P–416 Radiotherapy inflicts long-term damage upon the uterus, causing uterine artery endothelial dysfunction and pregnancy loss in mice

Study question

Does the uterus sustain direct and long-term damage following radiotherapy, independent of ovarian damage?

Summary answer

Radiotherapy causes direct and long-term uterine damage. Ovariectomised and hormonally supplemented mice experience uterine artery endothelial dysfunction and pregnancy loss following transfer of healthy blastocysts.

What is known already

The detrimental off-target impacts of cancer therapies on the ovary are well established, with some fertility preservation techniques available to ensure patients maintain their fertility following gonadotoxic treatment. Low doses of radiotherapy kill the majority of primordial follicle oocytes in the ovary, reducing the ovarian reserve and fertile lifespan. Patients who have received radiotherapy experience higher rates of pregnancy complications including preterm birth, low birth weight, and stillbirth. However, no studies have investigated if radiation inflicts direct, fertility compromising damage to the uterus.

Study design, size, duration

Adolescent female mice were untreated or exposed to whole body y-irradiation (7Gy), then ovariectomised. Immediate damage was assessed up to 24 hours post-irradiation (n = 4/group). Four weeks following treatment, mice were hormone primed to induce endometrial receptivity (n = 7/group), artificial decidualisation (n = 7–8/group), or receive embryo transfers from healthy, unexposed donor mice to assess embryo implantation (n = 11–13/group), and mid-gestation development (n = 8–10/group).

Participants/materials, setting, methods

Four week old C57BL6/CBA (F1) female mice were used for this study. Immunofluorescence and in situ hybridisation were utilised to localise markers of immediate DNA damage and cell death following irradiation, and markers of receptivity in hormone primed uteri. Measurements of uterine artery blood flow were recorded using Doppler ultrasonography, and indices of pulsatility and resistance calculated. Uterine artery wire myography was performed to assess competency of endothelial and smooth muscle compartments following irradiation.

Main results and the role of chance

Within 24 hours of irradiation, DNA damage (yH2AX) and apoptosis (Puma/TUNEL) were elevated in uteri, compared to control. Irradiated mice that received embryo transfers from untreated donors had similar numbers of implantation sites 3-days post-transfer versus controls, however uteri were pale and atrophic suggesting impaired vascularisation. By 10-days post-transfer, implantation sites in irradiated mice were resorbing (p < 0.001), although uterine artery Doppler ultrasound measurements demonstrated no change in pulsatility or resistance indices. When the brain was shielded from irradiation to protect the hypothalamic-pituitary-gonadal axis, resorption still occurred (p < 0.001), suggesting direct uterine damage is the likely cause of pregnancy loss. To investigate uterine damage in the absence of an embryo, endometrial receptivity was induced artificially. Uteri from irradiated animals were lighter compared to control (p < 0.05), however localisation of receptivity markers (E-cadherin, Mucin1, Ki67) was normal. When decidualisation was artificially induced irradiated uteri were also lighter (p < 0.01) indicating impaired decidualisation and reduced capacity to adapt to pregnancy. Wire myography performed on uterine arteries demonstrated endothelial dysfunction in irradiated mice (p < 0.0001).

Limitations, reasons for caution

Here, only a single age and dose of radiotherapy exposure are modelled. Patients of all ages can receive many doses of radiotherapy in combination with various chemotherapies. Our highly manipulable model enables any treatment variation to be modelled and the effect on the uterus and pregnancy examined.

Wider implications of the findings: Reproductive aged cancer patients need to be appropriately counselled regarding the risks to their long-term fertility following treatment. Until now, potential permanent impacts to the uterus following cancer treatment have not been considered. It is clear radiotherapy can impose long-term damage to the uterus and influence pregnancy success and fertility.

Trial registration number

NA

Engagement, satisfaction, retention and behavioural outcomes of linguistically diverse mothers and infants participating in an Australian early obesity prevention trial

BACKGROUND

Early obesity prevention research interventions in Australia generally expect participants to be able to communicate in English, but do not account for other languages. This study aimed to investigate engagement, satisfaction, retention and behavioural outcomes of linguistically diverse participants from a mainstream early childhood obesity prevention trial.

METHODS

Healthy Beginnings is a nurse-led intervention based in Sydney, supporting families with optimal infant feeding and active play via telephone. This secondary analysis assessed participant engagement in the nurse telephone calls (call completions), satisfaction and behavioural outcomes (6- and 12-month survey data) and retention (survey completions), in the first year of life according to participants' language spoken at home (English or other language).

RESULTS

Of 1155 mothers, 533 (46%) spoke a language other than English at home. Significantly fewer mothers speaking a language other than English completed the 6-month survey (79%) compared to those speaking English (84%), yet mothers speaking a language other than English who completed the program were more satisfied with the program overall. Significantly fewer mothers speaking a language other than English completed the final four nurse calls (of six) (56%-65%) compared to those speaking English (70%-80%). Adjusted odds ratios showed selected behavioural outcomes were significantly more positive for participants speaking English at home.

CONCLUSIONS

Healthy Beginnings trial participants who spoke a language other than English at home had less favourable engagement, retention and behavioural outcomes compared to those who spoke English. So what? Early obesity prevention interventions should consider cultural adaptations to improve engagement and effectiveness among culturally and linguistically diverse families.

Feasibility of a culturally adapted early childhood obesity prevention program among migrant mothers in Australia: a mixed methods evaluation

INTRODUCTION

Healthy Beginnings is an established nurse-led early childhood obesity prevention program that promotes healthy infant feeding practices and active play in the early years of life. To improve engagement with culturally and linguistically diverse populations, the Healthy Beginnings program delivered by telephone was culturally adapted and implemented with Arabic- and Chinese-speaking mothers in Sydney, Australia. The cultural adaptation process has been published separately. In this article, we aimed to evaluate the feasibility of the culturally adapted program.

METHODS

In 2018-2019, the culturally adapted Healthy Beginnings program was implemented with Arabic- and Chinese-speaking women recruited from antenatal clinics in Sydney. At four staged timepoints (from third trimester until 6 months of age), mothers were sent culturally adapted health promotion booklets and text messages and offered four support calls from bi-cultural child and family health nurses in Arabic and Chinese. A mixed methods evaluation included a) baseline and 6-month telephone surveys, followed by b) semi-structured follow-up interviews with a subset of participating mothers and program delivery staff. Main outcomes of this feasibility study were reach (recruitment and retention), intervention dose delivered (number of nurse support calls completed) and acceptability (appropriateness based on cognitive and emotional responses).

RESULTS

At recruitment, 176 mothers were eligible and consented to participate. Of 163 mothers who completed the baseline survey, 95% completed the program (n = 8 withdrew) and 83% completed the 6-month survey (n = 70 Arabic- and n = 65 Chinese-speaking mothers). Most mothers (n = 127, 78%) completed at least one nurse support call. The qualitative analysis of follow-up interviews with 42 mothers (22 Arabic- and 20 Chinese-speaking mothers) and 10 program delivery staff highlighted the perceived value of the program and the positive role of bi-cultural nurses and in-language resources. Mothers who completed more nurse support calls generally expressed greater acceptability.

CONCLUSIONS

The culturally adapted Healthy Beginnings program was feasible to deliver and acceptable to Arabic- and Chinese-speaking mothers. Our results highlight the importance of in-language resources and individualised bi-cultural nurse support by telephone for supporting culturally and linguistically diverse migrant families with infant feeding and active play. These findings support the potential for program refinements and progression to an effectiveness trial.

Ethnic inequalities in older adults bowel cancer awareness: findings from a community survey conducted in an ethnically diverse region in England

Background

To date, research exploring the public’s awareness of bowel cancer has taken place with predominantly white populations. To enhance our understanding of how bowel cancer awareness varies between ethnic groups, and inform the development of targeted interventions, we conducted a questionnaire study across three ethnically diverse regions in Greater London, England.

Methods

Data were collected using an adapted version of the bowel cancer awareness measure. Eligible adults were individuals, aged 60+ years, who were eligible for screening. Participants were recruited and surveyed, verbally, by staff working at 40 community pharmacies in Northwest London, the Harrow Somali association, and St. Mark’s Bowel Cancer Screening Centre. Associations between risk factor, symptom and screening awareness scores and ethnicity were assessed using multivariate regression.

Results

1013 adults, aged 60+ years, completed the questionnaire; half were of a Black, Asian or Minority ethnic group background (n = 507; 50.0%). Participants recognised a mean average of 4.27 of 9 symptoms and 3.99 of 10 risk factors. Symptom awareness was significantly lower among all ethnic minority groups (all p’s < 0.05), while risk factor awareness was lower for Afro-Caribbean and Somali adults, specifically (both p’s < 0.05). One in three adults (n = 722; 29.7%) did not know there is a Bowel Cancer Screening Programme. Bowel screening awareness was particularly low among Afro-Caribbean and Somali adults (both p’s < 0.05).

Conclusion

Awareness of bowel cancer symptoms, risk factors and screening varies by ethnicity. Interventions should be targeted towards specific groups for whom awareness of screening and risk factors is low.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10536-y.

The process of culturally adapting the Healthy Beginnings early obesity prevention program for Arabic and Chinese mothers in Australia

Background

Behavioural interventions for the early prevention of childhood obesity mostly focus on English-speaking populations in high-income countries. Cultural adaptation is an emerging strategy for implementing evidence-based interventions among different populations and regions. This paper describes the initial process of culturally adapting Healthy Beginnings, an evidence-based early childhood obesity prevention program, for Arabic and Chinese speaking migrant mothers and infants in Sydney, Australia.

Methods

The cultural adaptation process followed the Stages of Cultural Adaptation theoretical model and is reported using the Framework for Reporting Adaptations and Modifications-Enhanced. We first established the adaptation rationale, then considered program underpinnings and the core components for effectiveness. To inform adaptations, we reviewed the scientific literature and engaged stakeholders. Consultations included focus groups with 24 Arabic and 22 Chinese speaking migrant mothers and interviews with 20 health professionals. With input from project partners, bi-cultural staff and community organisations, findings informed cultural adaptations to the content and delivery features of the Healthy Beginnings program.

Results

Program structure and delivery mode were retained to preserve fidelity (i.e. staged nurse calls with key program messages addressing modifiable obesity-related behaviours: infant feeding, active play, sedentary behaviours and sleep). Qualitative analysis of focus group and interview data resulted in descriptive themes concerning cultural practices and beliefs related to infant obesity-related behaviours and perceptions of child weight among Arabic and Chinese speaking mothers. Based on the literature and local study findings, cultural adaptations were made to recruitment approaches, staffing (bi-cultural nurses and project staff) and program content (modified call scripts and culturally adapted written health promotion materials).

Conclusions

This cultural adaptation of Healthy Beginnings followed an established process model and resulted in a program with enhanced relevance and accessibility among Arabic and Chinese speaking migrant mothers. This work will inform the future cultural adaptation stages: testing, refining, and trialling the culturally adapted Healthy Beginnings program to assess acceptability, feasibility and effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10270-5.

Protocol for an Effectiveness-Implementation Hybrid Trial to Evaluate Scale up of an Evidence-Based Intervention Addressing Lifestyle Behaviours From the Start of Life: INFANT

INTRODUCTION

Promoting healthy eating and active play in early life is critical, however few interventions have been delivered or sustained at scale. The evaluation of interventions at scale is a crucial, yet under-researched aspect of modifying population-level health behaviours. INFANT is an evidence-based early childhood healthy lifestyle intervention that aims to improve parents' knowledge and skills around promoting optimal energy balance-related behaviours that, in turn, influence children's diet, activity and adiposity. It consists of: 1) Four group sessions delivered via first time parent groups across the first 12 months of life; 2) access to the My Baby Now app from birth to 18 months of age. This research aims to assess real-world implementation, effectiveness and cost-effectiveness of INFANT when delivered at scale across Victoria, Australia.

METHODS AND ANALYSIS

A hybrid type II implementation-effectiveness trial applying a mixed methods design will be conducted. INFANT will be implemented in collaboration with practice and policy partners including maternal and child health services, population health and Aboriginal health, targeting all local government areas (n=79) in Victoria, Australia. Evaluation is based on criteria from the 'Outcomes for Implementation Research' and 'RE-AIM' frameworks. Implementation outcomes will be assessed using descriptive quantitative surveys and qualitative interviews with those involved in implementation, and include intervention reach, organisational acceptability, adoption, appropriateness, cost, feasibility, penetration and sustainability. Process measures include organizational readiness, fidelity, and adaptation. Effectiveness outcomes will be assessed using a sample of INFANT participants and a non-randomized comparison group receiving usual care (1,500 infants in each group), recruited within the same communities. Eligible participants will be first time primary caregivers of an infant aged 0-3 months, owning a personal mobile phone and able to communicate in English. Effectiveness outcomes include infant lifestyle behaviours and BMIz at 12 and 18 months of age.

IMPACT

This is the first known study to evaluate the scale up of an evidence based early childhood obesity prevention intervention under real world conditions. This study has the potential to provide generalisable implementation, effectiveness and cost-effectiveness evidence to inform the future scale up of public health interventions both in Australia and internationally.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry https://www.anzctr.org.au/, identifier ACTRN12620000670976.

Improving Outcomes for Hospitalized Patients Pre- and Post-COVID-19

Purpose

Barriers to effective patient–provider communication increase the risk that a patient will experience a hospital-acquired condition (HAC) that will negatively impact the patient's health outcomes. Providing patients with communication tools can significantly reduce the risks of experiencing HACs. This article describes how barriers to effective patient–provider communication can impact patient outcomes and reports on the incidence of HACs in patients who received assistive technology to address barriers to patient–provider communication. This topic is of critical relevance, as the COVID-19 pandemic has dramatically increased the number of patients who face communication barriers and the accompanying challenges encountered by their health care providers.

Method/Approach

The researchers compared the number of expected HACs based on previously obtained data to the number of HACs reported among patients who received an assistive technology intervention. Additionally, the impact of COVID-19 on patient–provider communication was discussed through the provision of case descriptions from frontline speech-language pathologists who have worked in COVID-19 intensive care units.

Results

The patients who received the assistive technology intervention had a significantly lower incidence of HACs than what would be expected in hospital settings. Clinicians working directly with patients with COVID-19 identified suggestions on how both patients and providers can address the barriers to effective patient–provider communication.

Conclusion

A key to better patient outcomes and lower health care costs will require making the provision of communication tools part of the standard of care for all patients facing barriers to communication.

Use of a GP-endorsed non-participant reminder letter to promote uptake of bowel scope screening: A randomised controlled trial in a hard-to-reach population

Previous research suggests that sending non-participants a reminder letter, 1 year after their initial invitation, can improve coverage for bowel scope screening (BSS), also known as flexible sigmoidoscopy screening. We hypothesised that adding a general practitioner's (GPs) endorsement to the reminder letter could improve coverage even further. We conducted a randomised controlled trial in North West London, UK. Participants were screening-eligible men and women who had not responded to their initial BSS invitation at least 12 months prior to the trial period. Eligible adults were randomised in a 1:1 ratio to receive either a GP-endorsed reminder letter, or a standard reminder letter from June to August 2019. Logistic regression models were used to test the effect of the GP endorsement on attendance at BSS, adjusting for sex, clinical commissioning group, and local area socioeconomic deprivation. In total, 1200 participants were enrolled into the study and randomised to either the control (n = 600) or the intervention (n = 600) group. Those who received the GP-endorsed reminder letter were only slightly more likely to attend BSS than those who received the standard reminder letter (4% vs. 3%); this difference was not statistically significant (Adjusted OR = 1.30; 95% CI: 0.69, 2.43). Adding a GP-endorsement to the annual reminder letter did not have an effect on attendance at BSS. One possible explanation for this is that the endorsement used was not personalised enough. Future research should examine stronger GP-endorsements or other methods to promote uptake.

Teamworking in endoscopy: a human factors toolkit for the COVID-19 era

BACKGROUND

Endoscopy services have had to rapidly adapt their working practices in response to COVID-19. As recovery of endoscopy services proceeds, our workforce faces numerous challenges that can impair effective teamworking. We designed and developed a novel toolkit to support teamworking in endoscopy during the pandemic.

METHODS

A human factors model was developed to understand the impact of COVID-19 on endoscopy teams. From this, we identified a set of key teamworking goals, which informed the development of a toolkit to support several team processes. The toolkit was refined following expert input and refinement over a 6-week period.

RESULTS

The toolkit consists of four cognitive aids that can be used to support team huddles, briefings, and debriefs, alongside techniques to optimize endoscopic nontechnical skills across the patient-procedure pathway. We describe the processes that local endoscopy units can employ to implement this toolkit.

CONCLUSION

A toolkit of cognitive aids, based on human factors principles, may be useful in supporting teams, helping them adapt to working safely in the era of COVID-19.

Hypertension, antihypertensive medications use and risk of age-related macular degeneration in California Teachers Cohort

Sustained and inadequately controlled hypertension can promote the development of age-related macular degeneration (AMD) through multiple biologic pathways. Epidemiologic studies of high blood pressure, antihypertensive therapies, and the risk of AMD thus far have been inconclusive. However, few studies evaluated risks according to the use of different classes of antihypertensive drugs or took combinations of use into account. We performed a prospective cohort study by linking the California Teachers Study (CTS) cohort (N = 88 481) to statewide hospital discharge records up to December 31, 2012. History of high blood pressure, regular use of antihypertensive medications, and comprehensive risk factor information was collected via self-administered questionnaires at baseline in 1995-1996, and information on specific classes of antihypertensive drugs was provided by a subsample of CTS participants who completed a follow-up questionnaire in 2000. We identified 1762 female teachers with AMD during 14.8 years of follow-up on average. Applying Cox proportional hazard regression, we estimated increased risks of AMD among women treated for hypertension at baseline (HR = 1.15, 95% CI: 1.03, 1.30); the magnitude of the association increased with longer duration of antihypertensive treatment. In the subsample with more specific information on type of medication use, we estimated a 45% increased risk of AMD among women receiving diuretics as monotherapy compared to women with medications more potent than diuretics (HR = 1.45, 95% CI 1.10, 1.90). In women treated with a combination of antihypertensive drugs, we observed no increased risk of AMD for any individual class of drugs.

Improving pain management for children having dental extractions under general anaesthesia

Children provided with general anaesthesia for dental extractions at East Surrey Hospital were audited to determine the percentage of children who were prescribed adequate pain management in accordance with guidance published by the Association of Paediatric Anaesthetists of Great Britain and Ireland. Three audit cycles were completed. Data were collected retrospectively through case note review. The results from the first cycle showed that only 47% of children were prescribed with a recommended analgesic regimen. Implementation of change included the development of a protocol for analgesic delivery, which was disseminated to the anaesthetic and dental teams. Full compliance with the audit standards was then demonstrated in the second and third cycles. This audit demonstrates the importance of multidisciplinary collaboration in order to provide high standards of care for children undergoing dental extractions under general anaesthesia. The protocol developed could be applied to other surgical day case procedures for children to improve the patient experience.

Fine-scale acoustic telemetry in a riverine environment: movement and habitat use of the endangered Mary River cod Maccullochella mariensis

Understanding movement and habitat requirements of endangered species is critical to conservation management. We evaluate fine-scale acoustic telemetry to study breeding-related movement and habitat use of the endangered Mary River cod Maccullochella mariensis in a riverine environment and, in relation to key environmental variables, to inform management. Movement activity varied significantly in relation to water temperature and diel period, and spatial occupancy and habitat selection varied substantially in relation to the nesting behaviour of Mary River cod. Important nesting habitat included a large hollow log mid-channel and well-shaded logs and log jams adjacent to the river bank. Extrapolating this information to the general population was inhibited by relatively small sample sizes, due in part to the restricted spatial scale of the hydrophone arrays and longitudinal movements of tagged fish beyond the acoustic range of our array. Notwithstanding this, our results demonstrate that (1) fine-scale acoustic telemetry can quantify complex biological behaviours in riverine environments; (2) Mary River cod require specific environmental stimuli and habitat to support the reproductive cycle; and (3) changing environmental conditions may influence Mary River cod behaviour, and understanding this response is necessary for sustainable management. Findings from this study can inform future applications of this methodology in riverine environments and contribute to the development of management strategies and habitat restoration activities supporting the recovery of Mary River cod populations.

Optimising bowel preparation before colonoscopy

A clean colon is required for a colonoscopy to be effective. Therefore, patients undergo a bowel preparation in advance of the procedure to clear the colon. Typically, this involves drinking 2 litres of polyethylene glycol or macrogol (PEG) solution, but dislike of the taste or having to drink such a large volume causes some patients not to adhere to this regimen. To address this, a PEG solution has been developed that requires patients to drink only 1 litre of bowel preparation in two flavours. The hope is this will increase patient adherence.

Prescribers' experiences of, and attitudes to, use of morphine for palliative care at a tertiary hospital in Zambia

OBJECTIVE

To explore medical doctors' experiences of, and attitudes to, use of morphine for palliative care at a tertiary hospital in Zambia.

METHODS

A qualitative, exploratory case study was undertaken. Semi-structured interviews were used to collect data from 14 medical doctors working in the fields of oncology, pediatrics, and internal medicine at a tertiary hospital in Lusaka, Zambia, regarding their experiences and attitudes to prescribing morphine for palliative care. Thematic analysis of interview transcripts was carried out to establish common themes in the data. The study was approved by BSMS and UNZA research ethics committees.

RESULTS

All participants agreed that doctors were becoming more comfortable with the prescribing of morphine, although experiences were notably different for doctors working in oncology, compared to other departments. Themes of difficulty discussing end-of-life, poor recognition of pain, and fear of patient addiction, were more prominent in the responses of non-cancer doctors. Morphine use was generally restricted to cancer and sickle cell disease patients, with most non-cancer doctors stating that they rarely prescribe morphine for outpatient use. Training in pain management and the presence of a palliative care team were perceived to be facilitators to morphine prescribing.

CONCLUSIONS

Although there is an increased willingness to prescribe morphine, limited knowledge of pain management, especially for nonmalignant disease, underlies many of the findings in this study. Opportunity exists for professional development in pain management to further improve the acceptance and use of opioids in palliative care, especially for out-patients.

Developing a Culture of Successful Communication in Acute Care Settings: Part I. Solving Patient-Specific Issues

PURPOSE

Establishing services for hospitalized patients with complex communication needs requires identifying and addressing both patient-based and institutional barriers. In this 1st article, we focus on overcoming patient-based barriers. The companion paper (Marshall & Hurtig, 2019) addresses overcoming institutional barriers.

METHOD

We present a series of cases that illustrate both the challenges and some of the solutions that have emerged in addressing the specific needs of individual patients with complex communication needs.

RESULTS

Each case illustrates how a dynamic assessment approach was used to allow patients with complex communication needs to more effectively communicate with caregivers and participate in their care.

CONCLUSION

Building a culture of improved patient-provider communication involves more than just providing patients with augmentative and alternative communication tools.

Developing a Culture of Successful Communication in Acute Care Settings: Part II. Solving Institutional Issues

PURPOSE

Establishing services for hospitalized patients with complex communication needs (CCNs) requires identifying and addressing both patient-based and institutional barriers. Although the previous paper (Marshall & Hurtig, 2019) focused on patient-based barriers, this paper addresses overcoming institutional barriers.

METHOD

We present a series of cases to illustrate the institutional challenges in meeting the CCNs of patients in an acute care setting.

RESULTS

Each case illustrates how the deployment of augmentative and alternative communication tools required addressing institutional/systems barriers and how critical collaborations help patients with CCNs to more effectively communicate with caregivers and participate in their care.

CONCLUSION

Building a culture of improved patient-provider communication involves establishing a wider range of interprofessional collaborations and shared resources in order to effectively provide patients with CCNs the tools to summon assistance and communicate with their caregivers.

A systematic approach to map the adolescent human papillomavirus vaccine decision and identify intervention strategies to address vaccine hesitancy

OBJECTIVES

Unsubstantiated safety concerns with human papillomavirus (HPV) vaccines continue to linger. This study sought to identify factors that influence the adolescent HPV vaccine decision and systematically identify intervention functions and strategies likely to be effective in reducing vaccine hesitancy.

STUDY DESIGN

This is a qualitative focus group study.

METHODS

Focus groups were conducted with female adolescents (aged 14-16 years) in Cork and Kerry. During focus groups, the trained facilitator used a semistructured, Theoretical Domains Framework (TDF)-based topic guide to prompt discussion. Transcripts were thematically analysed using the TDF and Behaviour Change Wheel. Behaviour Change Technique Taxonomy version 1 was used to suggest intervention functions and strategies for addressing HPV vaccine hesitancy.

RESULTS

A total of 50 adolescents (96% vaccinated), participated in 10 focus groups. The key themes were presented by means of the relevant TDF domains. Seven domains were selected as the most relevant: knowledge, social influences, beliefs about capabilities, optimism, beliefs about consequences, emotion and environmental context and resources. Five intervention functions were identified, education, persuasion, enablement, modelling and environmental restructuring, and linked to 11 relevant Behaviour Change Technique (BCTs). Potential intervention strategies were developed.

CONCLUSIONS

This study provided a detailed insight into behavioural factors influencing the vaccine decision-making process. It was identified that awareness and knowledge about HPV and its health sequelae was low. Lack of information is a well-recognised determinant of vaccine hesitancy. Therefore, education was recommended as a key area to address in future intervention studies.