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Background Food insecurity has been identified as an important social determinant of health and is associated with many health issues prevalent in Medicaid members. Despite this, little research has been done around food insecurity within Medicaid populations. Objective Our objective was to estimate the prevalence of household food insecurity and identify factors associated with experiencing food insecurity in Iowa’s Medicaid expansion population. Design We conducted a cross-sectional telephone survey between March and May of 2019. Participants Our sample was drawn from Medicaid members enrolled in Iowa’s expansion program at least 14 months, stratified by Federal Poverty Level (FPL) category. Members who did not have valid contact information were excluded. We selected one individual per household to reduce the interrelatedness of responses. We sampled 6,000 individuals and had 1,349 respondents in the analytic sample. Main outcome measure Our main outcome was whether a respondent’s household experienced food insecurity in the previous year, using the Hunger Vital Sign screening tool. Statistical analyses performed We weighted responses to account for the sampling design and differential nonresponse between strata. We estimated the prevalence of food insecurity and used logistic regression to model food insecurity as a function of demographic (age, FPL category, gender, employment, education, race, rurality, and Supplemental Nutrition Assistance Program [SNAP] participation) and health-related (self-rated health, self-rated oral health, health literacy) factors. Results The estimated prevalence of experiencing food insecurity was 51.3%. Race, gender, education, employment, health literacy, and self-rated health were all significantly associated with food insecurity. Conclusions Our findings show that food insecurity is prevalent in Iowa’s Medicaid expansion population. Food insecurity should be more widely measured as a critical social determinant of health in Medicaid populations. Policymakers and clinicians should consider interventions that connect households experiencing food insecurity to food resources (eg, produce prescriptions and food pantry referrals) and policies that increase food access. Abbreviations Iowa Wellness Plan (IWP); Federal Poverty Level (FPL); Healthy Behavior Program (HBP); Supplemental Nutrition Assistance Program (SNAP)

Background Despite the human papillomavirus (HPV) vaccine being a safe, effective cancer prevention method, its uptake is subomptimal in the United States (U.S.). Previous research have found a variety of intervention strategies (environmental and behavioral) in increasing its uptake. The purpose of the study is to systematically review the literature for interventions to promote HPV vaccination from 2015 to 2020. Methods We updated a systemative review of interventions to promote HPV vaccine uptake globally. We ran key word searches in six bibliographic databases. Audiences, design, level of intervention, components and outcomes were abstracted from the full-text articles in Excel databases. Results Of the 79 articles, most were conducted in the U.S. (72.2%) and in clinical (40.5%) or school settings (32.9%), and were directed a single level (76.3%). Related to the intervention type, most were informational (n = 25, 31.6%) or patient-targeted decision support (n = 23, 29.1%). About 24% were multi-level interventions, with 16 (88.9%) combining two levels. Twenty-seven (33.8%) reported the use of theory in intervention development. Of those reporting HPV vaccine outcomes, post-intervention vaccine initiation ranged from 5–99.2%, while series completion ranged from 6.8–93.0%. Facilitators to implementation were use of patient navigators and user-friendly resources, while barriers included costs, time to implement and difficulties of integrating interventions into organizational workflow. Conclusions There is a strong need to expand implementation of HPV-vaccine promotion interventions beyond education alone and at a single level of intervention. Development and evaluation of effective strategies and multi-level interventions may increase the uptake of the HPV vaccine among adolescents and young adults.

Objective: Rural youth are more likely to be obese and have poor diets compared to their nonrural peers; therefore, our objective was to understand factors related to healthy eating habits in this population. Methods: We used survey data from 4th graders (N = 995) in a Midwestern state’s rural areas to explore nutrition knowledge, fruit or vegetable (F/V) attitudes, beliefs, preferences, and previous day’s consumption. We produced descriptive statistics, compared attitudes, beliefs, preferences, and consumption for fruits versus vegetables using multilevel linear regression, and used multilevel logistic regression to assess predictors of F/V consumption controlling for sociodemographic factors. Results: Fruit and vegetable consumption was low, with over 10% reporting no fruit consumption and over 20% reporting no vegetable consumption. Students rated fruits higher than vegetables on each variable of interest. Knowledge (OR = 1.2) and liking fruits (OR = 2.2) were associated with fruit consumption. Knowledge (OR = 1.2), liking vegetables (OR = 2.4), and vegetable preferences (OR = 1.4) were associated with vegetable consumption. Conclusions: Schools should implement interventions that increase access and exposure to healthy foods and target knowledge, attitudes around liking F/V, and vegetable preferences for rural youth, such as nutrition education, school gardens, and farm-to-school programs.

Nationally, human papillomavirus (HPV) vaccination rates fall short of the Healthy People 2020 goal of 80% completion. Although strategies to increase these rates exist, low rates persist. We used concept mapping with state-level stakeholders to better understand barriers and facilitators to HPV vaccination. Concept mapping is a participatory research process in which respondents brainstorm ideas to a prompt and then sort ideas into piles. We present results of the brainstorming phase. We recruited participants identified by researchers' professional connections (n = 134) via e-mail invitations from five states (Iowa, South Dakota, Minnesota, Oregon, and Washington) working in adolescent health, sexual health, cancer prevention and control, or immunization. Using Concept Systems' online software we solicited participants' beliefs about what factors have the greatest influence on HPV vaccination rates in their states. From the original sample 58.2% (n = 78) of participants completed the brainstorming activity and generated 372 statements, our team removed duplicates and edited statements for clarity, which resulted in 172 statements. We coded statements using the Social Ecological Model (SEM) to understand at what level factors affecting HPV vaccination are occurring. There were 53 statements at the individual level, 22 at the interpersonal level, 21 in community, 51 in organizational, and 25 in policy. Our results suggest that a tiered approach, utilizing multi-level interventions instead of focusing on only one level may have the most benefit. Moreover, the policy-level influences identified by participants may be difficult to modify, thus efforts should focus on implementing evidence-based interventions to have the most meaningful impact.

Engaging individuals in middle management positions (eg, nurse or clinic managers) could facilitate implementation of evidence-based interventions (EBIs) to improve uptake of human papillomavirus (HPV) vaccination. Our goal was to understand middle managers’ role in and perspectives on implementation of EBIs for HPV vaccination. We conducted qualitative interviews with middle managers in pediatric and family practice clinics. We used constructs from the Consolidated Framework for Implementation Research (CFIR) to design the interview guide and as a coding framework. Participants (n = 19) reported overseeing implementation related to HPV vaccination. Across interviews, CFIR inner setting constructs (eg, structural characteristics and implementation climate) were identified as being both barriers and facilitators. As evidenced in this study, middle managers have a deep understanding of organizational factors, and they have the ability to facilitate implementation efforts related to HPV vaccination. Future efforts could focus on engaging middle managers and leveraging their expertise and understanding of barriers and facilitators.

Statement of purpose Evaluation of community engagement in the development and dissemination of a rural roadway safety campaign. Methods/Approach We implemented ‘We’re On This Road Together,’ a health communication campaign that targeted rural drivers’ interactions with farm vehicles and had three main messages: Slow Down, Leave More Space, and Avoid Passing. Campaign development and implementation was guided by a community advisory board (CAB) who gave input and direction on campaign message design and dissemination at monthly meetings. They also led campaign activities (hanging banners, distributing swag--totes, car air fresheners, etc.). To guide our future collaborations with CABs, we conducted in-depth, semi-structured telephone interviews with CAB members (n=8) in the summer of 2020. Interviews were recorded and audio files were transcribed by a third-party service. After transcription, a research team member coded the interview transcripts. Codes were then organized by common themes: 1) overall experience, 2) responsibilities & commitment, 3) perceived campaign success, 4) resources needed for project implementation, and 5) recommendations for improvement. Results Interview length averaged 25 minutes (range: 16–41). CAB members reported overwhelmingly positive experiences, reasonable time commitment, and successful format and frequency of communication. They viewed the overall project a success and valued our team’s community engagement efforts. However, the CAB had recommendations for improving campaign impact and reach, including adding online/social media campaign elements, expanding diversity of CAB membership (age, occupation/industry), and team-building activities to increase group bonding. Conclusions Formation of a community advisory board was successful and critical in message development, implementation, and overall impact of our rural road safety campaign. Significance This project demonstrates how to engage community advisors in development and delivery of a road safety campaign, which can be applied to other injury and violence prevention campaign activities.

Introduction Human papillomavirus (HPV)-associated oropharyngeal cancer rates are rising, particularly in males, although rates of other HPV-related cancers are decreasing. Although the HPV vaccine is safe and effective, vaccination rates remain below the Healthy People 2030 goal of 80% coverage. Engaging dental providers, who have experience with patient education and oropharyngeal cancer, may prove useful in efforts to increase vaccination rates. Our research explores dental providers' (dentists, dental hygienists) willingness to participate in continuing education about HPV, educate parents of adolescents, recommend the vaccine for adolescents, and refer parents to medical providers. Methods We used a mixed-methods approach and conducted a survey with dental hygienists and semistructured interviews with dental providers. We produced frequencies and descriptive statistics for all variables and used regression modeling to explore factors related to willingness to promote the HPV vaccine. We used a deductive approach to code interview transcripts. Results Regression models using survey data (n = 470) showed that after controlling for demographic and practice-level characteristics, higher levels of willingness were associated with thinking that parents would act on a recommendation and thinking that engaging in HPV promotion is within the scope of practice. Interview data reflected willingness of dental providers to work on HPV vaccination, but revealed barriers (eg, time, knowledge) that need to be addressed. Discussion Overall, dental providers expressed a willingness to participate in HPV vaccine promotion, and future efforts should focus on addressing barriers to doing so. Engaging dental providers in HPV vaccine recommendation and referral can help prevent future HPV-related cancers.

Rural pharmacists have been identified as potential partners, along with health care providers, schools, and public health agencies, in administering and promoting the human papillomavirus (HPV) vaccine. We sought to understand the role of pharmacists in this work. We interviewed 11 pharmacists working at independently owned pharmacies in Iowa to explore their perspectives on HPV vaccine administration and promotion. Most pharmacists agreed that HPV vaccination was within their professional scope. They identified factors that facilitate vaccine administration (eg, accessibility of pharmacies). They also reported personal barriers (eg, lack of information, concerns about safety) and organizational barriers (eg, time and staff capacity). Future work should focus on alleviating barriers and building on strengths to improve vaccination rates and ultimately prevent HPV-related cancers.

Introduction Rural crashes result in fatality rates twice as high as urban, after accounting for vehicle miles traveled, and those involving farm vehicles tend to be the most severe. Farm vehicle crash interventions have focused on the farm equipment (e.g., lighting and marking) or the farm vehicle operator (e.g., training), despite crashes being most frequently caused by other vehicle driver actions. Community-based campaigns focused on rural drivers have potential to influence driver behavior. The objective of this study was to describe the role, formation, and lessons learned from a community advisory board (CAB) in the development and dissemination of a community-based rural roadway safety campaign. Methods The CAB provided campaign input through quarterly meetings and email. The campaign had three main CAB and crash data-informed messages: 1) Slow Down, 2) Leave More Space, and 3) Avoid Passing. The CAB led campaign activities to publicize the message, distribute swag, and organize event logistics. To evaluate CAB effectiveness and inform future community engagement efforts, we conducted in-depth, semi-structured telephone interviews with CAB members in July 2020. Interviews were transcribed, coded, and codes were categorized into five main themes. Results Overall, CAB membership was described as an overwhelmingly positive experience in terms of the CAB structure, culture fostered among the group, responsibilities, and time commitment. Board members reported successful campaign implementation, gave positive feedback regarding the research team's engagement efforts, and provided valuable recommendations for future campaigns (e.g., adding social media components, expansion of CAB age and industry diversity, and increasing group bonding activities). Conclusions Results from this study demonstrate the instrumental role and logistics involved in engagement of community advisors for the development and implementation of a rural roadway safety campaign. Steps and lessons from this study can be applied to other community-level injury and violence prevention topics, with a particular focus on rural communities.

Human papillomavirus (HPV) infection significantly contributes to the burden of cancer in the United States, despite the existence of a highly effective vaccine. While numerous interventions to address vaccination uptake exist, vaccination rates remain low. We conducted a concept mapping exercise to solicit perspectives on barriers and facilitators to HPV vaccination from state-level stakeholders in five states in the Midwest and West Coast of the U.S. We identified 10 clusters of barriers and facilitators based on participants’ statements. For rural areas specifically, clusters rated as most important included education and provider influence; those rated as most feasible were education and coordinated/consistent messaging. Our results suggest that a combination of important (but potentially more difficult to implement) strategies, combined with those rated as most feasible (but potentially less impactful) may be beneficial. Our findings highlight similarities across diverse states, suggesting that states can learn from each other and work together to improve HPV vaccination rates. Using concept mapping proved to be an efficient way to collect information from diverse, stakeholders in different locations, and is a methodology that could be used for program planning in areas beyond HPV vaccination.