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Objective: HPV vaccination is recommended for children beginning at age 9 to prevent several types of cancer. Many parents turn to Facebook for health information. This study describes changes in HPV vaccine-related articles shared on Facebook amidst the COVID-19 pandemic. Methods: HPV-related articles shared on Facebook (2019–2021) were collected using Buzzsumo, a social media analytics tool and analyzed using content analysis. Articles were categorized by valence, misinformation, evidence types, persuasive tactics, and framing. We quantified these data and tested for difference by article year. Results: Of the 138 included articles, 51% had positive valence towards the vaccine and 36% had negative valence. In 2021, there was a significant increase in positive messaging (72% vs. 44% in 2019/2020; p

Abstract Background The current study analyzed articles shared on Facebook between 2019 and 2021 that discuss the HPV vaccine. Results address a gap in knowledge about the persuasive strategies used in HPV vaccine discourse on Facebook. Methods Using Buzzsumo.com, we collected 138 articles, shared on Facebook between 2019 and 2021, with the highest “engagement scores,” or total number of reactions, comments, and shares. Using a content analysis methodology, three independent coders were trained in using the study codebook, achieved acceptable inter-rater reliability (Krippendorf’s alpha = 0.811), and coded each article in Atlas.ti. Results Seventy-two articles had a positive valence toward the HPV vaccine, 48 had a negative valence, and 18 were mixed-valence or neutral. Pro-vaccine articles presented a variety of evidence types in support of benefits of HPV vaccination. Pro-vaccine articles primarily originated from national and local news sources. Anti-vaccine articles combined presentation of evidence with persuasive arguments and strategies, such as mistrust of institutions, fear appeals, ideological appeals, presenting a high number of arguments or detail, and minimizing the severity of HPV. Three sources were responsible for producing 62.5% of all anti-vaccine articles in the dataset. Mixed-valence or neutral articles mixed cancer prevention discourse with ideological appeals about protecting parental rights, and were mostly produced by local news outlets. Conclusion The results of this study can help health communicators anticipate the types of discourses that vaccine-hesitant parents may have encountered online. Implications and suggestions for practice are discussed.

BackgroundSexual harassment (SH) and sexual assault (SA) are serious public health problems among US service members. Few SH and SA prevention interventions have been developed exclusively for the military. Code of Respect (X-CoRe) is an innovative web-based, multilevel, SA and SH intervention designed exclusively for the active-duty Air Force. The program’s goal is to increase Airmen’s knowledge and skills to build and maintain respectful relationships, ultimately reducing SH and SA and enhancing Airmen’s overall well-being and mission readiness. ObjectiveThis pilot study aimed to assess the short-term psychosocial impact (eg, knowledge, attitudes, and self-efficacy) of the web-based component of X-CoRe on a sample of junior enlisted and midlevel Airmen. MethodsAirmen from a military installation located in the Northeastern United States were recruited to complete the 10 web-based modules in X-CoRe (9/15, 60% male; 7/15, 54% aged 30-35 years). Participants were given pretests and posttests to measure short-term psychosocial outcomes associated with SH and SA. Descriptive statistics and paired 2-tailed t tests were conducted to assess differences from preintervention to postintervention time points. ResultsAfter completing X-CoRe, participants had a significantly greater understanding of active consent (P=.04), confidence in their healthy relationship skills (P=.045), and confidence to intervene as bystanders (P=.01). Although not statistically significant (P>.05), mean scores in attitudes about SH, couple violence, and cyberbullying; perceptions of sexual misconduct as part of military life; and relationship skills self-efficacy with a romantic partner and friend also improved. ConclusionsThe findings from this study demonstrate X-CoRe’s effectiveness in improving critical determinants of SH and SA, making it a promising intervention for SH and SA prevention. More rigorous research is needed to determine X-CoRe’s impact on SH and SA victimization and the long-term impact on associated psychosocial determinants.

BackgroundThe health and safety of workers who work in areas severely damaged by natural weather events (reconstruction workers) is becoming an increasingly important health problem as these disasters increase in intensity and frequency. An evidence-based, innovative e-learning tool, Pocket Ark, has been developed to meet this need.MethodsIntervention Mapping, an iterative public health programming methodology, was used to create strategies designed to support the development and implementation of the Pocket Ark application for the health and safety of reconstruction workers before, after, and during natural disasters.DiscussionThe development of an evidence-based application, Pocket Ark, uses the concept of the Intervention Mapping planning framework. It can be an effective bridge of pre-deployment education, deployment health, and safety support for the reconstruction work in the immediate post-disaster environment.

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study’s purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP’s effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11–17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.

Provider recommendation of human papillomavirus (HPV) vaccination among adolescents has steadily improved over the years, however, limited research has been conducted to examine if the COVID-19 pandemic disrupted this positive trend in parent-reported provider recommendation among minority adolescents. Therefore, we conducted the present study to determine if there is an association between the pandemic and parent-reported provider recommendation of HPV vaccine among non-Hispanic black and Hispanic adolescents. We also examined whether any changes in parent-reported provider recommendation in the years 2019, 2020, and 2021 differed by race or ethnicity. Using a cross-sectional design to examine data from the National Immunization Survey-Teen (2019–2021), a moderation analysis and logistic regression analysis were performed to model race-specific variation in parent-reported provider recommendation (n = 50,739). We found that Hispanic parents had lower odds (aOR = 0.80 [0.71, 0.91]) of reporting receiving a recommendation compared to non-Hispanic white parents. We also found that the odds of parent-reported provider recommendation were higher in 2020 (aOR = 1.15 [1.03–1.29]) than in 2019. Other variables–age, region, sex, health insurance status, and poverty status–were all associated with parent-reported provider recommendation. These findings demonstrated that the pandemic may not have triggered any race-related gap in the recommendation of HPV vaccines, however, more pandemic-resilient public health efforts are needed to improve parent and provider communication regarding HPV vaccination of adolescents.

Being a victim of sexual violence (SV) is generally believed to be associated with subsequent sexual risk behavior (SRB) during adolescence. While this assumption makes intuitive sense, it is based on methodologically limited research, including a reliance on cross-sectional data. To address this gap in research, we test whether experiencing SV victimization in early adolescence is associated with self-reported SRB approximately two years later. The sample comprised 4,618 youth (58% female; 52% Hispanic; 39% Black) attending 44 schools in the southern United States. Self-reported data were collected using an audio computer-assisted self-interview (ACASI). Baseline data were collected when students were in 7th or 8th grade and follow-up data were collected approximately 24 months later when students were in 9th or 10th grade. Indices of SRB included behaviors related to oral, vaginal, and anal sex (e.g., number of partners, number of times without a condom). Girls, but not boys, who reported SV victimization at baseline reported engaging more frequently in all oral and vaginal SRBs at 24 month follow-up compared to their non-victimized female counterparts. Additionally, girls reporting SV victimization reported more anal sex partners than non-victimized girls. Girls who are victims of SV engage in significantly more SRB by early high school placing them at greater risk to contract STIs and become pregnant. Victims of SV should be screened for SRB and provided access to the appropriate resources. Teen pregnancy and STI prevention planning should consider SV victimization in their strategy planning.

Abstract Background Many Indigenous communities across the USA and Canada experience a disproportionate burden of health disparities. Effective programs and interventions are essential to build protective skills for different age groups to improve health outcomes. Understanding the relevant barriers and facilitators to the successful dissemination, implementation, and retention of evidence-based interventions and/or evidence-informed programs in Indigenous communities can help guide their dissemination. Purpose To identify common barriers to dissemination and implementation (D&I) and effective mitigating frameworks and strategies used to successfully disseminate and implement evidence-based interventions and/or evidence-informed programs in American Indian/Alaska Native (AI/AN), Native Hawaiian/Pacific Islander (NH/PI), and Canadian Indigenous communities. Methods A scoping review, informed by the York methodology, comprised five steps: (1) identification of the research questions; (2) searching for relevant studies; (3) selection of studies relevant to the research questions; (4) data charting; and (5) collation, summarization, and reporting of results. The established D&I SISTER strategy taxonomy provided criteria for categorizing reported strategies. Results Candidate studies that met inclusion/exclusion criteria were extracted from PubMed (n = 19), Embase (n = 18), and Scopus (n = 1). Seventeen studies were excluded following full review resulting in 21 included studies. The most frequently cited category of barriers was “Social Determinants of Health in Communities.” Forty-three percent of barriers were categorized in this community/society-policy level of the SEM and most studies (n = 12, 57%) cited this category. Sixteen studies (76%) used a D&I framework or model (mainly CBPR) to disseminate and implement health promotion evidence-based programs in Indigenous communities. Most highly ranked strategies (80%) corresponded with those previously identified as “important” and “feasible” for D&I The most commonly reported SISTER strategy was “Build partnerships (i.e., coalitions) to support implementation” (86%). Conclusion D&I frameworks and strategies are increasingly cited as informing the adoption, implementation, and sustainability of evidence-based programs within Indigenous communities. This study contributes towards identifying barriers and effective D&I frameworks and strategies critical to improving reach and sustainability of evidence-based programs in Indigenous communities. Registration number N/A (scoping review)

BackgroundDespite CDC recommendations for breast and cervical cancer screening and HPV vaccination, cancer control behaviors are underutilized among low-income Latinas. Salud en Mis Manos (SEMM), adapted from Cultivando La Salud, is a community health worker- (CHW-) delivered evidence-based intervention (EBI), shown to increase breast and cervical cancer screening.MethodsWe used Implementation Mapping to create SEMM-Dissemination and Implementation Assistance (SEMM-DIA), a set of implementation strategies designed to support implementation and maintenance of SEMM in clinic settings. Specifically, we used Implementation Mapping's five iterative tasks to guide the use of theories and frameworks, evidence, new data, and stakeholder input to develop strategies to accelerate and improve implementation fidelity, reach, and maintenance of the SEMM intervention. The resulting implementation mapping logic model also guides the SEMM-DIA evaluation plan to assess reach, effectiveness, implementation, and maintenance.DiscussionIncreased use of implementation planning frameworks is necessary to accelerate the translation of EBIs to public health practice. This work demonstrates the application of Implementation Mapping to develop SEMM-DIA, providing a model for the development of other implementation strategies to support translation of evidence-based health promotion interventions into clinic settings.

Parents’ stigmatizing beliefs about the HPV vaccine, such as beliefs that it promotes adolescent sexual activity, constitute a notable barrier to vaccine uptake. The purpose of this study is to describe the associations between parents’ stigmatizing beliefs about the HPV vaccine, psychosocial antecedents to vaccination, and parents’ intentions to vaccinate their children. Parents of vaccine-eligible children (n = 512) were surveyed in a large urban clinical network. Results indicate that two stigmatizing beliefs were significantly associated with self-efficacy in talking with a doctor about the HPV vaccine. Believing that the vaccine would make a child more likely to have sex was associated with citing social media as a source of information about the vaccine. Other stigmatizing beliefs were either associated with citing healthcare professionals as sources of information about the vaccine, or they were not significantly associated with any information source. This finding suggests that stigmatizing beliefs might discourage parents from seeking out information about the vaccine. This study is significant because it further highlights the importance of doctor recommendations to all patients at recommended ages; doctor visits may represent one of the few opportunities to normalize HPV vaccination and address parents’ stigmatizing beliefs about the HPV vaccine.

Parent hesitancy contributes to reduced HPV vaccination rates. The HPVcancerfree app (HPVCF) was designed to assist parents in making evidence-based decisions regarding HPV vaccination. This study examined if parents of vaccine-eligible youth (11–12 yrs.) who use HPVCF in addition to usual care demonstrate significantly more positive intentions and attitudes toward HPV vaccination and greater HPV vaccination rates compared to those not using HPVCF. Clinics (n = 51) within a large urban pediatric network were randomly assigned to treatment (HPVCF + usual care) or comparison (usual care only) conditions in a RCT conducted between September 2017 and February 2019. Parents completed baseline and 5-month follow-up surveys. Participant-level analysis determined 1) change in HPV vaccination initiation behavior and related psychosocial determinants and 2) predictors of HPV vaccine initiation. Parents (n = 375) who completed baseline and 5-month follow-up surveys were female (95.2%), 40.8 (±5.8) yrs. married (83.7%), employed (68.3%), college educated (61.9%), and privately insured (76.5%). Between-group analysis of HPVCF efficacy demonstrated that parents assigned to receive HPVCF significantly increased knowledge about HPV and HPV vaccination (p

BackgroundAmerican Indian and Alaska Native (AI/AN) youth experience serious disparities in sexual and reproductive health, including the highest teen birth rate among racial/ethnic groups, and disproportionate rates of sexually transmitted infections (STI), including HIV. A growing number of evidence-based programs (EBPs) that integrate the strengths and cultural teachings of Native communities exist. Yet, multiple factors, including lack of trained personnel, limited resources, and geographic isolation, may hinder their adoption and implementation. Innovative implementation strategies that facilitate the adoption and implementation of sexual health EBPs in Native communities may help reduce these disparities.MethodsWe applied Implementation Mapping, a systematic planning framework that utilizes theory, empirical evidence, and community input, to adapt a theory-based, online decision support system, iCHAMPSS (CHoosing And Maintaining Effective Programs for Sex Education in Schools), to support underlying dissemination and implementation processes unique to Native communities. We used an iterative design process, incorporating input from Native practitioners and academicians, to ensure that the adapted decision support system reflects cultural identification, community values, and experiences.ResultsGrounded in diffusion of innovations, organizational stage theory, and social cognitive theory, the Healthy Native Youth Implementation Toolbox supports Native practitioners through five phases (Gather, Choose, Prepare, Implement, and Grow) to adopt, implement, and maintain a culturally-relevant, age-appropriate sexual health EBP. The Toolbox provides tools, ready-to-use templates, and guidance to plan, implement, and grow a culturally-relevant adolescent health program with their Tribe or community. Hosted within the Healthy Native Youth website (www.healthynativeyouth.org), the Toolbox comprises: (1) a curriculum portal with access to 15 culturally-relevant, age-appropriate evidence-based health promotion programs for AI/AN youth; (2) a “resource library” comprising 20+ support tools, templates, and links to external resources, and (3) “stories from the field” comprising testimonials from experienced Native educators, who have implemented sexual health programs.ConclusionThere is a continued need to design, test, and evaluate D&I strategies that are relevant to Native communities. The Healthy Native Youth Implementation Toolbox contributes to the dissemination and implementation of evidence-based, culturally-relevant sexual health education programs in diverse Native communities. Implementation Mapping provided a systematic approach to guide the adaptation process and integrate community voice with the ultimate goal of enhancing sexual health equity among AI/AN youth.

Human papilloma virus (HPV) vaccination rates remain below national goals in the United States despite the availability of evidence-based strategies to increase rates. The Adolescent Vaccination Program (AVP) is a multi-component intervention demonstrated to increase HPV vaccination rates in pediatric clinics through the implementation of six evidence-based strategies. The purpose of this study, conducted in Houston, Texas, from 2019–2021, was to adapt the AVP into an online decision support implementation tool for standalone use and to evaluate its feasibility for use in community clinics. Phase 1 (Adaptation) comprised clinic interviews (n = 23), literature review, Adolescent Vaccination Program Implementation Tool (AVP-IT) design documentation, and AVP-IT development. Phase 2 (Evaluation) comprised usability testing with healthcare providers (HCPs) (n = 5) and feasibility testing in community-based clinics (n = 2). AVP-IT decision support provides an Action Plan with tailored guidance on implementing six evidence-based strategies (immunization champions, assessment and feedback, continuing education, provider prompts, parent reminders, and parent education). HCPs rated the AVP-IT as acceptable, credible, easy, helpful, impactful, and appealing (≥80% agreement). They rated AVP-IT supported implementation as easier and more effective compared to usual practice (p ≤ 0.05). The clinic-based AVP-IT uses facilitated strategy implementation by 3-month follow-up. The AVP-IT promises accessible, utilitarian, and scalable decision support on strategies to increase HPV vaccination rates in pediatric clinic settings. Further feasibility and efficacy testing is indicated.

BackgroundDespite the availability of culturally responsive sexual health educational programs for American Indian and Alaska Native (AI/AN) youth, barriers to their uptake and utilization persist in tribal communities. These challenges were exacerbated by the COVID-19 pandemic, which required flexible program delivery using both in-person and virtual classrooms. ObjectiveThis exploratory study provides a preliminary understanding of the extent to which pre-existing challenges impact the delivery of culturally responsive sexual health education programs in Native communities and to what extent they were exacerbated by the COVID-19 pandemic. It also highlights the challenges faced by adolescent health advocates when adapting culturally responsive health curricula to online platforms. Finally, this study discloses major socioeconomic, health, and mental challenges experienced by AI/AN youth during the pandemic. MethodsAn exploratory, descriptive, qualitative design approach was adopted to carry out 5 individual and 1 collective in-depth key informant interviews. A total of 8 Native and non-Native sexual health educators served as key informants and shared their personal experiences with the delivery of sexual health education programs for youth during the COVID-19 pandemic. The interviews were conducted virtually from October to November 2020 using Zoom to reach participants dispersed across different regions of the United States. We followed the consolidated criteria for reporting qualitative research (COREQ) as a reference for the study methodology. We also used the Braun and Clarke framework (2006) to conduct a thematic analysis. ResultsExperts’ opinions were structured according to 5 main themes: (1) competing community priorities during COVID-19; (2) moving to web-based programming: skills, training, support; (3) recruiting youth; and (4) challenges for implementation in a household environment; and (5) recommendations to overcome implementation challenges. These themes are complementary, connected, and should be considered holistically for the development, dissemination, and implementation of online sexual health programs for AI/AN youth, specifically during the COVID-19 pandemic. The results raised the following points for discussion: (1) Building partnerships with schools and community organizations facilitates program adaptation and implementation, (2) there is a need to adopt a holistic approach when addressing youth sexual health in AI/AN communities, (3) a systematic and culturally responsive adaptation approach ensures effective virtual program delivery, and (4) community and youth engagement is essential for the success of virtual sexual health programs. ConclusionsFindings can provide recommendations on actions to be taken by sexual health educators and guidelines to follow to ensure cultural sensitivity, effective adaptation, and successful implementation when setting out to advocate for online sexual health programs for AI/AN youth.

BackgroundSurvivors of breast cancer can face internal barriers to physical activity, such as uncertainty and frustration stemming from physical limitations, decreased physical functioning, fatigue, and pain. Interventions that draw from the principles of Acceptance and Commitment Therapy (ACT) may help survivors of breast cancer overcome some of the internal barriers associated with physical activity. ObjectiveThe primary aim of this study was to investigate the acceptability of an electronically delivered physical activity intervention for survivors of breast cancer, centered on ACT processes. MethodsThis study used a 1-group pretest-posttest design. We recruited 80 insufficiently active female survivors of breast cancer using a web-based recruitment strategy. The 8-week intervention consisted of weekly modules that featured didactic lessons and experiential exercises targeting key ACT processes in the context of physical activity promotion (namely, values, committed action, acceptance, defusion, and contacting the present moment). We determined intervention acceptability according to study retention (≥70%), adherence rates (≥75% of the participants completing ≥50% of the modules), and posttest survey scores reflecting the perceived ease of use, perceived usefulness, and interest and enjoyment of the intervention (≥5 on a 7-point Likert-type scale). We also evaluated changes in self-reported aerobic and muscle strengthening–physical activity, physical activity acceptance, physical activity regulation, and health-related outcomes. ResultsThe retention rate (61/80, 76%), adherence rate (60/80, 75%), average perceived ease of use (6.17, SD 1.17), perceived usefulness (5.59, SD 1.40), and interest and enjoyment scores (5.43, SD 1.40) met the acceptability criteria. Participants increased their self-reported aerobic physical activity (Cohen d=1.04), muscle strengthening–physical activity (Cohen d=1.02), physical activity acceptance (cognitive acceptance: Cohen d=0.35; behavioral commitment: Cohen d=0.51), physical activity regulation (identified regulation: Cohen d=0.37; integrated regulation: Cohen d=0.66), increased their ability to participate in social roles and activities (Cohen d=0.18), and reported less fatigue (Cohen d=0.33) and sleep disturbance (Cohen d=0.53). ConclusionsElectronically delivered acceptance- and mindfulness-based interventions may be useful for promoting physical activity in survivors of breast cancer. Further research is needed to refine these approaches and evaluate their effectiveness.

BackgroundHuman papillomavirus (HPV)-attributed cancers are preventable, yet HPV vaccination rates severely lag behind other adolescent vaccinations. HPVcancerFree (HPVCF) is a mobile health (mHealth) intervention developed to influence parental HPV vaccination decision making by raising awareness of HPV, reducing HPV vaccination barriers, and enabling HPV vaccination scheduling and reminders through a smartphone app. Evaluating the user experience of mHealth interventions is a vital component in assessing their quality and success but tends to be underreported in mHealth intervention evaluation. ObjectiveWe aimed to evaluate the user experience of HPVCF, an HPV cancer prevention app designed for a pediatric clinic network, using mixed methods data collected from log files, survey measures, and qualitative feedback. MethodsStudy data were evaluated from parents in a large US pediatric clinic network using HPVCF in the treatment study condition of a group randomized controlled trial. Log data captured HPVCF retention and use. Postintervention rating scales and items assessed HPVCF utility, usefulness, understandability, appeal, credibility, and perceived impact. Overall quality was evaluated using the user version of the Mobile Application Rating Scale (uMars). Open-ended responses assessed parent recommendations for HPVCF enhancement. ResultsThe 98 parents were mainly female (n=94, 96%), 41 (5.67) years of age, college educated (n=55, 56%), and White and non-Hispanic (n=55, 56%) and had private health insurance for their children (n=75, 77%). Parents used HPVCF 197 times, with the average visit duration approximating 3.5 minutes. The uMARS app quality score was positively skewed (4.2/5.0). Mean ratings were highest for information (4.46 [SD 0.53]) and lowest for engagement (3.74 [SD 0.69]). In addition, of 95 parents, 45 (47%) rated HPVCF as helpful in HPV vaccination decision making and 16 (17%) attributed HPV vaccine initiation to HPVCF. Parents reported that HPVCF increased their awareness (84/95, 88%), knowledge (84/95, 88%), and HPV vaccination intentions (64/95, 67%). Most of the 98 parents rated the 4 HPVCF components as useful (72-92 [73%-94%]). Parents also agreed that HPVCF is clear (86/95, 91%), accurate (86/95, 91%), and more helpful than other HPV vaccine information they had received (89/95, 94%) and that they would recommend it to others (81/95, 85%). In addition, parents suggested ways to increase awareness and engagement with the app, along with opportunities to enhance the content and functionality. ConclusionsHPVCF was well received by parents and performed well on indicators of quality, usefulness, utility, credibility, and perceived impact. This study contributes a multimethod and multimeasure evaluation to the growing body of literature focused on assessing the user experience of patient-focused technology-mediated applications for HPV education.

Studies have consistently shown that vaccination rates against human papillomavirus (HPV) lag far behind other adolescent vaccinations recommended at the same age, resulting in exposing adolescents to unnecessary future risk of infection, and genital and head and neck cancers. Studies also have demonstrated that a major barrier to vaccination is lack of a strong provider recommendation. Factors that providers offer for failing to give a strong recommendation range from perception that the child is not at risk or the need to explain that the vaccine is not mandated (lack of equity and justice) or respect for parental autonomy. We look at the issue through a different lens, and reframe the above viewpoint by describing how failing to make a strong recommendation means the provider is not meeting the four principles of medical ethics (justice, beneficence, non-maleficence and autonomy).

BackgroundHuman papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making. ObjectiveThis study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI. MethodsWe conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network. ResultsThe 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience. ConclusionsSynchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child’s pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents.

BackgroundThe rapid growth of social media as an information channel has made it possible to quickly spread inaccurate or false vaccine information, thus creating obstacles for vaccine promotion. ObjectiveThe aim of this study is to develop and evaluate an intelligent automated protocol for identifying and classifying human papillomavirus (HPV) vaccine misinformation on social media using machine learning (ML)–based methods. MethodsReddit posts (from 2007 to 2017, N=28,121) that contained keywords related to HPV vaccination were compiled. A random subset (2200/28,121, 7.82%) was manually labeled for misinformation and served as the gold standard corpus for evaluation. A total of 5 ML-based algorithms, including a support vector machine, logistic regression, extremely randomized trees, a convolutional neural network, and a recurrent neural network designed to identify vaccine misinformation, were evaluated for identification performance. Topic modeling was applied to identify the major categories associated with HPV vaccine misinformation. ResultsA convolutional neural network model achieved the highest area under the receiver operating characteristic curve of 0.7943. Of the 28,121 Reddit posts, 7207 (25.63%) were classified as vaccine misinformation, with discussions about general safety issues identified as the leading type of misinformed posts (2666/7207, 36.99%). ConclusionsML-based approaches are effective in the identification and classification of HPV vaccine misinformation on Reddit and may be generalizable to other social media platforms. ML-based methods may provide the capacity and utility to meet the challenge involved in intelligent automated monitoring and classification of public health misinformation on social media platforms. The timely identification of vaccine misinformation on the internet is the first step in misinformation correction and vaccine promotion.

Self-management support (SMS) interventions help stroke survivors achieve behavior changes to control stroke risk factors. Goal-setting is a fundamental skill widely recognized as integral to SMS. Theories related to goal-setting describe a mediating effect between the quality of a goal and successful goal attainment. However, direct measurement of goal attainment and its mediated effect on sustained behavior change is not well quantified. We report findings from an updated systematic review of peer-reviewed systematic reviews to identify current valid, reliable measures of goal attainment, with specific focus on goal-attainment measurement used in SMS interventions for stroke risk factors. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to ensure transparent reporting. Databases used were Medline (Ovid), PubMed (National Library of Medicine), Embase (Ovid), and PsycINFO (Ovid). A priori eligibility criteria included outcome measures for goal attainment and publication in English (2006–2017), following last major review. Of 1363 citations found, 808 titles and abstracts were screened; 52 articles were included in the full review and nine in the final analysis. No measures of goal attainment in the context of SMS for stroke risk factors were identified. The only published measures of goal attainment related to stroke were in the stroke-rehabilitation context. The effect of goal attainment on effective SMS of stroke risks factors could not be determined. We conclude there remains an absence of outcome measures for goal attainment in the context of SMS and SMS interventions that target stroke risk factors.

Background: As schools of public health adapt to the new Council on Public Health (CEPH) competencies there is increased relevance in training public health professionals in public health entrepreneurship. Public health entrepreneurship provides an alternate process to traditional academic approaches focusing on translating public health knowledge into effective, sustainable, and scalable solutions.Objective: This study reports student perceptions of public health entrepreneurship and training needs for successfully equipping future public health professionals.Methods: Focus groups were conducted in April 2018 with graduate public health students in pilot entrepreneurship courses at two U.S.-based CEPH-accredited schools of public health.Results: Participating students (n = 29) were mainly pursing MPH degrees (62%) within Health Management and Policy (38%) or Health Promotion/Global Health (31%) departments. Most students (52%) were between 21 and 30 years old. For 71% of students this was their first academic course with a focus on entrepreneurial thinking. Four themes emerged regarding public health entrepreneurship and training needs for becoming a successful public health professional of the future. Students confirmed a place for public health entrepreneurship in the emerging educational paradigm because it is action-oriented, skills-driven, and fosters innovation through inter-professional collaboration and cross-pollination of knowledge and skills between professional disciplines.Conclusions: The competencies required for public health entrepreneurship are in alignment with CEPH competencies and are well-received by the next generation of public health professionals as an adjunct but nascent approach to stimulate public health innovation.

Tribal health educators across the United States have found it challenging to locate engaging, culturally-relevant sexual health curricula for American Indian and Alaska Native (AI/AN) youth. Healthy Native Youth is a new online resource that provides a “one-stop-shop” for tribal health advocates to access age-appropriate curricula. The site was designed by a team of advisers representing a diverse group of tribal communities, using a collaborative planning process. The website content and navigation was then refined through usability testing with the target audience. The portal allows users to filter and compare curricula on multiple dimensions, including: age, delivery setting, duration, cost, and evidence of effectiveness, to determine best-fit. It includes all materials needed for implementation free-of-charge, including: facilitator training tools, lesson plans, materials to support participant marketing and recruitment, information about each program's cultural relevance, evaluation methods and findings, and references to publications and reports. The website currently includes mCircle of Life, Native It's Your Game, Native STAND, Native VOICES, and Safe in the Village, among others. Since its launch in August 2016, the site has had over 31,000 page views in all 50 States. The Healthy Native Youth portal provides educators in rural communities a promising new tool to support the dissemination and implementation of evidence-based health curricula in geographically-disbursed AI/AN communities. Lessons learned during the design and dissemination of the Healthy Native Youth website may be of value to other Indigenous populations interested in our approach and our findings.

IntroductionEpilepsy is a neurological disorder involving recurrent seizures. It affects approximately 5 million people in the U.S. To optimize their quality of life people with epilepsy are encouraged to engage in self-management (S-M) behaviors. These include managing their treatment (e.g., adhering to anti-seizure medication and clinical visit schedules), managing their seizures (e.g., responding to seizure episodes), managing their safety (e.g., monitoring and avoiding environmental seizure triggers), and managing their co-morbid conditions (e.g., anxiety, depression). The clinic-based Management Information Decision Support Epilepsy Tool (MINDSET) is a decision-support system founded on theory and empirical evidence. It is designed to increase awareness by adult patients (≥18 years) and their health-care provider regarding the patient’s epilepsy S-M behaviors, facilitate communication during the clinic visit to prioritize S-M goals and strategies commensurate with the patient’s needs, and increase the patient’s self-efficacy to achieve those goals.MethodsThe purpose of this paper is to describe the application of intervention mapping (IM) to develop, implement, and formatively evaluate the clinic-based MINDSET prototype and in developing implementation and evaluation plans. Deliverables comprised a logic model of the problem (IM Step 1); matrices of program objectives (IM Step 2); a program planning document comprising scope, sequence, theory-based methods, and practical strategies (IM Step 3); a functional MINDSET program prototype (IM Step 4); plans for implementation (IM Step 5); and evaluation (IM Step 6). IM provided a logical and systematic approach to developing and evaluating clinic-based decision support toward epilepsy S-M.

In Texas and across the United States, unintended pregnancy, HIV, and sexually transmitted infections (STIs) among adolescents remain serious public health issues. Sexual risk-taking behaviors, including early sexual initiation, contribute to these public health problems. Over 35 sexual health evidence-based programs (EBPs) have been shown to reduce sexual risk behaviors and/or prevent teen pregnancies or STIs. Because more than half of these EBPs are designed for schools, they could reach and impact a considerable number of adolescents if implemented in these settings. Most schools across the U.S. and in Texas, however, do not implement these programs. U.S. school districts face many barriers to the successful dissemination (i.e., adoption, implementation, and maintenance) of sexual health EBPs, including lack of knowledge about EBPs and where to find them, perceived lack of support from school administrators and parents, lack of guidance regarding the adoption process, competing priorities, and lack of specialized training on sexual health. Therefore, this paper describes how we used intervention mapping (Steps 3 and 4, in particular), a systematic design framework that uses theory, empirical evidence, and input from the community to develop CHoosing And Maintaining Effective Programs for Sex Education in Schools (iCHAMPSS), an online decision support system to help school districts adopt, implement, and maintain sexual health EBPs. Guided by this systematic intervention design approach, iCHAMPSS has the potential to increase dissemination of sexual health EBPs in school settings.

Background: Low adolescent HPV vaccination initiation due to parents declining vaccination remains a challenge for providers. In 2018, 65% of adolescent girls and 56% of adolescent boys in Texas initiated HPV vaccination. Gaps between HPV vaccination rates and those for Tdap (83%) and meningococcal vaccines (87%) among 13-17 year olds highlights missed opportunities to prevent HPV-related cancers. While leading medical organizations endorse a presumptive, bundled recommendation, in which the provider presents HPV vaccination the same way as other vaccines, bundled between Tdap and meningococcal at 11- or 12-year-old visits, provider recommendations vary. Methods: In 2015, we surveyed pediatricians in a large Texas pediatric clinic network to assess physician knowledge, beliefs, attitudes and behaviors regarding adolescent HPV vaccination. To ascertain HPV vaccination outcomes, survey data were merged with patient electronic health records. We examined the association of pediatrician HPV vaccination recommendation and vaccination using multivariable multilevel generalized linear models clustered by physicians. Adjusted odds ratios were calculated. Results: Among 226 physicians, 59.8% completed the emailed survey. Controlling for patient and physician demographics, odds of HPV vaccination initiation were significantly increased if physicians used a bundled approach to recommend the HPV vaccine: "Your child is due for three vaccines: Tdap, HPV, and meningococcal vaccine" versus "Your child is due for two vaccines, Tdap and meningococcal. There is also the HPV vaccine, which is optional" (OR: 1.59, 95% CI 1.30-1.96). Conclusion: This study links physician HPV vaccine recommendation wording and outcomes, showing the significant effect of bundling HPV vaccination for adolescent patients.

A set of mediation analyses were carried out in this study using data from It’s Your Game. . .Keep It Real (IYG), a successful HIV/STI/pregnancy prevention program. The IYG study evaluated a skill and normbased. HIV/STI/pregnancy prevention program that was implemented from 2004 to 2007 among 907 urban low-income middle school youth in Houston, TX, USA. Analyses were carried out to investigate the degree to which a set of proposed psychosocial measures of behavioral knowledge, perceived self-efficacy, behavioral, and normative beliefs, and perceived risky situations, all targeted by the intervention, mediated the intervention’s effectiveness in reducing initiation of sex. The mediation process was assessed by examining the significance and size of the estimated effects from the mediating pathways. The findings from this study provide evidence that the majority of the psychosocial mediators targeted by the IYG intervention are indeed related to the desired behavior and provide evidence that the conceptual theory underlying the targeted psychosocial mediators in the intervention is appropriate. Two of the psychosocial mediators significantly mediated the intervention effect, knowledge of STI signs and symptoms and refusal self-efficacy. This study suggests that the underlying causal mechanisms of action of these interventions are complex and warrant further analyses.

Background: Sexting has emerged as a common socio-cultural problem in our society today. Few studies have estimated the prevalence of sexting among younger middle school youth and even fewer have assessed the relationship between sexting and mental health outcomes like anxiety and depression symptoms among middle school youth. Objectives: To estimate the prevalence of sexting among sixth and seventh-grade middle school students in a large urban school district in Southeast Texas and to assess its relationship with mental health outcomes (both anxiety and depression) among these youth. Methods: A retrospective analysis of an existing three-year randomized, two-arm, nested longitudinal study was conducted. Associations between sexting and depression symptoms; and sexting and anxiety symptoms were assessed via univariate and multivariate logistic analysis. Results: The prevalence of sexting among sixth graders was found to be 12%. Compared to youth who were not engaged in sexting, engagement in sexting was associated with significantly increased odds of depression and anxiety symptoms. Conclusion: Sexting is common among youth and is associated with poorer mental health outcomes such as anxiety and depression among these youth, but further validation of these findings is needed.