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Purpose: Virtual reality (VR) may be a viable method to observe and describe signals of implicit bias. Using the context of the human papillomavirus vaccine counseling, we sought to describe physicians' communication practices exploring differences when counseling parents with different skin colors., Methods: Physicians (N = 90) at an academic primary care center were recruited for a VR study in which they counseled dark or light-skinned parent avatars who expressed hesitation about human papillomavirus vaccination for their adolescent child. Investigators coded previously recorded simulations. Associations between communication and parent skin color were examined using t-tests and Chi-square tests., Results: Both direct (e.g., addressing the concern immediately) and circuitous (e.g., providing alternative information) communication patterns were observed. Physicians used passive voice less commonly when counseling dark-skinned versus light-skinned avatars (p < .05)., Discussion: VR demonstrated feasibility in capturing clinicians' communication behaviors including measuring eight distinct indicators of implicit bias., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Sickle cell disease (SCD), which occurs primarily in individuals of African descent, has been identified as a preexisting health condition for COVID-19 with higher rates of hospitalization, intensive care unit admissions, and death. National data indicate Black individuals have higher rates of vaccine hesitancy and lower COVID-19 vaccination rates. Understanding the key predictors of intention to receive a COVID-19 vaccine is essential as intention is strongly associated with vaccination behavior. This multisite study examined attitudes, beliefs, intentions to receive COVID-19 vaccines, and educational preferences among adolescents, young adults, and caregivers of children living with SCD. Participants completed an online survey between July 2021 and March 2022. Multivariate logistic regression was used to examine the association between participant age and COVID-19 vaccine attitudes, beliefs, and vaccine intentions. Of the 200 participants, 65.1% of adolescents, 62.5% of young adults, and 48.4% of caregivers intended to receive a COVID-19 vaccine for themselves or their child. Perception that the vaccine was safe was statistically significant and associated with patient and caregiver intention to receive the COVID-19 vaccine for themselves or their child. Participant age was also statistically significant and associated with the intent to get a booster for patients. Study findings highlight key concerns and influencers identified by patients with SCD and their caregivers that are essential for framing COVID-19 vaccine education during clinical encounters. Study results can also inform the design of messaging campaigns for the broader pediatric SCD population and targeted interventions for SCD subpopulations (eg, adolescents, caregivers)., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Identify variables, including moderating variables, associated with adolescents, young adults, and parents' intention to receive a COVID-19 vaccine in January 2021., Design: Cross-sectional survey., Setting: United States Midwestern academic medical center., Sample: Adolescents (n = 242); young adults (n = 333); parents (n = 563)., Measures: Associations between predictors-participant characteristics, general vaccine hesitancy, COVID-19 and vaccine knowledge, perceptions, and normative beliefs-and intention to receive a COVID-19 vaccine (outcome) were assessed. To determine variables impacting the strength of the relationship between predictors and outcome, moderators included 2020/2021 influenza vaccine receipt, having experienced discrimination, and primary sources of information for COVID-19., Analysis: Multivariable logistic regression examined associations, including moderating effects, for adolescents, young adults, parents, and parents for child., Results: With 20,231 email addresses receiving the survey, 1138 participants were included in the analysis. Intention to receive a COVID-19 vaccine was reported by 60.7% adolescents (n = 147), 65.2% young adults (n = 217), and 38.5% parents (n = 217) and 38.2% parents (n = 215) intended to vaccinate their child. Intention was associated with lower general vaccine hesitancy for adolescents (AOR = 1.50), young adults (AOR = 1.39), parents (AOR = 1.18), and parents' intention for their child (AOR = 1.17). Parents citing reputable medical experts as primary source of COVID-19 information positively moderated vaccine perceptions and intention for self (AOR = 8.25) and child (AOR = 6.37)., Conclusion: Clinician training to address vaccine hesitancy may be effective at promoting positive COVID-19 vaccine perceptions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Assessing trainees' skills via workplace-based assessments is challenging given the lack of psychometrically valid instruments. Our team previously developed an observation instrument to assess residents' competencies in behavioral health anticipatory guidance (BHAG) and motivational interviewing (MI) though its reliable usage required expert raters (e.g., paediatric psychologists). Our purpose was to establish validity evidence for a modified tool for clinicians., Approach: This study utilised data from a prior educational trial of a virtual reality (VR)-based behavioural health curriculum for paediatric residents. First, group interviews were conducted with clinicians to modify the expert instrument. Next, recorded VR simulations (n = 10) were scored to assess interrater reliability between clinicians. Finally, a physician used the tool to assess its ability to discriminate between residents' skill levels (n = 55)., Evaluation: Modifications during group interviews included a change from frequency counts for items related to MI to the binary outcome of present/absent and the addition of an entrustment item. On interrater-reliability testing, the clinician tool demonstrated mostly substantial or near perfect agreement for items related to BHAG. MI items demonstrated a range of agreement. Using 55 recorded VR simulations, the clinician tool discriminated between trained versus untrained residents in BHAG skills (p = 0.002) and level of entrustment (p = 0.001). Differences between groups in MI adherence was not statistically significant (p = 0.095) as it was on the expert instrument., Implications: VR demonstrated potential as a novel approach for obtaining validity evidence for tool development to support workplace-based assessments. Further work assessing usage of the clinician tool in real-world settings is warranted., (© 2023 Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Technology holds great potential to address many vaccine hesitancy determinants and support vaccine uptake given its ability to amplify positive messages, support knowledge, and enhance providers' recommendations. Modalities previously implemented with variable success have included automated reminder systems, decision support for clinicians, online education programs, social media campaigns, and virtual reality curricula. Further research is needed to identify the optimal uses of technology at the patient/parent and provider levels to overcome vaccine hesitancy. The most effective interventions will likely be multipronged providing patients, parents, and providers with information related to vaccine status., Competing Interests: Disclosure None of the authors have any commercial or financial relationships relevant to this article to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Effective educational strategies to train and assess residents' skills in behavioral health competencies have been limited. We hypothesized that a training curriculum using virtual reality (VR) simulations would enhance residents' evidence-based skills related to behavioral health anticipatory guidance (BHAG) and motivational interviewing (MI)., Methods: We conducted a randomized controlled pilot trial of our curriculum within an urban academic clinic. Intervention and control groups received four 15-minute, monthly didactics on BHAG and MI followed by VR simulations to 1) deliberately practice delivering BHAG by verbally counseling avatars, who responded real-time (intervention group) or 2) assessing pediatric respiratory distress (control group). Two months post-VR training, all residents participated in a unique VR behavioral health scenario which was recorded and coded by pediatric psychologists via an observation instrument to assess residents' skills. Differences in BHAG and MI competencies were assessed via independent samples t tests for continuous variables and Fisher's exact tests for categorical variables., Results: Sixty-six percent (n = 55) of eligible residents completed all study protocols comprising 35 intervention and 20 control participants. Intervention participants demonstrated an increase in BHAG skills (P = .002), percentage of open-ended questions asked (P = .04), and percentage of MI adherent behaviors (P = .04) when compared to the control group., Conclusions: VR may be an effective educational strategy for residents to acquire BHAG and MI skills though deliberate practice. Next steps will focus on assessing the generalizability of the VR curriculum as well as exploring the opportunities to enhance its scalability through artificial intelligence., (Copyright © 2022 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Although the strongest predictor of human papillomavirus (HPV) vaccination is a high-quality recommendation, physicians often provide weak recommendations. Thus, the authors developed Virtual Immersive Communication Training on Recommending Immunizations (VICTORI), a virtual reality (VR)‒based intervention that provided physicians the opportunity to deliberately practice recommendation behaviors. VICTORI included VR simulations during which participants counseled caregiver avatars hesitant to vaccinate. Before participation in VICTORI, participants reviewed a smartphone application on recommendation behaviors. A nonrandomized control trial of VICTORI was conducted with licensed and resident physicians. The intervention group completed the application and VICTORI simulations, whereas a comparison group completed only the application. The hypothesis was that HPV vaccination rates would increase for patients in the intervention group. The preintervention period was defined as the 6 months before allocated training (February 1, 2020-July 31, 2020), and the postintervention period was the 6 months after (October 1, 2020-March 31, 2021). The primary outcome was a change in the rates of human papillomavirus vaccine initiation among eligible patients presenting to clinic before and after. Of 142 eligible physicians, 134 (94%) chose to participate, with 93 of /97 (96%) intervention and 30 of 37 (81%) comparison participants completing study protocols. There was a statistically significant increase in patients' HPV vaccine initiation rates after training within the intervention group (54.3%‒72.4%; 18.1% difference [95% CI=11.0, 25.8]; p<0.001) but not within the comparison group (59.5%‒63.4%; 3.9% difference [95% CI= -11.0, 19.0]; p=0.609). In conclusion, HPV vaccine initiation increased after VR training, and further study is warranted., (Copyright © 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to evaluate a facilitated interactive role-playing activity on increasing human papillomavirus (HPV) vaccine recommendation skills for school nurses and school-based health center staff. A 1-day workshop was implemented for school-based clinicians focused on improving HPV vaccination rates in schools. The workshop included a facilitated interactive role-playing activity involving five scenarios related to recommending the HPV vaccine to parents. Participants completed a usability survey with open-ended questions assessing their experience. A general inductive approach was used to examine responses. Sixteen participants completed the usability survey. The major strength identified specific to the activity included opportunity to practice evidence-based recommendation skills (n = 10). Weaknesses of the activity identified included lack of diversity (n = 4) and complexity within the scenarios (n = 2). Results could shift current educational and clinical paradigms through the implementation of hands-on education strategies to effectively train school-based clinicians to strongly recommend the HPV vaccine., (© 2021. American Association for Cancer Education.)

Missed clinical opportunities and the lack of strong and consistent vaccine recommendations are key reasons for low HPV vaccination rates. The purpose of this study was to conduct a pilot evaluation of a web-based training's impact on knowledge, attitudes, and self-efficacy related to providing evidence-based HPV vaccine recommendations. Participants completed three online interactive learning modules and the HPV Vaccine: Same Way, Same Day ™ smartphone application (app). Participants completed a pre-training survey, immediate post-training survey, and two-month post-survey. Participants demonstrated a statistically significant increase in knowledge scores from T1 to T2 and T1 to T3. Mean attitudes for recommending HPV vaccination for female patients increased from T1 to T2 and T1 to T3. Mean attitudes for recommending HPV vaccination for male patients increased from T1 to T2 and T1 to T3. Mean self-efficacy scores increased from T1 to T2 and T1 to T3. The HPV Vaccine: Same Way, Same Day ™ app is a promising strategy for improving HPV vaccine recommendations among physicians. Future research should explore long-term effects and enroll attending and community physicians to examine its efficacy in other physician populations.

Objective: Scalable, deliberate practice training strategies to administer evidence-based recommendations are necessary to improve human papillomavirus (HPV) vaccination rates. We sought to characterize resident clinicians' perceptions regarding the usability of the HPV Vaccine: Same Way, Same Day smartphone application (app). Usability, a critical aspect of digital programs to promote behavior change, was evaluated., Methods: Fifteen third-year pediatric residents were recruited to complete a usability evaluation of the HPV Vaccine: Same Way, Same Day app, which includes simulated role-play scenarios in which users interact, as a pediatrician avatar, with an animated parent hesitant to accept the vaccine for her child. The app provides information about the vaccine and utilizes deliberate practice, a purposeful and systematic approach to improve performance, to teach evidence-based vaccine recommendation practices, including motivational interviewing skills. Data were derived from in-depth, semistructured interviews with pediatric residents. We used a constructivist general inductive approach to illuminate perspectives via inductive coding and pattern identification. Garrison's theoretical construct on self-directed learning was used to cluster themes into conceptual categories., Results: We classified interview data in 3 conceptual categories: self-management, internal monitoring and motivational principles. Residents described the app as interactive, easy to use, succinct, informative, engaging, and practical. All residents would recommend the HPV Vaccine: Same Way, Same Day app to a colleague. Residents suggested adding more complex cases for future iterations., Conclusions: From their perspective, pediatric residents reported that an app using deliberate practice principles has the potential to inform and advance providers' counseling skills regarding the HPV vaccine., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to determine individual- and partner-level factors associated with human papillomavirus (HPV) infection in vaccinated and unvaccinated men., Methods: A total of 747 men, aged 13-26 years, completed a survey of sexual behaviors and were tested for genital and perianal/anal HPV (36 types). Sexual network variables included recent and lifetime concurrency (being in more than one sexual relationship at the same time) and recent sex partner discordance (by race, ethnicity, age, and number of sexual partners). We determined individual-level and sexual network variables associated with ≥1 HPV type and HPV16/18, stratified by vaccination status, using separate multivariable logistic regression models., Results: Participants' mean age was 21.2 years; 64% were positive for ≥1 HPV type and 21% for HPV16/18. Factors associated with ≥1 HPV type in unvaccinated men included recruitment site and lifetime concurrency. Factors associated with ≥1 HPV type among vaccinated men included recruitment site, Chlamydia history, main male partner, number of lifetime female partners, and no condom use with female partner. Factors associated with HPV16/18 in unvaccinated men included race and partner concurrency. Factors associated with HPV16/18 in vaccinated men included ethnicity, main male partner, and recent concurrency., Conclusions: Sexual network variables associated with HPV infection were different based on vaccination status and HPV type, suggesting risk factors for HPV infection may change as the proportion of vaccinated men increases. In addition, participant report of concurrency and not knowing whether one had practiced concurrency were consistent risk factors; clinicians should consider including concurrency in the sexual history to determine the risk of HPV., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Due to social media's ability to publicize misinformation about vaccines, there is a need to study associations between social media engagement (SME) with human papillomavirus (HPV) and vaccine-related awareness and beliefs. Therefore, the study objectives were to (1) describe the SME of a nationally representative sample of US adults, and (2) determine the associations between SME and HPV-related awareness, HPV-related knowledge, HPV vaccine-related awareness, and perceived HPV vaccine efficacy. In 2019, we completed a secondary analysis of the 2017 Health Information National Trends Survey (Cycle 5.1). We created the SME index from 5 social media items. For each outcome variable, 3 models using binary and multinomial logistic regression were estimated. SME in the sample (n = 3171) was low (M = 0.9; range: 0-2). Respondents with higher SME had higher odds of HPV awareness (AOR = 1.56; 95% CI = 1.23, 1.99). Higher SME was associated with awareness of the HPV vaccine (AOR = 1.46; 95% CI = 1.16, 1.85). Respondents with higher SME had higher odds of perceiving HPV vaccine to be "not at all successful" (AOR = 2.22; 95% CI = 1.16, 4.24), "a little successful" (AOR = 1.99; 95% CI = 1.35, 2.94), "pretty successful" (AOR = 1.40; 95% CI = 1.04, 1.89), and "very successful" (AOR = 1.40; 95% CI = 1.02, 1.92) compared to those who selected "don't know" after adjusting for demographics and internet use. Our study highlights novel findings using a comprehensive SME index with a national sample providing insight to leverage existing consumer behaviors to better connect and disseminate accurate HPV information in a more strategic manner., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Recent guidelines indicate adults 27-45 years old can receive the human papillomavirus (HPV) vaccine based on a shared-decision with their healthcare provider. With this expansion in recommendations, there is a need to examine the awareness and knowledge of HPV and HPV vaccination among this age group for cancer prevention., Methods: HINTS-5 Cycle-2 is a national survey of US adults, and was restricted to a complete case analysis of adults ages 27-45 years (N = 725). Sociodemographic, healthcare, and health information correlates were assessed for the outcomes of HPV awareness, HPV vaccine awareness, knowledge of HPV and cervical cancer, and knowledge of HPV and non-cervical cancers. Survey-weighted logistic regression models were conducted., Results: Most respondents were aware of HPV (72.9%) and HPV vaccination (67.1%). Respondents were more likely to be aware of HPV and HPV vaccination if they were female, had a higher level of education, and had previous cancer information seeking behaviors. Although there was widespread knowledge of HPV as a cause of cervical cancer (79.6%), knowledge of HPV as a cause of non-cervical cancers was reported by a minority of respondents (36.1%). College education was positively associated with cervical cancer knowledge (aOR = 4.62; 95%CI: 1.81-11.78); however, no significant correlates were identified for non-cervical HPV associated cancer knowledge., Conclusion: While more than half of adults ages 27-45 years are aware of HPV and HPV vaccination, there are opportunities to improve awareness and knowledge, particularly related to non-cervical cancers, as these are critical first steps toward shared decision-making for HPV vaccination in mid-adulthood., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: School nurses and personnel play a vital role in promoting the human papillomavirus (HPV) vaccine. The purpose of this study was to identify factors associated with school nurses' and personnel's professional practice to provide parents with HPV vaccine information and to encourage parents to vaccinate their child against HPV., Methods: School nurses and personnel from Ohio and Missouri completed a survey to assess their professional practice in providing HPV vaccine information and encouraging parents to vaccinate their child against HPV. Independent variables included demographics, HPV knowledge/attitudes, perceptions of their as an opinion leader for the HPV vaccine, self-efficacy to provide vaccine education, and perception of school district support., Results: Providing parents with HPV vaccine information was predicted by age, role within the school, grade-serving, knowledge, perceptions, self-efficacy, and district support; accounting for 38% of the variance (p < .000, R 2  = .38). Encouraging parents to vaccinate their child against HPV was predicted by perception, self-efficacy, and grade-serving; accounting for 39% of the variance (p < .000, R 2  = .39)., Conclusions: To enhance school nurses' and personnel's professional practice, interventions should focus on nurses' and personnel's perception of their role as opinion leaders and self-efficacy to provide HPV education and vaccine recommendation., (© 2019, American School Health Association.)

Human papillomavirus (HPV) vaccination has the potential to reduce the burden of anogenital cancers. Vaccine uptake remains suboptimal, especially among young adults. Social determinants of health (SDOH) are societal level conditions that may indirectly influence health behaviors, including HPV vaccination. The purpose of this study was to assess HPV vaccination and SDOH among young adult women and men. The 2016 National Health Interview Survey was restricted to participants ages 18-26 (n = 3593). The Healthy People 2020 SDOH Framework was used to identify variables for economic stability, health and healthcare, education, social and community context, and neighborhood and built environment. Survey-weighted logistic regression models identified SDOH variables significantly associated with HPV vaccination. Reported HPV vaccination occurred for 45.7% of women and 14.5% of men in the sample. Among women, education determinants-highest level of education completed and English language-were significantly associated with HPV vaccination. Men (adjusted OR 0.65, 95% CI 0.54, 0.79) and women (adjusted OR 0.66, 95% CI 0.49, 0.90) who did not use the Internet to look up health information were at lower odds to be vaccinated for HPV. These findings can inform future HPV vaccine uptake efforts by focusing specifically on these SDOH areas-education and health and healthcare. Identifying SDOH leverage points is critical to promoting HPV vaccination and ultimately reducing HPV-associated cancers.

Numerous online HPV vaccine education interventions for clinicians have been created to improve HPV vaccinations rates. The aims for this study were to (1) assess the content of the purpose statements and learning objectives of online HPV vaccine continuing medical education (CME) activities developed for clinicians and (2) identify themes and gaps in the purpose statements and learning objectives. A content analysis was conducted of the purpose statements and learning objectives for each HPV vaccine online CME activity. Open coding identified the following purpose statements topics: 1) delivering recommendations, 2) HPV epidemiology, 3) HPV vaccine, 4) guidelines, and 5) medical news. The following topics for learning objectives were identified: 1) delivering recommendations, 2) strategies, 3) HPV epidemiology, 4) HPV vaccine, 5) guidelines, 6) prevention services, 7) HPV vaccination advocacy, and 8) disparities. Phrases about guidelines for vaccine administration and vaccine recommendation guidelines were the most common for purpose statements and learning objectives, respectively. One learning objective focused on behavior/skill change, which is concerning considering clinicians do not feel well prepared to provide strong vaccine recommendations. Clear and intentional purpose statements and learning objectives must be used to guide the development of effective CME activities.

The human papillomavirus (HPV) is a public health concern because of its association with cancer. HPV vaccine rates among college students remains low. This is a critical catch-up age for individuals to receive the HPV vaccine and research shows parents still play a role in college students' medical decision-making. Therefore, the purpose of this study was to examine factors related to college women making a solo decision to initiate the HPV vaccination in comparison to making a joint parent-daughter decision. Data collected using an internet-delivered questionnaire were analyzed from 799 college women who had initiated or completed the HPV vaccination. Multinomial logistic regression was performed to compare study variables on who decided the participant should be vaccinated (self-decision, parent-only decision, joint parent-daughter decision). Participants who were older (OR 1.68, p < 0.001) and sexually active (OR 4.97, p < 0.001) were significantly more likely to have made a solo decision to be vaccinated. Participants who completed the HPV vaccination (OR 0.33, p < 0.001) and those who talked with a parent about the HPV vaccine (OR 0.12, p < 0.001) were significantly less likely to have made a solo decision to be vaccinated. Findings indicate joint parent-daughter decisions may improve HPV vaccination cycle completion.

Human papillomavirus (HPV) has been identified as the leading cause of cervical cancer. While HPV risk factors have been well studied, less is known about those with HPV and their perceptions about health ramifications. The purposes of this study were to examine unmarried college student women's (1) HPV diagnosis status and (2) perceived risk of getting cervical cancer in the next 5 years. Data were analyzed from 1106 unmarried, sexually active college women aged 18 to 26. Binary logistic regression compared HPV-related knowledge, vaccination-related perceptions, mandate support, healthcare utilization, sexual behaviors, and personal characteristics. Multinomial logistic regression was performed to assess the degree to which these factors were associated with perceived risk of cervical cancer diagnosis. Relative to those not diagnosed with HPV, participants who had more lifetime sex partners (P < 0.001), unprotected sex during last intercourse (P = 0.003), Pap test in the past year (P < 0.001), and perceived themselves to be at higher risk for cervical cancer (P < 0.001) were significantly more likely to be diagnosed with HPV. Those with HPV were more likely to support HPV vaccination mandates (P = 0.036) and have fewer friends vaccinated (P = 0.002). Participants who were uninsured (P = 0.011), diagnosed with HPV (P < 0.001), and had a family member (P < 0.001) or friend (P < 0.001) with cervical cancer were more likely to perceive themselves at risk for developing cervical cancer in the next 5 years. Findings indicate women with HPV, despite engaging in risky sexual behaviors, acknowledge their cervical cancer risk and may be strong advocates for HPV vaccination mandates to protect youth against this preventable virus.

Clinicians' recommendation for the human papillomavirus (HPV) vaccine appears to be an important driver of parental decisions about vaccination. Our aim was to synthesize the best available evidence exploring the perceptions and experiences regarding HPV vaccination, from the perspective of the US clinician. We conducted a comprehensive literature search of Academic Search Complete, CINAHL Plus, Communication & Mass Media Complete, Consumer Health Complete (EBSCOhost), ERIC, Health and Psychosocial Instruments, MEDLINE with full text, and PsycINFO databases. We identified 60 eligible articles: 48 quantitative and 12 qualitative. We extracted the following information: study purpose, use of theory, location, inclusion criteria, and health care provider classification. Results were organized into 5 categories: 1) clinicians' knowledge and beliefs about HPV and the HPV vaccine, 2) clinicians' attitudes and beliefs about recommending HPV vaccines, 3) clinicians' intention to recommend HPV vaccines, 4) clinicians' professional practices regarding HPV vaccination, and 5) patient HPV vaccination rates. Although clinicians were generally supportive of HPV vaccination, there was a discrepancy between clinicians' intentions, recommendation practices, and patient vaccination rates. Studies reported that clinicians tended not to provide strong, consistent recommendations, and were more likely to recommend HPV vaccines to girls versus boys and to older versus younger adolescents. Analyses revealed a number of facilitating factors and barriers to HPV vaccination at the clinician, parent/patient, and systems levels, including clinician knowledge, clinician beliefs, and office procedures that promote vaccination. This review provides an evidence base for multilevel interventions to improve clinician HPV vaccine recommendations and vaccination rates., (Copyright © 2017 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Background: Human papillomavirus (HPV) vaccination rates fall far short of Healthy People 2020 objectives. A leading reason is that clinicians do not recommend the vaccine consistently and strongly to girls and boys in the age group recommended for vaccination. Although Web-based HPV vaccine educational interventions for clinicians have been created to promote vaccination recommendations, rigorous evaluations of these interventions have not been conducted. Such evaluations are important to maximize the efficacy of educational interventions in promoting clinician recommendations for HPV vaccination., Objective: The objectives of our study were (1) to expand previous research by systematically identifying HPV vaccine Web-based educational interventions developed for clinicians and (2) to evaluate the quality of these Web-based educational interventions as defined by access, content, design, user evaluation, interactivity, and use of theory or models to create the interventions., Methods: Current HPV vaccine Web-based educational interventions were identified from general search engines (ie, Google), continuing medical education search engines, health department websites, and professional organization websites. Web-based educational interventions were included if they were created for clinicians (defined as individuals qualified to deliver health care services, such as physicians, clinical nurses, and school nurses, to patients aged 9 to 26 years), delivered information about the HPV vaccine and how to increase vaccination rates, and provided continuing education credits. The interventions' content and usability were analyzed using 6 key indicators: access, content, design, evaluation, interactivity, and use of theory or models., Results: A total of 21 interventions were identified, out of which 7 (33%) were webinars, 7 (33%) were videos or lectures, and 7 (33%) were other (eg, text articles, website modules). Of the 21 interventions, 17 (81%) identified the purpose of the intervention, 12 (57%) provided the date that the information had been updated (7 of these were updated within the last 6 months), 14 (67%) provided the participants with the opportunity to provide feedback on the intervention, and 5 (24%) provided an interactive component. None of the educational interventions explicitly stated that a theory or model was used to develop the intervention., Conclusions: This analysis demonstrates that a substantial proportion of Web-based HPV vaccine educational interventions has not been developed using established health education and design principles. Interventions designed using these principles may increase strong and consistent HPV vaccination recommendations by clinicians., (©Brittany L Rosen, James M Bishop, Skye L McDonald, Jessica A Kahn, Gary L Kreps. Originally published in JMIR Cancer (http://cancer.jmir.org), 16.02.2018.)

We performed a secondary analysis of Adolescent Health Risk Behavior Survey data ( N = 937), examining associations between lifetime alcohol and marijuana use with intrapersonal (i.e., risk perceptions) and interpersonal (e.g., peer approval and behavior) factors. Multinomial and binary logistic regression analyses contend students reporting lifetime alcohol use-compared to students who had never used alcohol or marijuana-perceived lower alcohol risk ( p < .001), higher friend drinking approval ( p < .001), and greater friend drinking ( p = .003). Using both alcohol and marijuana in one's life was associated with being in public schools ( p = .010), higher grade levels ( p = .001), lower perceived alcohol ( p = .011) and marijuana use risk ( p = .003), higher friend approval of alcohol ( p < .001) and marijuana use ( p < .001), and believed more friends used alcohol ( p < .001). Compared to lifetime alcohol only, perceived friend academic performance decreased the risk of lifetime alcohol and marijuana use ( p = .043). Findings are beneficial to school nurses with students experiencing effects associated with substance use.

Understanding where adolescents obtain information about human papillomavirus (HPV) vaccines may be helpful in designing public health interventions promoting HPV vaccination. This study assessed the following: (1) exposure to specific sources of information about HPV vaccines, (2) self-reported helpfulness of these sources of information, and (3) whether the specific source of information was associated with knowledge and perceptions about HPV vaccines among adolescent girls. There were 339 adolescent girls (mean age = 16.8 years) recruited into the study. Television advertisements, the Internet, doctors/nurses, and mothers were the most frequently reported sources of vaccine information; more than 90% of participants who received information from these sources reported they were helpful. Adolescents who received information about HPV vaccines from television advertisements, the Internet, clinicians, and mothers had higher knowledge about HPV vaccines and more positive perceptions. Assuring the accuracy of messages from these sources will be essential, given their importance in influencing adolescents' knowledge and perceptions about HPV vaccines., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Kahn served as the chair of a grant review committee for a grant program sponsored by the Society for Adolescent Health and Medicine, which provided funding for public health demonstration projects to improve adolescent vaccination. Funding for the grant program was provided by Merck. Dr. Kahn has also served as cochair of two clinical trials of an HPV vaccine in HIV-infected individuals; these studies were funded primarily by the National Institutes of Health, but Merck provided vaccines and immunogenicity testing. Dr. Zimet has received funding for investigator-initiated HPV-related research from Merck and from Roche Diagnostics. Dr. Shew has and is currently participating as an investigator for Merck and Co, Inc, related HPV vaccine trials. She has received salary support for her efforts.

Purpose: Human papillomavirus (HPV) vaccination is recommended for 11- to 12-year-old U.S. adolescents. Unfortunately, HPV vaccine rates have been suboptimal. Parents are key decision agents regarding their adolescents' health; thus, it is necessary to understand their reasons for not vaccinating their adolescents. The purpose of this study was to compare parents' primary reasons for non-HPV vaccination by calendar year, sex of the child, and level of vaccine hesitancy., Methods: The National Immunization Survey-Teen 2012-2015 was subset to parents who did not intend for their adolescent to receive the HPV vaccine in the next 12 months (N = 59,897). Survey-weighted logistic regression models assessed the impact of year, sex, and level of hesitancy on main reasons for nonvaccination., Results: Not receiving a recommendation and lack of knowledge were significantly more likely to be the reasons for nonvaccination in 2012 and 2013 compared with 2015. The following reasons were significantly less likely to be reported for females compared with males: not recommended (odds ratio [OR] = .63, 95% confidence interval [CI], .58-.69) and lack of knowledge (OR = .86, 95% CI, .79-.94). In contrast, parents of females were more likely to state they were concerned about safety and side effects (OR = 2.19, 95% CI, 1.98-2.41). Differences in reasons for nonvaccination were observed between those who were unlikely and unsure regarding receiving the HPV vaccine., Conclusions: Findings indicate that U.S. parental attitudes about HPV vaccination have changed over time and reasons for nonvaccination vary based on the sex of the adolescent and the level of hesitancy of the parent. This information can shape how providers respond to parental concerns and HPV vaccine hesitancy., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to describe college-aged females' human papillomavirus (HPV) knowledge and beliefs, perceptions and perceived benefits of the HPV vaccine, and identify characteristics associated with vaccination status and support for HPV vaccine mandates. Data were collected from 1,105 females by an Internet-delivered questionnaire during February to March 2011. This descriptive study utilizes χ 2 tests and t-tests to compare participant responses. HPV-related knowledge scores were 8.08 out of 11 points. Those who initiated HPV vaccination were significantly younger, single, engaged in sex, were sexually active, and had a Pap test. Participants who had more friends receiving the vaccine were significantly more likely to support mandates for 9-11 and 12-17 years and were more likely to complete the HPV vaccination cycle. Findings suggest the importance of educational programs adopted and delivered by school nurses, which aim to improve student knowledge and reduce misconceptions related to the HPV vaccine and vaccination mandates.

School nurses are at the intersection of the healthcare and school communities, thus, they can be considered opinion leaders in providing health advice - including information about the human papillomavirus (HPV) vaccine - to parents and students. This study examined school nurses' attitudes toward the HPV vaccine based on age, years as a school nurse, geographic location, urban vs. rural work setting, HPV and vaccine knowledge, perception of role as opinion leaders, and school district support in providing health education. Participants (n = 413) were systematically sampled from the National Association of School Nurses' membership and completed a web-based survey. Multiple regression was used to predict positive HPV vaccine attitudes. The model was statistically significant accounting for 50.8% of the variance (F [9, 400] = 45.96, p < .001). Positive attitudes regarding the HPV vaccine were predicted by higher HPV and vaccine knowledge (β = .096, p < .001) and stronger perceptions of role as opinion leaders for the vaccine (β = .665, p < .001). No other variables were found to be statistically significant. These results suggest knowledge is essential in predicting positive attitudes, but not the strongest predictor as perceptions of role as opinion leaders was more crucial in terms of predicting school nurses' positive attitudes towards HPV vaccine. Despite school nurses being seen as champions for adolescent vaccines, they need additional professional development to increase their HPV vaccine knowledge and attitudes to encourage parents and adolescents to consider the uptake of HPV vaccination. To engage school nurses' in promoting HPV vaccine uptake, interventions need to focus on increasing school nurses' perception of their role as opinion leaders for HPV vaccine and knowledge to increase positive attitudes towards HPV vaccination for youth.

Human papillomavirus (HPV) is a contemporary public health concern because of its association with cervical cancer. Despite evidence about HPV vaccination benefits, debate surrounds whether or not to vaccinate American youth. While no nationwide mandate exists, understanding the behaviors and intentions of future parents may provide insight about our ability to protect the next generation of school-aged youth. The purposes of this study were to examine factors associated with unmarried college students' intentions to: (1) vaccinate their daughters against HPV and (2) give their daughters the choice about whether or not to be vaccinated. Data were analyzed from 1606 college students aged 18-26 using an internet-delivered questionnaire. Two binary logistic regression analyses were performed identifying predictor variables associated with participants' intentions when having daughters in the future to vaccinate them against HPV and whether or not they would let their daughters decide to get the vaccination. Relative to those who did not intend to vaccinate their daughters against HPV, participants who were female (OR 1.55, P = 0.018), sexually active (OR 1.62, P = 0.001), diagnosed with HPV (OR 2.64, P < 0.001), received a flu shot in the past 12 months (OR 1.63, P = 0.002), perceived the HPV vaccine to be safe (OR 1.19, P < 0.001), and supported HPV vaccination mandates for school-aged youth (OR 2.58, P < 0.001) were more likely to report intentions of vaccinating their daughters against HPV. Participants who were sexually active (OR 1.45, P = 0.002) and perceived the HPV vaccine to be safe (OR 1.05, P = 0.012) were more likely to report they would allow their daughters to choose whether to be vaccinated against HPV. Until HPV vaccination mandates are enacted, parental support of vaccines are among the most effective way of increasing vaccine uptake. Identifying HPV vaccination support among future parents has potential to inform parent vaccination education programs related and advocacy for HPV vaccination policies.

Background: We examine personal characteristics, alcohol consumption, normative beliefs, household factors, and extracurricular engagement associated with intentions to have intercourse before marriage among abstinent students., Methods: Data were analyzed from 245 freshmen enrolled in a school-based abstinence-only-until-marriage program. Two binary logistic regression analyses identified factors associated with intentions to engage in intercourse before marriage and within the next year., Results: Approximately 21% and 14% of participants reported intentions to have intercourse. Respondents participated in 2.2 (standard deviation [SD] = 1.2) extracurricular activities. Freshmen who were male, perceived their friends to approve of premarital sex, and consumed alcohol were more likely to report intentions to have intercourse. For every additional extracurricular activity in which freshmen participated, they were less likely to report intentions to have intercourse within the next year (odds ratio [OR] = 0.56)., Conclusions: Factors such as extracurricular activities provide youth with opportunities to build supportive relationships, connect with peers and role models, and positively engage in schools and communities. Extracurricular activities typically already exist, have funding, and are generally well-supported. School-based strategies can increase teenagers' autonomy by providing a variety of activities to participate in and reduce unsupervised time. This, in turn, has the potential to decrease sexual risk taking behaviors., (© 2016, American School Health Association.)

Because U.S. human papillomavirus (HPV) vaccination rates remain low, we evaluated school nurses' knowledge, attitudes, perceptions of their role as opinion leaders, self-efficacy, intention, and professional practice regarding the HPV vaccine and determined if these variables influenced their professional practice concerning the HPV vaccine. We utilized a cross-sectional design by recruiting Ohio Association of School Nurses (OASN) members. Participants (n = 145) completed a paper survey during the OASN annual conference. Structural equation modeling was used to examine the proposed model. Our model yielded a well-fitting solution, χ2 = 1.118 (degrees of freedom = 2, p = .57). Knowledge had positive effects on intention and self-efficacy. Attitude had a positive effect on perception of role as opinion leaders. Intention to provide HPV vaccine education had a positive effect on professional practice. To develop school nurses' practice, interventions should center on increasing knowledge, attitudes, and intention toward providing HPV vaccine education., (© The Author(s) 2015.)

Objective: The purpose of this study was to examine well-being or flourishing of adolescents with asthma as well as factors influencing flourishing for these adolescents., Methods: A secondary analysis of data collected for the 2011-2012 National Survey of Children's Health was conducted. Flourishing of adolescents with and without asthma was compared. Parent coping and anger, child sex and age and child flourishing were examined for adolescents with asthma., Results: Youth with asthma had lower flourishing than those without this disease. Positive parent coping was related to flourishing, while parent anger negatively influenced flourishing of adolescents with asthma. Interaction terms were significant, indicating that the aforementioned variables interacted with adolescent age and sex., Conclusions: Study results point to a complex relationship between parent- and adolescent-level factors and adolescent well-being. Further research is needed to examine relations among flourishing and health outcomes in youth with asthma.

Background: Because human papillomavirus (HPV) vaccine rates remain low, we evaluated US school nurses' knowledge, attitudes, perceptions of their role as opinion leaders, and professional practice regarding HPV vaccine, and assessed whether knowledge, attitudes, and perceptions of being an opinion leader influenced their professional practice regarding the HPV vaccine., Methods: We used a cross-sectional design by recruiting members from the National Association of School Nurses. All participants (N = 505) were e-mailed a survey designed for this study. Structural equation modeling (SEM) tested direct and indirect effects., Results: Overall, school nurses had knowledge about HPV and the vaccine, and positive attitudes toward the vaccine. They had less-than-enthusiastic perceptions of their role as opinion leaders regarding the vaccine and implemented few activities related to providing vaccine information. The model revealed a good fit (χ(2)=20.238 [df=8, p< .01]), with knowledge directly related to attitudes, attitudes directly related to perceptions and practice, and perceptions directly affecting practice. In our model, perceptions functioned as a partial mediator., Conclusions: To enhance school nurses' practice regarding the HPV vaccine, focus should be on increasing positive attitudes toward the vaccine and strengthening perceptions of their role as opinion leaders., (© 2015, American School Health Association.)

A patient with steatocystoma multiplex (SM) with severe inflammation was treated with oral isotretinoin. Inflamed cysts markedly improved with treatment. However, after eight weeks of therapy, many pre-existing cysts rapidly enlarged and new cysts occurred. Therapy was then discontinued. Isotretinoin may have exacerbated or worsened this condition.