Search

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

Women living with HIV (WLWH) are at increased risk of anal cancer compared to women without HIV, often due to persistent human papillomavirus (HPV) infections. This paper describes current practices and challenges conducting anal cancer screening for WLWH at an urban integrated safety-net system and a non-profit community-based HIV clinic. We conducted 25 semi-structured interviews with clinical and administrative stakeholders to assess knowledge, clinic practices and procedures, and experiences with anal cancer screening. Interview transcripts and fieldnotes were thematically analyzed using an iterative deductive and inductive coding scheme. Findings were organized by the Consolidated Framework for Implementation Research (CFIR) domains and constructs. Provider-level barriers to conducting anal cancer screening included limited knowledge of guidelines. System-level barriers included: structural characteristics such as lack of coordination between clinics to discern provider roles and responsibilities; and limitations in available resources such as configuration of electronic health records and infrastructure to manage referrals of abnormal anal Pap results. We conclude that anal cancer screening and follow-up for WLWH requires organization and coordination between multiple care teams, updated clinical information systems to facilitate communication and support anal Pap ordering and result documentation, and infrastructure that includes policies and protocols for management of abnormal results. Trial registration: ClinicalTrials.gov identifier: NCT02135419.

Background Human Papillomavirus (HPV) vaccination is recommended for children aged 11-12 years in the United States. One factor that may contribute to low national HPV vaccine uptake is parental exposure to misinformation on social media. Objective This study aimed to examine the association between parents’ perceptions of the HPV vaccine information on social media and internet verification strategies used with the HPV vaccine decision-making stage for their child. Methods Parents of children and adolescents aged 9-17 years were recruited for a cross-sectional survey in North Texas (n=1192) and classified into 3 groups: children and adolescents who (1) were vaccinated, (2) unvaccinated and did not want the vaccine, and (3) unvaccinated and wanted the vaccine. Multinomial logistic regression models were estimated to identify factors associated with the HPV vaccine decision-making stage with children and adolescents who were vaccinated as the referent group. Results Of the 1192 respondents, 44.7% (n=533) had an HPV-vaccinated child, 38.8% (n=463) had an unvaccinated child and did not want the vaccine, and 16.4% (n=196) had an unvaccinated child and wanted the vaccine. Respondents were less likely to be “undecided/not wanting the vaccine” if they agreed that HPV information on social media is credible (adjusted odds ratio [aOR] 0.40, 95% CI 0.26-0.60; P=.001), disagreed that social media makes them question the HPV vaccine (aOR 0.22, 95% CI 0.15-0.33; P Conclusions Interventions that promote web-based health literacy skills are needed so parents can protect their families from misinformation and make informed health care decisions.

Objective Efficiently addressing patient priorities and concerns remains a challenge in oncology. Systematic operationalization of patient-centered care (PCC) can support improved assessment and practice of PCC in this unique care setting. This review aimed to synthesize the qualitative empirical literature exploring the National Academy of Medicine (NAM)'s PCC constructs of values, needs, and preferences among patients' during their cancer treatment experiences. Methods A systematic review of qualitative studies published between 2002 and 2018 addressing adult patient values, needs, and preferences during cancer treatment was conducted. Medline, EMBASE, PsycINFO, and SCOPUS databases were searched on September 10, 2018. Methodological rigor was assessed using a modified version of the Evaluation Tool for Qualitative Studies. Included study findings were analyzed using line-by-line coding; and the emergent themes were compared to the National Academy of Medicine (NAM)'s PCC dimensions. Results Twenty-nine primary studies were included in the synthesis. Descriptive themes for values (autonomy, being involved, family, hope, normality, and sincerity), needs (care coordination, information, privacy, support of physical well-being, emotional support (family/friends, peer, provider), and self-support), and preferences (care coordination, decision-making, information delivery, source of social support, and treatment) were identified. "Cancer care context" emerged as an important domain in which these constructs are operationalized. This thematic framework outlines PCC attributes that oncology care stakeholders can evaluate to improve patient experiences. Conclusions These findings build on previous PCC research and may contribute to the systematic assessment of patient priorities and the improvement of oncology care quality from the patient perspective.

Highlights • Providers (29%) experience HPV-specific vaccine hesitancy from parents. • Providers feel least confident in responding to families’ religious beliefs. • Some providers (25%) agree with dismissal policies for families refusing vaccines., Parental vaccine hesitancy is a growing concern. Less is known about provider or practice characteristics that encounter HPV-specific vaccine-hesitant parents, the providers’ confidence in responding to HPV vaccine concerns, and the attitudes and use of vaccine dismissal policies (i.e., removing patients from the practice). North Texas providers completed an online survey. Dependent variables assessed: (1) percentage of HPV vaccine-hesitant parents encountered in practice defined as substantive, or high (≥11%, or among more than one out of ten adolescent patient encounters) versus low (≤10%) levels; (2) confidence in responding to 11 HPV vaccine concerns; (3) attitudes and use of vaccine dismissal policies. Chi-square and Fisher’s exact tests were conducted. Among 156 providers, 29% reported high HPV vaccine hesitancy (≥11% of patient population). Overall, providers reported being “very confident” in addressing vaccine concerns (mean: 3.37 out of 4, SD: 0.57). Mean confidence scores were significantly higher for white (vs. non-white) providers and for pediatricians (vs. family practitioners). Providers were least confident in responding to parents’ religious/personal beliefs (69%). Some providers (25%) agreed with policies that dismissed vaccine-hesitant parents after repeated counseling attempts. More providers used dismissal policies for childhood (19%) than adolescent (10%) immunizations. Provider communication training should include parental religious/personal beliefs to effectively address HPV vaccine hesitancy. Other regions should examine their HPV-specific vaccine hesitancy levels to understand how the use of dismissal policies might vary between adolescent and childhood immunizations.

Key Points Question What are the barriers to coordinating care for underinsured and uninsured patients with cancer and chronic conditions during and after cancer treatment at a safety-net health system? Findings This qualitative study of interviews and observation of 93 health system stakeholders identified system-level challenges (ie, challenges to accessing primary care, lack of communication between oncology and primary care clinicians, leadership awareness of care coordination challenges) and clinician-level challenges (ie, unclear role delineation, lack of clinician knowledge and preparedness to manage cancer and chronic conditions). Meaning These findings suggest that survivorship care delivery strategies that bridge oncology and primary care may be required to meet the care coordination needs of underinsured and uninsured patients with cancer amid the fragmented US health care system., This qualitative study assesses barriers to coordinating care for patients with cancer and chronic conditions during and after cancer treatment., Importance Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care. Objective To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions. Design, Setting, and Participants This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020. Main Outcomes and Measures Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders. Results Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions. Conclusions and Relevance Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study’s findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Purpose This study aimed to (1) assess the accuracy of parental recall of adolescent (11–17 years) daughters’ HPV vaccine initiation in a low-income, urban Hispanic population, and (2) describe the correlates of accurate recall. Methods We compared parental recall of HPV vaccine naivety to daughter’s electronic medical records to calculate the proportion of parents accurately reporting HPV naive status. We used mixed effects logistic regression to identify correlates of accurate recall. Results We verified vaccination status for 1103 daughters of participants who reported their daughters were HPV vaccine-naive; 69.3% of parents accurately reported their daughters as HPV vaccine-naive. Parents of older daughters (13–17 years) compared to younger daughters (11–12 years) had significantly lower odds of accurately reporting daughters as unvaccinated (AOR = 0.60; 95% CI 0.42–0.83). Discussion Underreporting of vaccination status among our study population corresponds with national data that suggest lower income and minority populations underreport HPV vaccination initiation and completion.

Objectives The aims of the study were (1) to describe anal cancer knowledge, perceived risk, screening barriers, and acceptability of sample self-collection among women living with HIV (WLWH) at an integrated safety-net system and (2) to describe differences in demographic and psychosocial variables among a subsample of WLWH with a history of abnormal cervical cytology results versus those with normal results. Materials and methods We conducted telephone surveys with English- and Spanish-speaking WLWH (N = 99) and used electronic health record data to extract insurance type, CD4+ cell count, RNA viral load, and cervical cytology results. We calculated descriptive statistics for participant demographics, HIV laboratory results, and psychosocial variables. Among the subsample of women who completed a recent cervical Pap, we used Fisher exact test to assess differences in demographic variables, CD4+ counts, RNA viral loads, knowledge, awareness, acceptability, and perceived risk by cervical cytology results. Results Most participants (70%) reported knowing nothing about anal cancer; 28% correctly responded that HIV increases one's chance of getting anal cancer. Most (68%) never heard of an anal Pap test. Forty percent would get an anal Pap if they could self-collect the sample, whereas 59% were neutral or disagreed. The 2 most commonly cited barriers to obtaining an anal Pap were "I do not know enough about it" (n = 15) and "It might hurt" (n = 9). Conclusions This study highlights a gap in knowledge and awareness among WLWH regarding their heightened risk for anal cancer. It indicates the need for health education and suggests an opportunity for a self-collection intervention.

Introduction: A healthcare provider's ability to give a strong recommendation for the HPV vaccine is of utmost importance in increasing HPV vaccination. To reduce the burden of HPV-related cancers, there is a critical need to develop and implement theory-based interventions aimed at strengthening healthcare providers' communication about the HPV vaccine.Methods: We used Intervention Mapping (IM) steps 1–5 to develop and implement a provider-level intervention that aligns with the priorities and needs of a large, urban Federally Qualified Health Center (FQHC).Results: In step 1, a diverse planning group identified barriers to HPV vaccination in clinical settings and generated process maps and a logic model of the problem. Step 2 outlined outcomes and provider performance objectives of the intervention and identified knowledge, skills, self-efficacy, outcome expectations, and normative beliefs as modifiable targets that need to change for providers to deliver strong recommendations for the HPV vaccine to parents and patients. In step 3, the planning group mapped the methods of persuasive communication, information, and modeling and skills training to behavioral targets and outlined the program practical applications (strategies) components, scope, and sequence. In steps 4 and 5, the planning group produced the intervention and planned for program implementation. The iterative and participatory process of IM resulted in modifications to the initial intervention that aligned with the needs of the FQHC.Discussion: IM provided a systematic, participatory, and iterative approach for developing a theory-based provider-level intervention aimed at strengthening healthcare providers' ability to provide a strong recommendation for the HPV vaccine to eligible patients and parents served by a large FQHC. IM assisted with the identification of behavioral targets and methods that move beyond HPV knowledge and reminders to create behavior change. IM can help researchers and planners describe the processes and rational behind developing interventions and may help to facilitate implementation in real-world clinical settings by tailoring intervention components to the needs of the population.

Background Accurate and valid measures for implementation constructs are critical to advance research and guide implementation efforts. However, there is a continued need for valid and reliable measures for implementation research. The purpose of this study was to assess the psychometric properties of measures for the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR) in a network of pediatric clinics. Methods This study used cross-sectional survey data collected from physicians, advanced practice providers, clinic managers, and clinical staff (n = 546) working in a pediatric clinic network (n = 51). Surveys included measures assessing Inner Setting constructs from CFIR (culture, learning climate, leadership engagement, and available resources). We used a series multilevel confirmatory factor analysis (CFA) models to assess factorial validity. We also examined measure correlations to test discriminant validity and intraclass correlation coefficients, ICC(1) and ICC(2), to assess inter-rater reliability. Results Factor loadings were high (≥0.60) for all but one of the measurement items. Most CFA models for respective constructs demonstrated adequate or good model fit (CFI > 0.90, TLI > 0.90, RMSEA

Purpose: The HIV Medicine Association recommends anal Pap tests for women living with HIV (WLWH) with a history of abnormal cervical Pap tests, ano-receptive intercourse, or genital warts. This study describes current anal cancer screening practices and provider- and staff-identified challenges conducting anal cancer screening for WLWH in an integrated safety-net healthcare institution and community healthcare organization serving underinsured patients in a metropolitan city in Texas. Findings inform our understanding of factors that need to be addressed prior to implementation of system-level anal cancer screening policies and protocols for WLWH, a population at increased risk for anal cancer due to persistent HPV infection. Methods: We purposefully sampled providers, clinical staff, and administrative staff to participate in in-person semi-structured interviews assessing participant experiences with anal cancer screening, documentation, and follow up, and attitudes toward future anal cancer screening among WLWH. Audio-recorded interviews and field notes were transcribed and thematically analyzed using an iterative deductive and inductive coding scheme. Results: We completed interviews with 25 individuals: providers (n=11: 7 safety-net, 4 community), clinical staff (n=10: 8 safety-net, 2 community), and administrative staff (n=4: safety-net). Current practices. No system-level policies or protocols for anal cancer screening existed within the safety-net institution or community organization for WLWH. Instead, HIV providers performed anal Pap tests ad hoc, most frequently as diagnostic evaluations based on visual inspections or patient-reported symptoms. To follow up on abnormal test results, providers referred patients to Proctology Clinic, where wait for an appointment was about one year. Challenges. Without anal cancer screening policies or protocols, clinical teams were unclear on whether the HIV team or gynecology specialty team should lead screening efforts. Electronic health records only recorded cervical Pap test results in the “Pap” field, leaving providers to record anal Pap results in a notes section. This limited the ability to produce systematic reports or track screening. Finally, providers and staff expressed reluctance to conduct systematic anal cancer screening until greater infrastructure existed to manage referrals for abnormal anal Pap test results. Conclusions: Anal cancer screening and follow-up for WLWH require organization and coordination between multiple care teams, and protocols should clarify clinical pathways and responsibilities as patients transition between HIV, gynecology, and proctology teams. Further, clinical information systems must be updated to facilitate teams’ communication and to support anal Pap test ordering and documentation. Finally, downstream infrastructure to support follow-up must accompany upstream implementation of an anal cancer screening policy. Citation Format: Serena A Rodriguez, Robin T Higashi, Andrea B Betts, Cynthia Ortiz, Jasmin A Tiro, Amneris Luque, Arti Barnes. Challenges implementing anal cancer screening for women living with HIV: Clinical providers and staff perspectives [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C126.

Multilevel factors impact HPV vaccine series initiation and completion among adolescents in the U.S. Synthesis of these factors is needed to inform intervention development and to direct future research. Current frameworks synthesizing factors focus on females only and do not include both series initiation and completion outcomes. We conducted a systematic review of reviews to identify modifiable individual-, provider-, and clinic-level factors associated with HPV vaccination outcomes among U.S. adolescents and developed a multilevel framework illustrating relations between factors to inform intervention development. We searched Medline, PsychInfo, Pubmed, CINAHL, and ERIC databases and included reviews published 2006 to July 2, 2018 describing individual-, provider-, or clinic-level factors quantitatively associated with HPV vaccination among U.S. adolescents. Two coders independently screened reviews, extracted data, and determined quality ratings. Sixteen reviews containing 481 unique primary studies met criteria. Factors synthesized into the multilevel framework included parent psychosocial factors (knowledge, beliefs, outcome expectations, intentions) and behaviors, provider recommendation, and patient-targeted and provider-targeted clinic systems. The scope of our framework and review advances research in two key ways. First, the framework illustrates salient modifiable factors at multiple levels on which to intervene to increase HPV vaccination. Second, the review identified critical gaps in the literature at each level. Future research should link the body of literature on parental intentions to vaccination outcomes, identify provider psychosocial factors associated with recommendation behaviors and subsequent vaccine uptake in their patient population, and understand clinic factors associated with successful implementation of patient- and provider-targeted system-level interventions.

Vaccination reminders must both inform and persuade, and text messages designed for this purpose must do so in 160 characters or less. We tested a strategy for improving the impact of HPV vaccination text message reminders through strategic wording. In an experiment conducted in community settings, 167 Spanish-speaking Latina mothers reviewed text message reminders that assigned the cause or "agency" for HPV transmission to their daughters or the virus, and assigned protection agency to the mothers or the vaccine. Reminder messages framing transmission as an action of the virus prompted mothers to perceive the threat as more severe than messages describing their daughters as the cause. Assigning transmission agency to the virus also held a persuasive advantage in boosting mothers' intentions to seek vaccination, particularly when the message cast mothers as agents of protection rather than the vaccine.

Background: HPV vaccination among Hispanic adolescents falls below the national goal. Tailored interventions to increase vaccination among Hispanic populations are needed to reach national goals and to reduce HPV-related cancer disparities. Aim: We used the intervention mapping (IM) framework to develop and adapt two educational interventions, a print fotonovela and a tailored interactive multimedia intervention (TIMI), targeting Hispanic parents of adolescents to increase HPV vaccine uptake. Methods: To develop the interventions, we followed IM steps 1-6 to 1) develop a logic model of the problem and identify modifiable factors associated with vaccination by conducting literature reviews, focus groups, and in-depth interviews with Hispanic parents; 2) develop behavioral outcomes, identify determinants, and develop a matrix of change objectives; 3) develop a program theme and program components, identify theoretical methods, and operationalize methods as practical applications; 4) develop an intervention design plan; 5) develop implementation strategies; and 6) evaluate the interventions. To adapt the interventions, we followed steps 1-6 for the new target population, Hispanic parents of adolescent males. Throughout the adaptation process, we assessed the outputs from the original intervention development process to identify needed adaptations. Results: Through formative research in step 1, we identified modifiable determinants associated with parental decision-making about vaccinating their daughters. In step 2, we crossed performance objectives with these factors to produce a matrix of change objectives that served as a blueprint for program development. We then identified tailoring and targeting, framing and anticipated regret, modeling, skill building, and education and counseling as theoretical methods to address the determinants and create behavior change. We produced two program components, a print fotonovela and TIMI, with the theme “For Our Daughters.” Our implementation plan identified lay health workers as implementers. A logic model of change guided evaluation planning. We later adapted the intervention content for parents of Hispanic adolescent males and changed the theme to “For Our Children.” We identified new knowledge gaps as parents were less informed about the HPV vaccine for males. We made surface adaptations including filming new scenes to produce a new fotonovela and TIMI. We conducted content analysis to ensure intervention messages corresponded to change objectives. Conclusion: IM provided a systematic methodology for program development and adaptation to produce two educational interventions to increase HPV vaccination among Hispanic adolescents. Tasks in each step built upon one another integrating findings from the literature, previous research, qualitative findings, and theory. The systematic process allowed us to develop messages and materials targeting factors beyond HPV knowledge or awareness to create behavior change.

Background: We examined effectiveness of two lay health worker-delivered educational interventions for parents to increase HPV vaccination among Hispanic girls. Methods: Twenty-nine clinics were randomized to standard care or one of two interventions: a print fotonovela or an tailored interactive multimedia intervention (TIMI). Lay health workers delivered the interventions to parents. Data collectors completed follow-up assessments at 6 and 12 months. We assessed vaccine initiation at first follow-up and series completion by end of the study. Data were analyze using hierarchical logistic regression. Results: Among all participants recruited at baseline (576= fotonovela intervention group; 389=TIMI intervention group; 433=control group) intent-to-treat analysis indicated significant differences in vaccine initiation between TIMI and control at 6-month follow-up (OR: 1.63, 95% CI: 1.13-2.35, p=0.01), and between fotonovela and control (OR: 1.67, 95% CI: 1.20-2.32, p=0.002). Per protocol analyses (including only parents who completed follow-up surveys or whose daughter's vaccination status was ascertained through medical records) showed significant differences in initiation at 6 month follow-up: between TIMI and control (OR: 1.79, 95% CI: 1.21-2.70, p=0.004) and between fotonovela and control (OR: 1.65, 95% CI: 1.17-2.34, p=0.004). There were no statistically significant differences between TIMI and fotonovela (OR: 1.08 CI: 0.76-1.55, p=0.66). Conclusion: Hispanic parents receiving education - either the fotonovela or the TIMI - were more likely to initiate HPV vaccination within 6 months than parents in the comparison group. We will determine education effectiveness on completion of the 3-dose HPV series at 12-month follow-up. Citation Format: Maria E. Fernandez, Lara Savas, Roncancio Angelica, Myrna Khan, Natalie Fernandez-Espada, Serena Rodriguez, Sally Vernon. Evaluation of two HPV vaccination educational interventions for Hispanic parents. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A27.