons' age had an important role in support for vaccination days and preferences for sharing vaccination information with health care professionals. Parents and sons had similar beliefs about vaccination in schools, but the sons' responses suggested an interest in greater autonomy., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Electronic cigarettes (e-cigarettes) are a new type of device that delivers vaporized nicotine without the tobacco combustion of regular cigarettes. We sought to understand awareness of and willingness to try e-cigarettes among adolescent males, a group that is at risk for smoking initiation and may use e-cigarettes as a "gateway" to smoking., Methods: A national sample of 11-19-year-old males (n = 228) completed an online survey in November 2011. We recruited participants through their parents, who were members of a panel of U.S. households constructed using random-digit dialing and addressed-based sampling., Results: Only two participants (< 1%) had previously tried e-cigarettes. Among those who had not tried e-cigarettes, most (67%) had heard of them. Awareness was higher among older and non-Hispanic adolescents. Nearly 1 in 5 (18%) participants were willing to try either a plain or flavored e-cigarette, but willingness to try plain versus flavored varieties did not differ. Smokers were more willing to try any e-cigarette than nonsmokers (74% vs. 13%; OR 10.25, 95% CI 2.88, 36.46). Nonsmokers who had more negative beliefs about the typical smoker were less willing to try e-cigarettes (OR .58, 95% CI .43, .79)., Conclusions: Most adolescent males were aware of e-cigarettes, and a substantial minority were willing to try them. Given that even experimentation with e-cigarettes could lead to nicotine dependence and subsequent use of other tobacco products, regulatory and behavioral interventions are needed to prevent "gateway" use by adolescent nonsmokers. Campaigns promoting negative images of smokers or FDA bans on sales to youth may help deter use., (Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: We examined parents' and adolescents' preferences regarding potential strategies to increase human papillomavirus (HPV) vaccination rates, including offering the vaccine in alternative settings, concomitant administration of vaccines, and optimizing the structure of vaccination medical visits., Methods: A national sample of U.S. parents of adolescent boys aged 11-17 years (n = 506) and their sons (n = 391) completed online surveys in August and September 2010. We used analysis of variance for mixed designs to examine preferences for vaccination settings., Results: Parents and sons were most comfortable with sons receiving HPV vaccine in a doctor's office. Parents of sons who had not visited their regular health care providers in the past year were more comfortable with sons receiving HPV vaccine at a public clinic (p < .001) or school (p < .05) compared with parents whose sons had recent visits. Results from the son survey showed a similar pattern. Parents and sons reported moderate levels of acceptability of concomitant administration. They most preferred to have the three HPV vaccine shots administered during brief nurse visits., Conclusions: Offering HPV vaccine in alternative settings and administering it with other recommended adolescent vaccines may increase uptake among adolescent boys. Parents and sons may prefer HPV vaccines be administered during brief nurse visits., (Copyright © 2012 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Parent-child conversations about human papillomavirus (HPV) vaccine may provide parents with the opportunity to talk with their daughters about sexual health. We sought to characterize mothers' communication with their adolescent daughters about HPV vaccine., Methods: We surveyed 609 mothers of girls aged between 11 and 20 years living in North Carolina in Fall 2008. We used logistic regression to identify the correlates of mother-daughter communication., Results: Most mothers (81%) reported having discussed HPV vaccine with their daughters. For almost half of these families (47%), discussion of HPV vaccine led to a conversation about sex. This was more common among mothers who believed that their daughters may be sexually active (odds ratio [OR]: 1.88; 95% confidence interval [CI]: 1.25-2.83), had greater knowledge of HPV vaccine (OR: 2.46; 95% CI: 1.07-5.64), lived in urban areas (OR: 1.75; 95% CI: 1.21-2.54), or reported being born-again Christians (OR: 1.74; 95% CI: 1.17-2.58). Most mothers who talked with their daughters about HPV vaccine reported having discussed the reasons for and against getting vaccinated (86%). Mothers most commonly reported having discussed the potential HPV vaccine benefits, usually protection against cervical cancer (56%), and less frequently reported having discussed the perceived disadvantages of HPV vaccine., Conclusions: HPV vaccine conversations may provide opportunities for sexual health promotion and sexually transmitted infection (STI) prevention., (Copyright © 2011 Society for Adolescent Health and Medicine. All rights reserved.)

Purpose: To examine correlates of human papillomavirus (HPV) vaccine awareness and information sources in a state requiring schools to inform parents about HPV vaccine., Methods: Telephone survey of a North Carolina population-based sample of 696 parents of females aged 10-17 years about HPV vaccine awareness and information sources (daughters' schools, healthcare provider, drug company advertisements, news stories) was conducted., Results: Overall, 91% of parents had heard of HPV vaccine. Parents were more likely to be aware if they had household incomes of $50,000 or higher, were women, had non-Hispanic white daughters, or had daughters vaccinated against meningitis. Information sources included drug company advertisements (64%), healthcare providers (50%), news stories (50%), and schools (9%). Only parents who heard from their children's healthcare providers were more likely to initiate HPV vaccine for their daughters., Conclusions: Parents had rarely heard of the vaccine through schools. The only source associated with vaccine initiation was hearing from a healthcare provider.

Purpose: To assess availability of human papillomavirus (HPV) vaccine at medical practices in an area with elevated cervical cancer rates., Methods: During July-November 2007, we conducted a telephone survey of staff at medical practices providing outpatient care to 9- to 26-year-old females in four North Carolina counties with elevated cervical cancer rates. We assessed availability of HPV vaccine and concerns about its provision., Results: Staff from 71 of 96 eligible practices completed a full interview. Overall, 62% of these practices had HPV vaccine available to patients (family practice, 74%; pediatrics, 75%; obstetrics-gynecology, 64%; internal medicine, 15%). In multivariate analysis, practice characteristics that independently predicted a lower likelihood of carrying HPV vaccine were having at least 50% African-American patient population (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.06-0.63) and providing only privately purchased (and no state-supplied) vaccines (OR 0.19, 95% CI 0.06-0.63). HPV vaccine nonproviders were significantly more likely than HPV vaccine providers to report "large" concerns about the up-front costs of purchasing HPV vaccine (52% vs. 27%, p < .05) and late reimbursement (33% vs. 14%, p < .05)., Conclusions: Approximately 1 year after its introduction, HPV vaccine was available at three-quarters of family practice and pediatrics practices, two-thirds of obstetrics-gynecology practices, and few internal medicine practices in an area with elevated cervical cancer rates. Practices' concerns about cost and reimbursement have implications for accessibility of HPV vaccine to those who need it most.

Purpose: We assessed human papillomavirus (HPV) vaccination of adolescent girls living in communities with elevated cervical cancer rates., Methods: During July to October 2007, we conducted interviews with a probability sample of parents (or guardians) of 10- to 18-year-old girls in five North Carolina counties with cervical cancer rates substantially higher than the national average. Estimates are weighted., Results: We interviewed 889 (73%) of 1220 eligible parents; 38% were black. Overall, 10.3% (95% confidence interval [CI] 7.7%-13.5%) of daughters had received at least 1 dose of HPV vaccine. Only 6.4% of 10- to 12-year-olds had initiated vaccination, versus 17.5% of 16- to 18-year-olds (odds ratio [OR] 3.1, 95% CI 1.4-6.9). Older age of daughters and doctor's recommendation were the only factors independently associated with vaccine initiation. Main reasons reported for not initiating HPV vaccine were: needing more information (22%) or never having heard of the vaccine (14%), believing daughter is too young (16%) or not yet sexually active (13%), and not having gone to the doctor yet (13%). Only 0.5% of parents cited concern about HPV vaccine making a teenage girl more likely to have sex as a main reason for not vaccinating. Of 780 parents with unvaccinated daughters, 62% reported their daughters "probably" or "definitely" will, and 10% reported their daughters "definitely won't" get HPV vaccine in the next year., Conclusions: Approximately 1 year after its introduction, HPV vaccine had been initiated by only 10% of adolescent girls in an area with elevated cervical cancer rates; however, most parents intended for their daughters to be vaccinated. Additional efforts are needed to ensure that parents' intentions to vaccinate are realized.

Purpose: Potential barriers to widespread vaccination of adolescent girls against human papillomavirus (HPV) infection are poorly understood. We provide an overview of potential barriers to provision of HPV vaccine and empirical data on the concerns of medical practices that may inhibit HPV vaccine provision., Method: We conducted phone interviews with medical practices in rural areas in southeastern North Carolina with high rates of cervical cancer to assess 10 potential concerns about HPV vaccine provision., Results: Concerns most commonly reported by medical practices (N = 71) were inadequate reimbursement (68%), high cost of the vaccine to patients (66%), and burden of determining insurance coverage (66%). Practices that were not providing the vaccine reported more concerns about HPV vaccine provision on average than practices providing the vaccine (6.0 vs. 4.5 concerns, p < .05)., Conclusions: Medical practices' concerns about the HPV vaccine may be barriers to stocking it and, thus, to providing it to adolescents. Even providers who stock the vaccine reported concerns. Research is needed to address ways to ameliorate these medical practices' concerns and also to understand other potential barriers to vaccine coverage.

Research has shown that judgments tend to assimilate to irrelevant "anchors." We extend anchoring effects to show that anchors can even operate across modalities by, apparently, priming a general sense of magnitude that is not moored to any unit or scale. An initial study showed that participants drawing long "anchor" lines made higher numerical estimates of target lengths than did those drawing shorter lines. We then replicated this finding, showing that a similar pattern was obtained even when the target estimates were not in the dimension of length. A third study showed that an anchor's length relative to its context, and not its absolute length, is the key to predicting the anchor's impact on judgments. A final study demonstrated that magnitude priming (priming a sense of largeness or smallness) is a plausible mechanism underlying the reported effects. We conclude that the boundary conditions of anchoring effects may be much looser than previously thought, with anchors operating across modalities and dimensions to bias judgment.