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OBJECTIVE: Optimizing a self-persuasion intervention app for adolescent HPV vaccination requires investigating its hypothesized mechanisms. Guided by the experimental medicine approach, we tested whether (a) self-persuasion intervention components (verbalize vaccination reasons, choose HPV topics) changed putative mechanisms (memory, autonomous motivation) and (b) measures of the putative mechanisms were associated with HPV vaccination. METHODS: These are secondary analyses from a randomized 2 (cognitive processing: verbalize reasons vs. listen) × 2 (choice: choose HPV topics vs. assigned) factorial trial (Tiro et al., 2016). Undecided parents (N = 161) with an unvaccinated child (11–17 years old) used the self-persuasion app, recalled reasons for vaccination (memory measure), and completed an autonomous motivation measure. Adolescent vaccination status was extracted from electronic medical records 12 months post-intervention. RESULTS: The verbalize component resulted in greater recall accuracy of vaccination reasons (p < .001); however, the choose topics component did not increase autonomous motivation scores (p = .74). For associations with HPV vaccination, recall accuracy was not associated (ps > .51), but autonomous motivation scores significantly predicted vaccination (ps < .03), except when controlling for baseline motivation (p = .22). CONCLUSION: The intervention app engages parents in reasons for vaccination; however, memory may not be a viable mechanism of vaccination. Although the intervention did not affect autonomous motivation, associations with vaccination status suggest it is a viable intervention target for HPV vaccination but alternative strategies to change it are needed. Future testing of a refined app should examine implementation strategies to optimize delivery in clinical or community settings.

Purpose The purpose of this study is to examine the factor structure of the Risk Perception Survey for Developing Diabetes (RPS-DD) and test for factorial invariance by language (English, Spanish) and gender (males, females) in a clinically engaged, racially diverse, low-education population. Methods Adult patients seen in a safety-net health system (N = 641) answered an interviewer-administered survey via telephone in their preferred language (English: 42%, Spanish: 58%). Three constructs in the RPS-DD were assessed—personal control (2 items for internal control and 2 for external control), optimistic bias (2 items), and worry (2 items). Single and multigroup confirmatory factor analyses (CFAs) were performed using maximum-likelihood estimation to determine the factor structure and test for invariance. Results Contrary to previous psychometric analyses in white, educated populations, CFAs supported a 4-factor measurement model with internal and external control items loading onto separate factors. The 4-factor structure was equivalent between males and females. However, the structure varied by language, with the worry subscale items loading more strongly for English than Spanish speakers. Conclusions The RPS-DD can be used to investigate group differences across gender and language and to help understand if interventions have differential effects for subgroups at high risk for diabetes. Given the increasing prevalence of diabetes among Spanish speakers, researchers should continue to examine the psychometric properties of the RPS-DD, particularly the worry subscale, to improve its validity and clinical utility.

The literature on affective determinants of physical activity (PA) is growing rapidly. The present paper aims to provide greater clarity regarding the definition and distinctions among the various affect-related constructs that have been examined in relation to PA. Affective constructs are organized according to the Affect and Health Behavior Framework (AHBF), including: (1)affective response(e.g., how one feels in response to PA behavior) to PA; (2)incidental affect(e.g., how one feels throughout the day, unrelated to the target behavior); (3)affect processing(e.g., affective associations, implicit attitudes, remembered affect, anticipated affective response, and affective judgments); and (4)affectively charged motivational states(e.g., intrinsic motivation, fear, and hedonic motivation). After defining each category of affective construct, we provide examples of relevant research showing how each construct may relate to PA behavior. We conclude each section with a discussion of future directions for research.

BACKGROUND Unhealthy behaviors (eg, poor food choices) contribute to obesity and numerous negative health outcomes, including multiple types of cancer and cardiovascular and metabolic diseases. To promote healthy food choice, diet interventions should build on the dual-system model to target the regulation and reward mechanisms that guide eating behavior. Episodic future thinking (EFT) has been shown to strengthen regulation mechanisms by reducing unhealthy food choice and temporal discounting (TD), a process of placing greater value on smaller immediate rewards over larger future rewards. However, these interventions do not target the reward mechanisms that could support healthy eating and strengthen the impact of EFT-anchored programs. Increasing positive affect (PosA) related to healthy food choices may target reward mechanisms by enhancing the rewarding effects of healthy eating. An intervention that increases self-regulation regarding unhealthy foods and the reward value of healthy foods will likely have a greater impact on eating behavior compared with interventions focused on either process alone. OBJECTIVE This study aimed to introduce a protocol that tests the independent and interactive effects of EFT and PosA on TD, food choice, and food demand in overweight and obese adults. METHODS This protocol describes a factorial, randomized, controlled pilot study that employs a 2 (affective imagery: positive, neutral) by 2 (EFT: yes, no) design in which participants are randomized to 1 of 4 guided imagery intervention arms. In total, 156 eligible participants will complete 2 lab visits separated by 5 days. At visit 1, participants complete surveys; listen to the audio guided imagery intervention; and complete TD, food demand, and food choice tasks. At visit 2, participants complete TD, food demand, and food choice tasks and surveys. Participants complete a daily food frequency questionnaire between visits 1 and 2. Analyses will compare primary outcome measures at baseline, postintervention, and at follow-up across treatment arms. RESULTS Funding notification was received on April 27, 2017, and the protocol was approved by the institutional review board on October 6, 2017. Feasibility testing of the protocol was conducted from February 21, 2018, to April 18, 2018, among the first 32 participants. As no major protocol changes were required at the end of the feasibility phase, these 32 participants were included in the target sample of 156 participants. Recruitment, therefore, continued immediately after the feasibility phase. When this manuscript was submitted, 84 participants had completed the protocol. CONCLUSIONS Our research goal is to develop novel, theory-based interventions to promote and improve healthy decision-making and behaviors. The findings will advance decision-making research and have the potential to generate new neuroscience and psychological research to further understand these mechanisms and their interactions. CLINICALTRIAL ISRCTN Registry ISRCTN11704675; http://www.isrctn.com/ISRCTN11704675 (Archived by WebCite at http://www.webcitation.org/760ouOoKG) INTERNATIONAL REGISTERED REPOR DERR1-10.2196/12265

Background. “I don’t know” (DK) responses are common in health behavior research. Yet analytic approaches to managing DK responses may undermine survey validity and researchers’ ability to interpret findings. Objective. Compare the usefulness of a methodological strategy for reducing DK responses to 3 analytic approaches: 1) excluding DKs as missing data, 2) recoding them to the neutral point of the response scale, and 3) recoding DKs with the mean. Methods. We used a 4-group design to compare a methodological strategy, which encourages use of the response scale after an initial DK response, to 3 methods of analytically treating DK responses. We examined 1) whether this methodological strategy reduced the frequency of DK responses, and 2) how the methodological strategy compared to common analytic treatments in terms of factor structure and strength of correlations between measures of constructs. Results. The prompt reduced DK response frequency (55.7% of 164 unprompted participants vs. 19.6% of 102 prompted participants). Factorial invariance analyses suggested equivalence in factor loadings for all constructs throughout the groups. Compared to excluding DKs, recoding strategies and use of the prompt improved the strength of correlations between constructs, with the prompt resulting in the strongest correlations (.589 for benefits and intentions, .446 for perceived susceptibility and intentions, and .329 for benefits and perceived susceptibility). Limitations. This study was not designed a priori to test methods for addressing DK responses. Our analysis was limited to an interviewer-administered survey, and interviewers did not probe about reasons for DK responses. Conclusion. Findings suggest that use of a prompt to reduce DK responses is preferable to analytic approaches to treating DK responses. Use of such prompts may improve the validity of health behavior survey research.

OBJECTIVES: To prevent human papillomavirus (HPV)–related cancers, providers must effectively communicate with HPV vaccine–hesitant parents. Here, we developed a typology characterizing parent-provider communication around HPV vaccine hesitancy. METHODS: We audio-recorded 43 visits with unvaccinated adolescents at 6 pediatric clinics in Dallas, Texas in which parents were undecided about HPV vaccination. We qualitatively coded how parents verbally expressed hesitancy (assertive response, asking a question, or expressing concern) and whether providers responded with acquiescence (agree to defer vaccination) and/or persistence (continue discussion). We described the frequency of parent and provider communication codes and same-day vaccination. RESULTS: Among the 43 visits, 37 parents expressed hesitancy ≥1 times in many ways. Assertive responses were most common (27 visits), followed by questions (16 visits), and concerns (12 visits). When the first expression of hesitancy was a question or concern, 71% and 75% of adolescents, respectively, received same-day vaccinations, whereas 33% of adolescents who received an initial assertive response were vaccinated. Providers responded with only persistence in 18 visits, a mix of acquiescence and persistence in 13 visits, and only acquiescence in 6 visits. When providers only used persistence, 17 of 18 adolescents were vaccinated; when providers responded with only acquiescence, no adolescents received the vaccine. CONCLUSIONS: Our exploratory analysis reveals that providers engaging hesitant parents and addressing their concerns can lead to same-day HPV vaccination. Data reveal that even parents making assertive statements are amenable to influence by providers. Our findings reveal an important missed opportunity when providers simply acquiesce to parental hesitation.

People have much to gain from regular exercise, such as improved sleep, increased cognitive function, and reduced risk for cardiovascular disease, and these benefits may be particularly important for people experiencing deficits in these areas due to depressive symptoms (Kubesch et al., 2003; Lett et al., 2004; Rethorst et al., 2013). Moreover, regular exercise can be an effective treatment for depression (Babyak et al., 2000; Dunn et al., 2005; Mather et al., 2002; Mota-Pereira et al., 2011; Rethorst, Wipfli, & Landers, 2009). Despite the myriad benefits of regular exercise, adults with depressive symptoms have lower exercise levels than other adults (Patten, Williams, Lavorato, & Eliasziw, 2009; Roshaneai-Moghaddam, Katon, & Russo, 2009) and those with depressive symptoms who initiate a regular exercise regimen are more likely than others to discontinue it (DiMatteo, Lepper, & Croghan, 2000; Teixeira et al., 2004). Therefore, it is important to understand the reasons why people with depressive symptoms have difficulty initiating and maintaining regular exercise. Models of health behavior change, such as the Health Action Process Approach, Theory of Planned Behavior, and Social Cognitive Theory, emphasize the role of self-efficacy in successful behavior change (Ajzen, 1991; Bandura, 1997; Schwarzer, 1992). Self-efficacy is a person’s belief in his or her own ability to execute a specific behavior (Bandura, 1997), and it is central to behavior change because it guides what behaviors people choose to engage in and how people respond to obstacles and challenges in changing their behaviors (Bandura, 1997). Self-efficacy is known to be a predictor of successful initiation and maintenance of regular exercise (Rodgers, Hall, Blanchard, McAuley, & Munroe, 2002; Williams et al., 2008). Low self-efficacy may be one reason why people with depressive symptoms have difficulties initiating and maintaining regular exercise. People with depressive symptoms report lower self-efficacy than people without depressive symptoms across various behaviors (Bandura, 1998; Robinson-Smith, Johnston & Allen, 2000; Sacco et al., 2005). However, to date, it is unclear how depressive symptoms affect people’s self-efficacy while they attempt to initiate regular exercise. Self-efficacy beliefs are based on perceptions of ability to execute the relevant behavior, as well as perceptions of specific task demands and situational circumstances. Self-efficacy is theorized to stem from four sources: personal experience, vicarious experience, social persuasion (e.g., verbal encouragement), and physiological factors (e.g., arousal such as increased heart rate can lead to perceived inefficacy). Among these different sources, personal experience in executing the relevant behavior is the strongest source of self-efficacy perceptions (Bandura, 1997). Consistent with the proposition that personal experience is the strongest source of self-efficacy, exercise self-efficacy has been shown to significantly increase following participation in exercise. This has been observed after individual bouts of exercise (McAuley, 1995; McAuley et al., 2011) and long-term interventions for regular exercise (Marcus, Selby, Niaura, & Rossi, 1992; McAuley, 1995). This pattern of self-efficacy increases following the execution of exercise is consistent across the literature among healthy adults (Keller, Fleury, Gregor-Holt, & Thompson, 1999). In contrast, self-efficacy has been shown to decrease when individuals do not adhere to regular exercise, especially during the initiation of regular exercise as a new behavior (Parschau, Richert, Koring, Lippke, & Schwarzer, 2012). These findings all demonstrate that perceptions of self-efficacy are sensitive to whether people are successfully engaging in exercise or not. However, Bandura (1997) emphasized that it is not simply objective task execution that influences self-efficacy, but also the subjective perceptions and interpretations associated with the behavior. Subjective perceptions can be influenced by personal factors, such as differences in affective and cognitive processing. Depressive symptoms may be a personal factor that moderates the path between personal experience with exercise and self-efficacy. Depression is characterized by negative interpretations of experiences that are influenced by rumination, negative cognitions, and negative recall bias (Beck, 1991). The result of these negative interpretations is a tendency to minimize successes and exaggerate failures (Bandura, 1997). There is evidence to suggest that depressive symptoms influence self-efficacy to exercise regularly, but the evidence does not specifically address how this occurs. For example, older adults with depressive symptoms who enrolled in a 10-week progressive resistance-training program did not report increases in self-efficacy despite regular participation in exercise and objective gains in physical capability (Singh et al., 1997). This finding suggests the possibility that people with depressive symptoms have difficulties deriving self-efficacy from successfully performing exercise. This would be consistent with evidence that depressive symptoms are associated with a tendency to minimize successes (Bandura, 1997; Beck, 1991). Alternatively, Conroy and colleagues (2007) analyzed cross-sectional data one year after an exercise intervention in order to understand lapses (i.e., two weeks of failed adherence) during the initiation of a regular exercise regimen. They found that participants with high depressive symptoms were more likely than other participants to never return to regular exercise after a lapse to inactivity. This suggests that not exercising for two weeks was more detrimental to regular exercise behavior for participants with high depressive symptoms than those with low symptoms. One possible explanation is that participants with depressive symptoms may have experienced greater decreases in self-efficacy when they did not exercise regularly. This would be consistent with evidence that depressive symptoms can also be associated with a tendency to exaggerate failures (Bandura, 1997; Beck, 1991). However, this possibility was not directly examined. If depressive symptoms moderate the relation between exercise and self-efficacy, the moderation effect could be manifest in two different ways. First, depressive symptoms may dampen an increase in self-efficacy when people exercise (e.g., self-efficacy is lower for people with high depressive symptoms than those with low symptoms on days they exercise). Second, depressive symptoms may amplify a decrease in self-efficacy when people do not exercise (e.g., self-efficacy is lower for people with high depressive symptoms than those with low symptoms on days they do not exercise). Current evidence is unclear as to whether either or both effects occur for people with depressive symptoms (Singh et al., 1997; Conroy et al., 2007). Elucidating how these effects unfold on a daily basis would help specify why people with depressive symptoms have difficulties initiating regular exercise. Self-efficacy and exercise both have unique features that would benefit from daily examination over time. First, self-efficacy is not a static construct; it varies according to a person’s experiences (Shiffman et al., 2000). Second, the first days and weeks of initiating regular exercise are a sensitive period in both the formation of self-efficacy (Bandura, 1997) and establishing regular exercise (Dishman, Ickes, & Morgan, 1980), thus it is likely that exercise self-efficacy will be particularly sensitive to daily influences during this critical phase. Third, regular exercise is a health behavior that does not necessitate daily adherence, unlike other health behaviors such as smoking cessation or medication adherence. Indeed, public health guidelines for physical activity recommend activity on most but not all days of the week (USDHHS, 2008). Consequently, for people initiating regular exercise, there will routinely be days on which they exercise and days on which they do not. Distinguishing between experiences that occur on days of exercise and days of no exercise is relevant to understanding the daily psychological processes that occur during the initiation phase of regular exercise.

Objective Self-persuasion is an effective behavior change strategy, but has not been translated for low-income, less educated, uninsured populations attending safety-net clinics or to promote human papillomavirus (HPV) vaccination. We developed a tablet-based application (in English and Spanish) to elicit parental self-persuasion for adolescent HPV vaccination and evaluated its feasibility in a safety-net population. Methods Parents (N = 45) of age-eligible adolescents used the self-persuasion application. Then, during cognitive interviews, staff gathered quantitative and qualitative feedback on the self-persuasion tasks including parental decision stage. Results The self-persuasion tasks were rated as easy to complete and helpful. We identified six question prompts rated as uniformly helpful, not difficult to answer, and generated non-redundant responses from participants. Among the 33 parents with unvaccinated adolescents, 27 (81.8%) reported deciding to get their adolescent vaccinated after completing the self-persuasion tasks. Conclusions The self-persuasion application was feasible and resulted in a change in parents’ decision stage. Future studies can now test the efficacy of the tablet-based application on HPV vaccination. Practice implications The self-persuasion application facilitates verbalization of reasons for HPV vaccination in low literacy, safety-net settings. This self-administered application has the potential to be more easily incorporated into clinical practice than other patient education approaches.

According to Self-Determination Theory, the extent to which the motivation underlying behavior is self-determined or controlled influences its sustainability. This is particularly relevant for behaviors that must be repeated, such as completion of the human papillomavirus (HPV) vaccine series. To date, no measures of motivation for HPV vaccination have been developed.As part of a larger study, parents (N=223) whose adolescents receive care at safety-net clinics completed a telephone questionnaire about HPV and the vaccine. We modified the Treatment Self-Regulation Questionnaire to assess parents' motivation for HPV vaccination in both Spanish and English. We used confirmatory factor analysis to test a three-factor measurement model.The three-factor model fit the data well (RMSEA=0.04, CFI=0.98, TLI=0.96), and the scales' reliabilities were adequate (autonomous: α=0.87; introjected: α=0.72; external: α=0.72). The factor loading strength for one item was stronger for Spanish- than English-speaking participants (p0.05); all others were equivalent. The intercorrelations among the scales ranged from -0.17 to 0.32, suggesting discriminant factors. The scales displayed the expected pattern of correlations with other psychosocial determinants of behavior. Vaccination intentions showed a strong correlation with autonomous motivation (r=0.52), but no correlation with external motivation (r=0.02), suggesting autonomous motivation may be particularly important in vaccine decision-making.Findings support the use of three subscales to measure motivation in HPV vaccination and suggest possible cultural differences in motivation.

Objective Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations. Methods We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination. Results We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale. Conclusion Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction. Practice implications Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale.

Objectives: Even after acute coronary syndrome (ACS) is ruled out, observational studies have suggested that many patients with nonspecific chest pain have a high burden of cardiovascular risk factors (CRFs) and are at increased long-term risk of ischemic heart disease (IHD)-related mortality. The aim of this study was to evaluate the premise that evaluation in an observation unit for symptoms of possible ACS is a “teachable moment” with regard to modification of CRFs. Methods: The authors conducted a baseline face-to-face interview and a 3-month telephone interview of 83 adult patients with at least one modifiable CRF who presented with symptoms of possible ACS to an academic medical center. Existing questionnaires were adapted to measure Health Belief Model (HBM) constructs for IHD. Stage of change and self-reported CRF-related behaviors (diet, exercise, and smoking) were assessed using previously validated measures. The paired t-test or signed rank test was used to compare baseline and 3-month measures of health behavior within the analysis sample. Results: Of the 83 study patients, 45 and 40% reported having received clinician advice regarding diet and physical activity during the observation unit encounter, respectively; 69% of current smokers received advice to quit smoking. Patients reported lower susceptibility to IHD (13.3 vs. 14.0, p = 0.06) and greater perceived benefit of healthy lifestyles (27.5 vs. 26.4, p = 0.0003) at 3-month follow-up compared to baseline. Patients also reported greater readiness to change and improved self-reported behaviors at follow-up (vs. baseline): decreased intake of saturated fat (10.1% vs. 10.5% of total calories, p = 0.005), increased fruit and vegetable intake (4.0 servings/day vs. 3.6 servings/day, p = 0.01), and fewer cigarettes (13 vs. 18, p = 0.002). Conclusions: Observed changes in IHD health beliefs and CRF-related behaviors during follow-up support the idea that observation unit admission is a teachable moment. Patients with modifiable risk factors may benefit from systematic interventions to deliver CRF-related counseling during observation unit evaluation.

Background: Congruence between patients’ and providers’ preferred healthcare role orientations has been shown to be important for improved clinical outcomes and patient satisfaction. Thus, it is important to know how different patient and provider populations might vary in preferred role orientations. Objective: To measure the range of role orientation preferences among patients and providers in two different general medicine clinic populations. Methods: Role orientation preferences of patients (n = 319) and providers (n = 151) in six Veterans Administration (VA) primary care clinics and two university-based primary care clinics were measured in a cross sectional survey using the 9-item Patient-Practitioner Orientation Scale (PPOS) sharing subscale among patients and providers. Results: VA patients had lower mean PPOS scores (i.e. more provider-centered role preference) than the university clinic patients (31.2 vs 39.7, respectively; p< 0.001). The difference remained significant even after adjusting for age, sex, and education. VA and university clinic providers had similar mean PPOS scores (41.5 vs 42.6, respectively; p = 0.27). Greater differences were found in mean PPOS scores between VA patients and their providers (31.2 vs 41.5, respectively; p < 0.001) than university clinic patients and their providers (39.7 vs 42.6, respectively; p = 0.12). Conclusions: VA patients reported preferences for a more provider-centered role than university clinic patients and there was greater mean difference in preferred role orientations between VA patients and their providers than between university clinic patients and their providers. Differences in preferred role orientations by patients and providers should be considered when designing clinical initiatives and research to improve patient care.

We sought to determine whether different social, psychological, emotional, and physiological experiences associated with quitting smoking related to people’s satisfaction with cessation systematically, and whether the strength of the relations changes at different points during the cessation process and for different people (e.g., optimists). Using data from smokers enrolled in a cessation program, we used mixed models to assess the average longitudinal relation between people’s experiences and satisfaction measured at seven time points and whether the relations were moderated by key variables. Eight of nine experiences were related to people’s satisfaction (ps < 0.05) and the models accounted for 39–44% of the within-person variance in satisfaction. Current smoking behavior was more strongly related to people’s satisfaction during their early efforts to quit, whereas some experiences (e.g., feedback from others) had a stronger relation with satisfaction during people’s later efforts to quit or maintain abstinence (ps < 0.05). Individual differences in optimism and prior cessation experience moderated some of the relations (ps < 0.05). The findings mark the first evidence of factors that might influence how people determine their satisfaction with smoking cessation. The implications for tailoring interventions and potentially increasing the likelihood that people maintain abstinence are discussed.

Introduction: The human papillomavirus (HPV) vaccine is highly efficacious and universally recommended, yet US adolescent vaccination rates remain suboptimal. Vaccination rates are lowest among racial/ethnic minorities and other medically underserved (uninsured, and low-income) populations. Many parents are ambivalent or hesitant about the HPV vaccine and delay making a decision. Self-persuasion – the process of generating one's own arguments for changing behavior – has been an effective approach to influence motivation and behavior. But, self-persuasion's effectiveness for HPV vaccination among safety-net populations is unknown. Also, evidence is unclear about the optimal method to elicit self-persuasion. We describe development of a tablet-based application with two different elicitation methods (verbalizing own arguments versus listening to peer-generated narratives) to encourage HPV vaccination among parents of adolescents attending safety-net clinics. Methods: We recruited participants from six clinics in Dallas, TX, the 9th largest US county— a diverse population of low-literacy Spanish- and English-speaking parents. In the first phase of the project, we developed application functions, interface, and language-specific (English and Spanish) scripts. Culturally-matched graphics and narrators were selected for an educational video and self-persuasion elicitation question prompts. In the second phase, we conducted cognitive interviews where parents used the tablet application and then were queried about the experience (e.g., feedback on comprehension of instructions and educational video as well as the time spent on each task). The goal of the interview was to identify prompts that were perceived as helpful and elicited detailed responses. Results: We dropped prompts that did not elicit new or relevant arguments and modified the language of other prompts to improve parents' understanding (e.g. the item addressing anticipated regret was reworded as it was eliciting parental concerns about potential vaccine side effects rather than perceived future regret for not vaccinating). Parents reported they enjoyed using the application, found the self-persuasion prompts helpful in vaccine decision-making, and confirmed that tablet use did not raise concerns about the HPV vaccine. We used the audio-recorded responses of 45 parents to generate peer narratives with the vernacular of the target population. The final version of the application will be used in a randomized factorial design trial to examine basic psychological processes underlying why self-persuasion is effective. Conclusion: It is feasible for safety-net parents to use a tablet application and verbalize their self-generated arguments for HPV vaccination. Tablet-based interventions may be ideal to deliver educational messages in busy clinic settings because it is self-administered and addresses literacy limitations of safety-net parents. Citation Format: Jasmin A. Tiro, Simon Craddock Lee, David Farrell, Emily G. Marks, Austin S. Baldwin, Deanna C. Denman. Development of a tablet-based application to elicit self-persuasion about HPV vaccination among undecided parents. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B87.

We examined factors associated with information seeking about the human papillomavirus vaccine among mothers of adolescent girls by testing whether information seeking and vaccination intentions for their daughters are associated with perceived vulnerability, severity, and vaccine benefits in an ethnically diverse sample. Mothers ( N = 256) of unvaccinated girls living in Dallas, Texas, were surveyed (49% Black, 29% Hispanic, and 18% White). Perceived vulnerability to human papillomavirus was associated with talking with others (odds ratio = 1.71, 95% confidence interval = 1.09, 2.66) and talking with a doctor about the vaccine (odds ratio = 1.42, 95% confidence interval = 1.01, 1.99), and perceived vaccine benefits were associated with vaccination intentions (odds ratio = 2.96, 95% confidence interval = 1.98, 4.42), but the perceived severity was not associated with any dependent measure. Beliefs about human papillomavirus risk are associated with seeking information from a doctor and interpersonal sources, but ethnic minorities are less likely to talk with others about the vaccine.

Previous examinations of depression as a predictor of mortality in end-stage renal disease have yielded inconsistent findings. We sought to clarify the possible link with mortality by assessing depression at an earlier stage of renal impairment before the uremic disease state and depressive symptoms become highly confounded, and then following patients during the period of disease progression.Prospective design using an assessment of depression before initiation of renal replacement therapy to predict mortality status an average of 81 months later in patients in the early stages of chronic kidney disease.Mortality status.After controlling for relevant mortality risk factors (i.e., age, gender, presence of diabetes and cardiovascular disease, and potassium level), results of Cox regression analyses indicated that higher levels of nonsomatic depression symptoms were predictive of an increased mortality risk, χ²(1, N = 359) = 8.02, p = .005. Patients with nonsomatic depression scores 1 SD above the mean had an estimated mortality rate 21.4% higher than average scorers in this sample.Clinical implications of these findings point to the importance of assessment and treatment of depressive symptoms in patients with chronic kidney disease.

Recent research has shown that satisfaction with weight loss is predictive of weight loss maintenance, yet empirical evidence for how people derive satisfaction with weight loss is quite limited.To determine whether satisfaction with weight change systematically covaries with various weight-loss-related outcomes and experiences (e.g., improvement in physical appearance, amount of frustration experienced), which outcomes and experiences are the strongest longitudinal correlates of satisfaction, and whether the longitudinal covariations are due to between-person differences and/or within-person changes.We analyzed longitudinal data obtained from overweight or obese individuals enrolled in a weight-loss program who were followed for 18 months using random coefficient models.In univariate analyses controlling for the amount of weight people lost, nine of ten outcomes and experiences independently covaried with people's satisfaction, and the models accounted for 21-38% of the within-person variance in satisfaction. In a multivariate analysis, four outcomes and experiences remained as significant longitudinal covariates of satisfaction. In both sets of analyses, there were more significant relations due to within-person changes than to between-person differences.The results suggest that people's weight loss satisfaction systematically covaries with ongoing changes in weight-loss-related outcomes and experiences. The findings help elucidate how people derive satisfaction with weight loss.

Background: Human papillomavirus (HPV)-related cancers are a significant burden on the US health care system that can be prevented through adolescent HPV vaccination. Despite guidelines recommending vaccination, coverage among US adolescents is suboptimal particularly among underserved patients (uninsured, low income, racial, and ethnic minorities) seen in safety-net health care settings. Many parents are ambivalent about the vaccine and delay making a decision or talking with a provider about it. Self-persuasion—generating one’s own arguments for a health behavior—may be particularly effective for parents who are undecided or not motivated to make a vaccine decision. Objective: Through a 3-stage mixed-methods protocol, we will identify an optimal and feasible self-persuasion intervention strategy to promote adolescent HPV vaccination in safety-net clinics. Methods: In Stage 1, we will define content for a tablet-based self-persuasion app by characterizing (1) parents’ self-generated arguments through cognitive interviews conducted with parents (n=50) of patients and (2) parent-provider HPV vaccine discussions through audio recordings of clinic visits (n=50). In Stage 2, we will compare the effects of the four self-persuasion intervention conditions that vary by cognitive processing level (parents verbalize vs listen to arguments) and choice of argument topics (parents choose vs are assigned topics) on parental vaccine intentions in a 2 × 2 factorial design randomized controlled trial (n=160). This proof-of-concept trial design will identify which intervention condition is optimal by quantitatively examining basic self-persuasion mechanisms (cognitive processing and choice) and qualitatively exploring parent experiences with intervention tasks. In Stage 3, we will conduct a pilot trial (n=90) in the safety-net clinics to assess feasibility of the optimal intervention condition identified in Stage 2. We will also assess its impact on parent-provider discussions. Results: This paper describes the study protocol and activities to date. Currently, we have developed the initial prototype of the tablet app for English- and Spanish-speaking populations, and completed Stage 1 data collection. Conclusions: Our systematic collaboration between basic and applied behavioral scientists accelerates translation of promising basic psychological research into innovative interventions suitable for underserved, safety-net populations. At project’s end, we plan to have a feasible and acceptable self-persuasion intervention that can affect key cancer disparities in the United States through prevention of HPV-related cancers. Trial Registration: ClinicalTrials.gov http://clinicaltrials.gov/ct2/show/NCT02537756 and http://clinicaltrials.gov/ct2/show/NCT02535845 (Archived by WebCite at http://www.webcitation.org/6e5XcOGXz and http://www.webcitation.org/6e5XfHoic, respectively). [JMIR Res Protoc 2016;5(1):e19]