Coaching and Communication Training for HPV Vaccination: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

US health departments routinely conduct in-person quality improvement (QI) coaching to strengthen primary care clinics' vaccine delivery systems, but this intervention achieves only small, inconsistent improvements in human papillomavirus (HPV) vaccination. Thus, we sought to evaluate the effectiveness of combining QI coaching with remote provider communication training to improve impact.

METHODS

With health departments in 3 states, we conducted a pragmatic 4-arm cluster randomized clinical trial with 267 primary care clinics (76% pediatrics). Clinics received in-person QI coaching, remote provider communication training, both interventions combined, or control. Using data from states' immunization information systems, we assessed HPV vaccination among 176 189 patients, ages 11 to 17, who were unvaccinated at baseline. Our primary outcome was the proportion of those, ages 11 to 12, who had initiated HPV vaccination at 12-month follow-up.

RESULTS

HPV vaccine initiation was 1.5% points higher in the QI coaching arm and 3.8% points higher in the combined intervention arm than in the control arm, among patients ages 11 to 12, at 12-month follow-up (both P < .001). Improvements persisted at 18-month follow-up. The combined intervention also achieved improvements for other age groups (ages 13-17) and vaccination outcomes (series completion). Remote communication training alone did not outperform the control on any outcome.

CONCLUSIONS

Combining QI coaching with remote provider communication training yielded more consistent improvements in HPV vaccination uptake than QI coaching alone. Health departments and other organizations that seek to support HPV vaccine delivery may benefit from a higher intensity, multilevel intervention approach.

Reducing Misperceptions About Very Low Nicotine Content Cigarettes: Insights From Adults Who Smoke

INTRODUCTION

Many people incorrectly think that very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes. This risk misperception by people who smoke could reduce motivation to quit under a nicotine reduction policy. We qualitatively examined perspectives on campaign messages designed to reduce misperceptions.

AIMS AND METHODS

Adults who smoke from North Carolina participated in online interviews. After being introduced to the idea of a VLNC policy, participants were shown VLNC messages and asked about their perceptions on the clarity, understandability, persuasiveness, and meaning of the messages. We conducted a thematic content analysis of the transcripts.

RESULTS

Thirty adults who smoke cigarettes participated (15 females, 13 males, 2 nonbinary) with a mean age of 43 years. Central themes that emerged were: (1) Confusion about the proposed VLNC cigarette policy affected how messages were interpreted; (2) Messages that promote self-efficacy for quitting rather than guilt or fear were better received; and (3) Direct and succinct messages were seen as more able to grab attention and inform people who smoke. Some participant concerns focused on whether VLNC cigarettes would relieve their nicotine cravings and whether they would need to smoke more VLNC cigarettes to feel satisfied.

CONCLUSION

Campaign messages to educate the public about the harmful effects of smoking VLNC cigarettes may be more effective if people who smoke are informed about the policy's rationale to understand why nicotine is removed rather than the other harmful chemicals. Messages should also acknowledge the difficulty of quitting and be short and direct to capture attention.

IMPLICATIONS

Adults who smoke have some confusion about nicotine reduction in cigarettes and this affects how they perceive potential communication campaign messages about the risk of smoking VLNC cigarettes. In our qualitative research, we found that adults who smoke prefer messages about VLNC cigarettes that acknowledge the challenge of quitting and that are direct and succinct. With further development, campaign messages may be able to reduce misperceptions about VLNC cigarettes and maximize the public health benefit of a nicotine reduction policy.

Explaining higher Covid-19 vaccination among some US primary care professionals

Background and objective

Research in several countries shows higher Covid-19 vaccination willingness and uptake among physicians than nurses. Our paper aims to characterize and explain this difference.

Methods

In early 2021, we surveyed 1047 U.S. primary care professionals who served adolescents, ages 11–17. The national sample included physicians (71%) as well as nurses and advanced practice providers. The survey assessed the three domains of the Increasing Vaccination Model: thinking and feeling, social processes, and direct behavior change.

Results

Covid-19 vaccine uptake was higher among physicians than among nurses and advanced practice providers (91% vs. 76%, p < .05). Overall, in the thinking and feeling domain, higher confidence in Covid-19 vaccination, higher perceived susceptibility to the disease, and stronger anticipated regret were associated with higher vaccine uptake (all p < .05). In the social processes domain, perceiving more positive social norms for Covid-19 vaccination, receiving recommendations to get the vaccine, and wanting to help others were associated with higher vaccine uptake (all p < .05). In the direct behavior change domain, receiving an invitation to get the vaccine and better access to vaccination were associated with higher uptake (both p < .05). Of these variables, most of the thinking and feeling and social processes variables mediated the association of training with vaccine uptake.

Conclusions

Physicians had higher Covid-19 vaccine uptake than nurses and advanced practice providers, corresponding with their more supportive vaccine beliefs and social experiences. Efforts to reach the remaining unvaccinated cohort can build on these findings.

Association of community engagement with vaccination confidence and uptake: A cross-sectional survey in Sierra Leone, 2019

Background

The 2014-2016 Ebola epidemic disrupted childhood immunization in Sierra Leone, Liberia, and Guinea. After the epidemic, the Government of Sierra Leone prioritized community engagement to increase vaccination confidence and uptake. To support these efforts, we examined potential drivers of vaccination confidence and uptake in Sierra Leone.

Methods

We conducted a population-based household survey with primary caregivers of children in a birth cohort of 12 to 23 months in four districts with low vaccination coverage in Sierra Leone in 2019. Modified Poisson regression modeling with robust variance estimation was used to examine if perceived community engagement in planning the immunization program in the community was associated with vaccination confidence and having a fully vaccinated child.

Results

The sample comprised 621 age-eligible children and their caregivers (91% response rate). Half of the caregivers (52%) reported that it usually takes too long to get to the vaccination site, and 36% perceived that health workers expect money for vaccination services that are supposed to be given at no charge. When mothers were the decision-makers of the children’s vaccination, 80% of the children were fully vaccinated versus 69% when fathers were the decision-makers and 56% when other relatives were the decision-makers. Caregivers with high confidence in vaccination were more likely to have fully vaccinated children compared to caregivers with low confidence (78% versus 53%). For example, caregivers who thought vaccines are ‘very much’ safe were more likely to have fully vaccinated children than those who thought vaccines are ‘somewhat’ safe (76% versus 48%). Overall, 53% of caregivers perceived high level of community engagement, 41% perceived medium level of engagement, and 6% perceived low level of engagement. Perceiving high community engagement was associated with expressing high vaccination confidence (adjusted prevalence ratio (aPR) = 2.60; 95% confidence interval (CI) = 1.67-4.04) and having a fully vaccinated child (aPR = 1.67; 95% CI = 1.18-2.38).

Conclusions

In these four low coverage districts in Sierra Leone, the perceived level of community engagement was strongly associated with vaccination confidence among caregivers and vaccination uptake among children. We have provided exploratory cross-sectional evidence to inform future longitudinal assessments to further investigate the potential causal effect of community engagement on vaccination confidence and uptake.

The impact of cigarette pack anti-littering messages

OBJECTIVE

Tobacco butts are the most littered item worldwide and pose a critical environmental and public health hazard. Given the positive impact of required graphic warnings on smoking, we sought to assess the impact of a policy requiring cigarette pack anti-littering messages on smokers' littering intentions.

METHODS

We randomly assigned US adult smokers (n = 719) to receive labels on the side of their cigarette packs for three weeks: anti-littering messages or messages about chemicals in cigarette smoke.

RESULTS

Anti-littering messages elicited higher intentions to refrain from littering in the next month compared to chemical messages (p < .05). Anti-littering messages also led to increased knowledge about cigarette butts being the most common form of litter, the number of conversations about littering, and thinking about the proper disposal of cigarettes (all p < .05). Finally, smoking from packs labeled with anti-littering messages led to fewer weeks littering from car windows compared to packs labeled with chemical messages (p < .05), but did not affect completely refraining from littering cigarette butts. Mediators of the messages' impact on littering intentions were thinking about proper cigarette butt disposal and perceived message effectiveness (both p < .05).

CONCLUSIONS

Policies requiring anti-littering messages on cigarette packs would raise awareness about the problem of cigarette butt litter and bolster intentions to not litter.

Prevalence of High-Risk Human Papillomavirus by RNA Assay in Home Self-Collected Samples Among Underscreened People in North Carolina

BACKGROUND

Low-income and uninsured people with a cervix (PWC) are at the highest risk of being underscreened for cervical cancer. We evaluated the prevalence of high-risk human papillomavirus (hrHPV) on home self-collected samples, as well as rates of in-clinic follow-up and risk factors associated with hrHPV positivity in this at-risk population.

METHODS

My Body My Test 3 was conducted between 2016 and 2019 in North Carolina among individuals aged 25 to 64 years, overdue for cervical cancer screening, and with incomes of <250% of the US Federal Poverty Level. Our analytic sample included participants randomized to the self-collection arm who returned self-collected cervicovaginal brush samples for HPV testing (n = 329). Samples were tested for 14 hrHPV types by an HPV RNA assay and further genotyped for HPV-16 and HPV-18/45. We examined behavioral risk factors for hrHPV positivity using logistic regression and between-subject t tests.

RESULTS

High-risk HPV RNA prevalence was 16% (n = 52/329) in self-collected samples. Of the hrHPV-positive participants, 24 (46%) presented for in-clinic cervical cancer screening, compared with 56 (20%) of hrHPV-negative participants. Those with ≥2 sexual partners in the past year were twice as likely to be hrHPV positive in adjusted analyses (adjusted odds ratio, 2.00 [95% confidence interval, 1.03-3.88]). High-risk HPV-positive and HPV-negative participants had similar attitudes toward screening, with the exception of hrHPV-positive participants who reported a lower perceived risk of cervical cancer than those who were hrHPV negative (P < 0.05).

CONCLUSION

The hrHPV RNA prevalence was similar to findings in other underscreened PWC in the United States. Efforts to reach underscreened PWC are critical for cervical cancer prevention. Future studies aimed at home self-collection should address methods of increasing clinic attendance and completion of treatment among those with HPV-positive results.

Considerations and opportunities for multilevel HPV vaccine communication interventions

From 2016 to 2019, the National Cancer Institute and the Centers for Disease Control and Prevention funded three Special Interest Projects focused on developing and testing multilevel HPV vaccination communication interventions. In this commentary, we highlight lessons learned from the funded projects, including the importance of engaging community members in the early stages of the research process, the challenges of evaluating multilevel interventions, and the need to consider stakeholder implementation preferences.

COVID-19 and missed or delayed vaccination in 26 middle- and high-income countries: An observational survey

BACKGROUND

The COVID-19 pandemic has disrupted vaccination services and raised the risk of a global resurgence of preventable diseases. We assessed the extent of and reasons for missed or delayed vaccinations (hereafter 'missed') in middle- and high-income countries in the early months of the pandemic.

METHODS

From May to June 2020, participants completed an online survey on missed vaccination. Analyses separated missed childhood and adult vaccination in middle-and high-income countries.

RESULTS

Respondents were 28,429 adults from 26 middle- and high-income countries. Overall, 9% of households had missed a vaccine, and 13% were unsure. More households in middle- than high-income countries reported missed childhood vaccination (7.6% vs. 3.0%) and missed adult vaccination (9.6% vs. 3.4%, both p < .05). Correlates of missed childhood vaccination in middle-income countries included COVID-19 risk factors (respiratory and cardiovascular diseases), younger age, male sex, employment, psychological distress, larger household size, and more children. In high-income countries, correlates of missed childhood vaccination also included immunosuppressive conditions, but did not include sex or household size. Fewer correlates were associated with missed adult vaccination other than COVID-19 risk factors and psychological distress. Common reasons for missed vaccinations were worry about getting COVID-19 at the vaccination clinic (15%) or when leaving the house (11%). Other reasons included no healthcare provider recommendation, clinic closure, and wanting to save services for others.

INTERPRETATION

Missed vaccination was common and more prevalent in middle- than high-income countries. Missed vaccination could be mitigated by emphasizing COVID-19 safety measures in vaccination clinics, ensuring free and accessible immunization, and clear healthcare provider recommendations.

Provider response and follow-up to parental declination of HPV vaccination

OBJECTIVE

Parents often decline HPV vaccination, but little is known about how healthcare providers should promote vaccination at a later visit for secondary acceptance. We examined the associations of two factors, providers' response to declination during the visit and follow-up after the visit, with secondary acceptance.

METHODS

We conducted a cross-sectional survey of US parents whose 9- to 17-year-old child had not yet completed the HPV vaccination series. Parents who declined HPV vaccination during an initial discussion with a provider (n = 447) reported whether their provider engaged in any active response during the visit (e.g., giving information, trying to change their mind) or any follow-up after the visit (e.g., scheduling another visit). We conducted multivariable logistic regression to determine whether an active response or follow-up was associated with secondary acceptance of HPV vaccination.

RESULTS

Only about one-third of parents reported an active response during the visit (35%) or follow-up after the visit (39%) following HPV vaccination declination. Parents had higher odds of secondary acceptance of HPV vaccine if they received any provider follow-up after the visit (43% vs. 20%, aOR:3.19; 95% CI:2.00:5.07). Receipt of an active provider response was not associated with secondary acceptance. More parents thought a provider should actively respond and follow-up (61% and 68% respectively), compared with those who received such a response (both p < .01).

CONCLUSIONS

Providers' follow-up after the visit may be important for promoting secondary acceptance of HPV vaccination. Parents who decline HPV vaccination often prefer to receive an active response or follow-up from a provider.

Implementation of quality improvement coaching versus physician communication training for improving human papillomavirus vaccination in primary care: a randomized implementation trial

Many US health departments (HDs) conduct in-person quality improvement (QI) coaching to help primary care clinics improve their HPV vaccine delivery systems and communication. Some HDs additionally conduct remote communication training to help vaccine prescribers recommend HPV vaccination more effectively. Our aim was to compare QI coaching and communication training on key implementation outcomes. In a cluster randomized trial, we offered 855 primary care clinics: 1) QI coaching; 2) communication training; or 3) both interventions combined. In each trial arm, we assessed adoption (proportion of clinics receiving the intervention), contacts per clinic (mean number of contacts needed for one clinic to adopt intervention), reach (median number of participants per clinic), and delivery cost (mean cost per clinic) from the HD perspective. More clinics adopted QI coaching than communication training or the combined intervention (63% vs 16% and 12%, both p < .05). QI coaching required fewer contacts per clinic than communication training or the combined intervention (mean = 4.7 vs 29.0 and 40.4, both p < .05). Communication training and the combined intervention reached more total staff per clinic than QI coaching (median= 5 and 5 vs 2, both p < .05), including more prescribers (2 and 2 vs 0, both p < .05). QI coaching cost $439 per adopting clinic on average, including follow up ($129/clinic), preparation ($73/clinic), and travel ($69/clinic). Communication training cost $1,287 per adopting clinic, with most cost incurred from recruitment ($653/clinic). QI coaching was lower cost and had higher adoption, but communication training achieved higher reach, including to influential vaccine prescribers.

Guaranteed Financial Incentives for COVID-19 Vaccination: A Pilot Program in North Carolina

This quasi-experimental study examines whether offering an incentive cash card to adults who receive or drive someone to receive their first dose of COVID-19 vaccine raises vaccination rates.

Report of Health Care Provider Recommendation for COVID-19 Vaccination Among Adults, by Recipient COVID-19 Vaccination Status and Attitudes - United States, April-September 2021

Vaccination is critical to controlling the COVID-19 pandemic, and health care providers play an important role in achieving high vaccination coverage (1). To examine the prevalence of report of a provider recommendation for COVID-19 vaccination and its association with COVID-19 vaccination coverage and attitudes, CDC analyzed data among adults aged ≥18 years from the National Immunization Survey-Adult COVID Module (NIS-ACM), a nationally representative cellular telephone survey. Prevalence of report of a provider recommendation for COVID-19 vaccination among adults increased from 34.6%, during April 22-May 29, to 40.5%, during August 29-September 25, 2021. Adults who reported a provider recommendation for COVID-19 vaccination were more likely to have received ≥1 dose of a COVID-19 vaccine (77.6%) than were those who did not receive a recommendation (61.9%) (adjusted prevalence ratio [aPR] = 1.12). Report of a provider recommendation was associated with concern about COVID-19 (aPR = 1.31), belief that COVID-19 vaccines are important to protect oneself (aPR = 1.15), belief that COVID-19 vaccination was very or completely safe (aPR = 1.17), and perception that many or all of their family and friends had received COVID-19 vaccination (aPR = 1.19). Empowering health care providers to recommend vaccination to their patients could help reinforce confidence in, and increase coverage with, COVID-19 vaccines, particularly among groups known to have lower COVID-19 vaccination coverage, including younger adults, racial/ethnic minorities, and rural residents.

Promoting COVID-19 vaccine acceptance: recommendations from the Lancet Commission on Vaccine Refusal, Acceptance, and Demand in the USA

Since the first case of COVID-19 was identified in the USA in January, 2020, over 46 million people in the country have tested positive for SARS-CoV-2 infection. Several COVID-19 vaccines have received emergency use authorisations from the US Food and Drug Administration, with the Pfizer-BioNTech vaccine receiving full approval on Aug 23, 2021. When paired with masking, physical distancing, and ventilation, COVID-19 vaccines are the best intervention to sustainably control the pandemic. However, surveys have consistently found that a sizeable minority of US residents do not plan to get a COVID-19 vaccine. The most severe consequence of an inadequate uptake of COVID-19 vaccines has been sustained community transmission (including of the delta [B.1.617.2] variant, a surge of which began in July, 2021). Exacerbating the direct impact of the virus, a low uptake of COVID-19 vaccines will prolong the social and economic repercussions of the pandemic on families and communities, especially low-income and minority ethnic groups, into 2022, or even longer. The scale and challenges of the COVID-19 vaccination campaign are unprecedented. Therefore, through a series of recommendations, we present a coordinated, evidence-based education, communication, and behavioural intervention strategy that is likely to improve the success of COVID-19 vaccine programmes across the USA.

Partnering with healthcare systems to improve HPV vaccination:The perspective of immunization program managers

The US's 64 CDC-funded immunization programs are at the forefront of efforts to improve the quality of adolescent vaccination services. We sought to understand immunization program managers' perspectives on partnering with healthcare systems to improve HPV vaccine uptake. Managers of 44 state and local immunization programs completed our online survey in 2019. Immunization managers strongly endorsed the importance of partnering with systems to improve HPV vaccine uptake (mean = 3.8/4.0), and most wanted to do so in the next year (mean = 3.5). Immunization managers reported that common barriers included difficulty contacting systems' leadership (57%), differing organizational cultures (52%), and time (52%). Many perceived systems as not prioritizing HPV vaccination (77%). Immunization managers expressed strong interest in participating in a training on partnering with systems (mean = 3.5). Overall, immunization managers are highly interested in partnering with systems to improve HPV vaccine uptake. Training and other support are needed to expand programs' capacity for such partnerships.

Reducing Poverty-Related Disparities in Cervical Cancer: The Role of HPV Vaccination

BACKGROUND

Near elimination of cervical cancer in the United States is possible in coming decades, yet inequities will delay this achievement for some populations. We sought to explore the effects of human papillomavirus (HPV) vaccination on disparities in cervical cancer incidence between high- and low-poverty U.S. counties.

METHODS

We calibrated a dynamic simulation model of HPV infection to reflect average counties in the highest and lowest quartile of poverty (percent of population below federal poverty level), incorporating data on HPV prevalence, cervical cancer screening, and HPV vaccination. We projected cervical cancer incidence through 2070, estimated absolute and relative disparities in incident cervical cancer for high- versus low-poverty counties, and compared incidence with the near-elimination target (4 cases/100,000 women annually).

RESULTS

We estimated that, on average, low-poverty counties will achieve near-elimination targets 14 years earlier than high-poverty counties (2029 vs. 2043). Absolute disparities by county poverty will decrease, but relative differences are estimated to increase. We estimate 21,604 cumulative excess cervical cancer cases in high-poverty counties over the next 50 years. Increasing HPV vaccine coverage nationally to the Healthy People 2020 goal (80%) would reduce excess cancer cases, but not alter estimated time to reach the near-elimination threshold.

CONCLUSIONS

High-poverty U.S. counties will likely be delayed in achieving near-elimination targets for cervical cancer and as a result will experience thousands of potentially preventable cancers.

IMPACT

Alongside vaccination efforts, it is important to address the role of social determinants and health care access in driving persistent inequities by area poverty.

Using Telehealth to Deliver Primary Care to Adolescents During and After the COVID-19 Pandemic: National Survey Study of US Primary Care Professionals

BACKGROUND

The COVID-19 pandemic has led to unprecedented use of telehealth, including by primary care professionals (PCPs) who serve adolescents.

OBJECTIVE

To inform future practice and policies, we sought to characterize PCPs' recent experience using adolescent telehealth as well as their support for it after the COVID-19 pandemic is over.

METHODS

From February to March 2021, we conducted a web-based survey of 1047 PCPs in the United States. Our national sample included physicians (747/1047, 71%), advanced practice providers (177/1047, 17%), and nurses (123/1047, 12%) who provided primary care to adolescents aged 11-17 years.

RESULTS

Most PCPs reported using telehealth for a low, moderate, or high proportion of their adolescent patients in the three months prior to the survey (424/1047, 40%, 286/1047, 27%, and 219/1047, 21%, respectively); only 11% (118/1047) reported no use. A majority of respondents agreed that adolescent telehealth increases access to care (720/1047, 69%) and enables them to provide high-quality care (560/1047, 53%). Few believed that adolescent telehealth takes too much time (142/1047, 14%) or encourages health care overuse (157/1047, 15%). Most supported giving families the option of adolescent telehealth for primary care after the pandemic is over (683/1047, 65%) and believed that health insurance plans should continue to reimburse for telehealth visits (863/1047, 82%). Approximately two-thirds (702/1047, 67%) wanted to offer adolescent telehealth visits after the pandemic, with intentions being higher among those with recent telehealth experience (P<.001).

CONCLUSIONS

PCPs in our national sample reported widespread use of and predominantly positive attitudes toward adolescent telehealth. Our findings also suggest broad support among PCPs for continuing to offer adolescent telehealth after the COVID-19 pandemic ends.

Health Warnings and Beverage Purchase Behavior: Mediators of Impact

BACKGROUND

To reduce diet-related chronic disease, policymakers have proposed requiring health warnings on sugar-sweetened beverages (SSBs). Health warnings reduced purchases of these products by 22% in our recent randomized controlled trial, but the mechanisms remain unclear.

PURPOSE

We sought to identify the psychological mechanisms that explain why SSB health warnings affect purchase behavior.

METHODS

In 2018, we recruited 400 adult SSB consumers to complete a shopping task in a naturalistic convenience store laboratory in North Carolina, USA. We randomly assigned participants to either a health warning arm (all SSBs in the store displayed a text health warning) or to a control arm (SSBs displayed a control label). Participants selected items to purchase with cash.

RESULTS

Compared to control labels, health warnings elicited more attention, negative affect, anticipated social interactions, and thinking about harms (range of ds = 0.63-1.34; all p < .001). Health warnings also led to higher injunctive norms about limiting SSB consumption (d = 0.27, p = .008). Except for attention, all of these constructs mediated the effect of health warnings on SSB purchases (all p < .05). In contrast, health warnings did not influence other attitudes or beliefs about SSBs or SSB consumption (e.g., healthfulness, outcome expectations, and response efficacy).

CONCLUSIONS

Health warnings on sugar-sweetened beverages affected purchase behavior by eliciting negative emotions, increasing anticipated social interactions, keeping SSBs' harms at top of mind, and shifting norms about beverage consumption. Results are consistent with recent studies of why tobacco warnings influence quitting behavior, pointing toward a general framework for understanding how health warnings affect behavior.

CLINICAL TRIALS REGISTRATION

NCT #03511937.

A critical review of measures of childhood vaccine confidence

The World Health Organization and global partners sought to identify existing measures of confidence in childhood vaccines, as part of a broader effort to measure the range of behavioural and social drivers of vaccination. We identified 14 confidence measures applicable to childhood vaccination in general, all published between 2010 and 2019. The measures examined 1-5 constructs and included a mean of 12 items. Validation studies commonly examined factor structure, internal consistency reliability, and criterion-related validity. Fewer studies examined convergent and discriminant validity, test-retest reliability, or used cognitive interviewing. Most measures were developed and validated only in high-income countries. These findings highlight the need for a childhood vaccine confidence measure validated for use in diverse global contexts.

Barriers and facilitators to achieving food security during the COVID-19 pandemic

The COVID-19 pandemic has considerably increased food insecurity. To identify where intervention and policy solutions are most needed, we explored barriers to obtaining food and predictors of experiencing food insecurity due to the COVID-19 pandemic. Between May and July 2020, we conducted cross-sectional online surveys with two convenience samples of U.S. adults (Study 1: n = 2,219, Study 2: n = 810). Roughly one-third of participants reported experiencing food insecurity due to the COVID-19 pandemic (Study 1: 32%, Study 2: 35%). Between one-third and half reported using the charitable food system (Study 1: 36%, Study 2: 46%). The majority of participants experienced barriers to getting food (Study 1: 84%, Study 2: 88%), of which the most commonly reported were not having enough money to buy food (Study 1: 48%; Study 2: 53%) and worrying about getting COVID-19 at the store (Study 1: 50%; Study 2: 43%). Higher education was associated with greater risk of food insecurity in both studies (all p < 0.05). Receipt of aid from SNAP buffered against the association between financial struggles and food insecurity in Study 1 (p = 0.03); there was also some evidence of this effect in Study 2 (p = 0.05). Our findings suggest that food insecurity might be reduced by mitigating financial struggles (e.g., by increasing access to SNAP) and by addressing barriers to obtaining food (e.g., by expanding accessibility of food delivery programs).

Provider communication and HPV vaccine uptake: A meta-analysis and systematic review

Provider communication can be critically important to families as they consider HPV vaccination. We sought to characterize the association of provider communication and HPV vaccine uptake, and when communication better motivates vaccination. We searched four databases for studies published between 2006 and 2019. Eligible studies examined health care provider communication (defined as recommendation or discussion) and HPV vaccine uptake (defined as initiation, completion, or follow-through) in the US. Two coders independently identified eligible studies and coded effect sizes and study characteristics. We pooled effect sizes using random-effects meta-analysis. We identified 59 eligible studies of 265,083 patients. Receiving a provider recommendation was associated with higher HPV vaccine initiation (pooled OR = 10.1, 95% CI: 7.6-13.4). HPV vaccine initiation was 24% for patients without and 60% for patients with a provider recommendation. The pooled effect size for provider recommendation and initiation was smaller for probability samples, clinical records, and NIS-Teen (all p < 0.002). Recommendations were equally effective for males and females, for different patient ages, and over time. Provider recommendation was also associated with higher HPV vaccine series completion and follow-through. Provider discussion was similarly associated with higher HPV vaccine initiation (OR = 12.4, 95% CI: 6.3-24.3). In summary, provider communication was robustly associated with HPV vaccination initiation, completion, and follow-through. These findings suggest that US public health efforts to increase HPV vaccine coverage should continue to emphasize provider communication.