Home Self-Collection by Mail to Test for Human Papillomavirus and Sexually Transmitted Infections

OBJECTIVE

To evaluate the validity and acceptability of at-home self-collection to test for high-risk human papillomavirus (HPV) and sexually transmitted infections among women overdue for cervical cancer screening by national guidelines.

METHODS

Low-income, infrequently screened women were recruited from the general population in North Carolina to participate in an observational study. Participants provided two self-collected cervicovaginal samples (one at home and one in the clinic) and a clinician-collected cervical sample. Samples were tested for high-risk HPV, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium. Cervical samples were also tested by liquid-based cytology.

RESULTS

Overall, 193 women had conclusive high-risk HPV results for all three samples and cytology results. Prevalence of high-risk HPV within self-home samples (12.4%) was not different from that within clinician samples (11.4%; P=.79) and from that within self clinic samples (15.5%; P=.21). Positivity for high-risk HPV in all sample types increased with increasing grades of cervical abnormality (P<.001). Self-home samples detected high-risk HPV in all identified cases of high-grade squamous intraepithelial lesions and of cervical intraepithelial neoplasia 2 or worse. Detection was comparable across sample types for T vaginalis (range 10.2-10.8%), M genitalium (3.3-5.5%), C trachomatis (1.1-2.1%), and N gonorrhoeae (0-0.5%). Kappa values between sample types ranged from 0.56 to 0.66 for high-risk HPV, 0.86-0.91 for T vaginalis, and 0.65-0.83 for M genitalium. Most participants reported no difficulty understanding self-collection instructions (93.6%) and were willing to use self-collection in the future (96.3%).

CONCLUSION

Mail-based, at-home self-collection for high-risk HPV and sexually transmitted infection detection was valid and well accepted among infrequently screened women in our study. These findings support the future use of high-risk HPV self-collection to increase cervical cancer screening rates among higher risk women in the United States.

HPV Vaccination Recommendation Practices among Adolescent Health Care Providers in 5 Countries

STUDY OBJECTIVE

To assess adolescent health care providers' recommendations for, and attitudes towards human papillomavirus (HPV) vaccination in 5 countries.

DESIGN

In-depth interviews of adolescent health care providers, 2013-2014.

SETTING

Five countries where HPV vaccination is at various stages of implementation into national programs: Argentina, Malaysia, South Africa, South Korea, and Spain.

PARTICIPANTS

Adolescent health care providers (N = 151) who had administered or overseen provision of adolescent vaccinations (N = Argentina: 30, Malaysia: 30, South Africa: 31, South Korea: 30, Spain: 30).

MAIN OUTCOME MEASURES

Frequency of HPV vaccination recommendation, reasons providers do not always recommend the vaccine and facilitators to doing so, comfort level with recommending the vaccine, reasons for any discomfort, and positive and negative aspects of HPV vaccination.

RESULTS

Over half of providers 82/151 (54%) recommend HPV vaccination always or most of the time (range: 20% in Malaysia to 90% in Argentina). Most providers 112/151 (74%) said they were comfortable recommending HPV vaccination, although South Korea was an outlier 10/30 (33%). Providers cited protection against cervical cancer 124/151 (83%) and genital warts 56/151 (37%) as benefits of HPV vaccination. When asked about the problems with HPV vaccination, providers mentioned high cost 75/151 (50% overall; range: 26% in South Africa to 77% in South Korea) and vaccination safety 28/151 (19%; range: 7% in South Africa to 33% in Spain). Free, low-cost, or publicly available vaccination 59/151 (39%), and additional data on vaccination safety 52/151 (34%) and efficacy 43/151 (28%) were the most commonly cited facilitators of health provider vaccination recommendation.

CONCLUSION

Interventions to increase HPV vaccination should consider a country's specific provider concerns, such as reducing cost and providing information on vaccination safety and efficacy.

A content analysis of HPV vaccination messages available online

Parents have varied HPV vaccine communication needs, which presents a challenge for healthcare providers. To improve communication resources for providers, we sought to characterize HPV vaccination messages available in existing educational materials. In fall 2016, we searched PubMed, educational material clearinghouses, and Google for English language HPV vaccination messages. We extracted messages that a provider might use when raising the topic of HPV vaccination, answering common questions, and motivating vaccination. Two reviewers independently coded each message. The search identified 267 unique messages about HPV vaccination. Messages generally were long (mean no. of words = 44, standard deviation [SD] = 33) and required a high level of education to read (mean reading grade level = 10, SD = 3). Only 32% of messages were shorter than 25 words, and 12% had a readability at or below grade 6. Most frequent were messages to address common parent questions or concerns (62%); the most common topics were diseases prevented by HPV vaccine (18%) and safety and side effects (16%). Many messages included information about cancer prevention (26%) and same-day vaccination (13%). Few messages (6%) used a presumptive style to recommend HPV vaccination. In conclusion, available messages about HPV vaccination were markedly varied. We identified few messages that were both brief (to facilitate providers memorizing them) and accessible (to facilitate parents understanding them). Future research should identify which messages lead to HPV vaccine uptake.

Engaging parents around vaccine confidence: proceedings from the National HPV Vaccination Roundtable meetings

HPV vaccine uptake remains below national goals in the US, driven in part by parental uncertainty about the vaccine fueled by negative stories on social media and other information platforms. To identify opportunities for mobilizing parents to increase HPV vaccination uptake, the National HPV Vaccination Roundtable and Vaccinate Adolescents Against Cancers program convened two national meetings in 2016 at the American Cancer Society. Stakeholders recommended a focus on positive message to parents; cultivating parent champions to use the power of personal storytelling and to distribute these messages; and defining the role of national organizations in supporting parent champions. Stakeholders supported three message themes: HPV vaccination is the norm, HPV vaccination is cancer prevention, and HPV vaccination supports families across generations. Parents' negative stories about vaccination are especially difficult to counteract with scientific evidence, making the cultivation of pro-vaccine parent champions an especially promising intervention on social media and other information platforms.

Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence

BACKGROUND

Social interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior.

PURPOSE

We sought to establish whether and how smokers' conversations explain the effect of pictorial warnings on quit attempts.

METHODS

US adult smokers (n = 2149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models.

RESULTS

The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p < .001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations was associated with greater cognitive elaboration, which in turn was associated with being more likely to make a quit attempt (p < .05). Social norms did not explain the influence of conversations on quit attempts.

CONCLUSIONS

Pictorial warnings increased conversations about the warnings, which led to greater cognitive elaboration, which led to greater quit attempts. Our findings suggest designing warnings that increase conversations in order to better inform and motivate smokers. Furthermore, these findings improve our understanding of why conversations matter in health communication.

Preference for Human Papillomavirus Self-Collection and Papanicolaou: Survey of Underscreened Women in North Carolina

OBJECTIVES

Self-collection of samples for human papillomavirus (HPV) testing (self-collection) has the potential to increase cervical cancer screening among underscreened women. We assessed attitudes toward at-home HPV self-collection compared with clinic-based Pap testing in this higher-risk population.

MATERIALS AND METHODS

Participants were low-income women in North Carolina overdue for cervical cancer screening. Women self-collected samples at home, returned samples by mail for HPV testing, and completed phone questionnaires about at-home HPV self-collection. Participants were referred to clinic-based Pap testing and invited to complete a second questionnaire about Pap testing. A cross-sectional questionnaire compared attitudes, experiences, and preferences for self-collection versus Pap testing and assessed predictors of preference for HPV self-collection.

RESULTS

Half (51%) of 221 women reported a preference for HPV self-collection, 19% preferred Pap testing, and 27% reported no preference. More women reported difficulty finding time to do the Pap test (31%) than the self-test (13%, p = .003) and being afraid of the self-test results (50%) than the Pap test results (36%, p = .02). There were relatively fewer reports of physical discomfort and pain from self-collection than Pap testing (discomfort: 18% self; 48% Pap; pain: 8% self; 30% Pap, p = .001). No differences were found in positive versus negative thoughts about the tests, trust in the tests' safety and accuracy, or willingness to do tests again.

CONCLUSIONS

Overall positive attitudes toward HPV self-collection compared with Pap testing among underscreened women suggest that self-collection is a promising option to increase cervical cancer screening in this high-risk population.

"That's probably what my mama's lungs look like": how adolescent children react to pictorial warnings on their parents' cigarette packs

BACKGROUND

Pictorial cigarette pack warnings discourage smoking, but most evidence comes from studies of adults. Our qualitative study explored adolescents' reactions to pictorial warnings on their parents' cigarette packs.

METHODS

We interviewed 24 adolescents whose parents received pictorial warnings on their cigarette packs as part of a randomized clinical trial. We conducted a thematic content analysis of the interview transcripts.

RESULTS

Pictorial cigarette pack warnings led adolescents to imagine the depicted health effects happening to their parents, which elicited negative emotions. The warnings inspired adolescents to initiate conversations with their parents and others about quitting smoking. Adolescents believed the warnings would help smokers quit and prevent youth from starting smoking. Some current smokers said the warnings made them consider quitting.

CONCLUSIONS

Conversations about the pictorial warnings may amplify their effectiveness for smokers, their adolescent children, and friends of the adolescent children. Cigarette pack warnings may reach a broad audience that includes adolescent children of smokers.

Impact of modified risk tobacco product claims on beliefs of US adults and adolescents

Objective

Under US law, tobacco product marketing may claim lower exposure to chemicals, or lower risk of health harms, only if these claims do not mislead the public. We sought to examine the impact of such marketing claims about potential modified risk tobacco products (MRTPs).

Methods

Participants were national samples of 4797 adults and 969 adolescent US smokers and non-smokers. We provided information about a potential MRTP (heated tobacco product, electronic cigarette or snus). Experiment 1 stated that the MRTP was as harmful as cigarettes or less harmful (lower risk claim). Experiment 2 stated that the MRTP exposed users to a similar quantity of harmful chemicals as cigarettes or to fewer chemicals (lower exposure claim).

Results

Claiming lower risk led to lower perceived quantity of chemicals and lower perceived risk among adults and adolescents (all p<0.05, Experiment 1). Among adults, this claim led to higher susceptibility to using the MRTP (p<0.05). Claiming lower exposure led to lower perceived chemical quantity and lower perceived risk (all p<0.05), but had no effect on use susceptibility (Experiment 2). Participants thought that snus exposed users to more chemicals and was less safe to use than heated tobacco products or electronic cigarette MRTPs (Experiments 1 and 2).

Discussion

Risk and exposure claims acted similarly on MRTP beliefs. Lower exposure claims misled the public to perceive lower perceived risk even though no lower risk claim was explicitly made, which is impermissible under US law.

Effective Message Elements for Disclosures About Chemicals in Cigarette Smoke

Introduction

Cigarette smoke contains at least 93 chemicals or "constituents" that the Food and Drug Administration has identified as harmful and potentially harmful constituents to human health. Our study sought to identify which constituent disclosure message elements are most effective in discouraging people from smoking.

Methods

Three hundred eighty eight current smokers aged 18 and older completed an online survey in February 2015. We randomized participants to respond to one of two sets of 13 toxic products that contain cigarette constituents and 25 health effects associated with cigarette constituents.

Results

Products that elicited the most discouragement were those with lower chances of exposure (e.g., explosives), followed by products with possible exposure (e.g., rat poison), and products with a high likelihood of exposure (e.g., floor cleaner). Awareness of toxic products that constituents are found in (p < .001) and low exposure products (p < .001) were associated with higher discouragement. Health effects that people had heard are caused by cigarette smoke constituents elicited higher discouragement from smoking cigarettes (p < .001). Cancer was associated with higher discouragement relative to respiratory, cardiovascular, and reproductive health effects (all p < .001).

Conclusions

Cigarette smoke constituent messages may be more effective at discouraging smoking if they include information about carcinogenic health effects (e.g., mouth cancer and lung tumors) and low exposure toxic products (e.g., explosives and radioactive material) as message elements.

Implications

Our study identified health effects and toxic products, especially cancers and rarely encountered toxic products, that may discourage smoking when included in disclosure messages. By constructing messages that communicate the harms associated with tobacco use by contextualizing those harms in terms of specific constituents, tobacco education messaging efforts may be increasingly successful.

Why smokers avoid cigarette pack risk messages: Two randomized clinical trials in the United States

BACKGROUND

Message avoidance (e.g., trying not to look at the message) may be motivated by reactance, a maladaptive rejection of the message. An alternative view is that avoidance indicates that a message is eliciting fear and other negative affect, thereby increasing the likelihood of behavioral change. We sought to identify which psychological mechanism-reactance or fear and other negative affect-explains message avoidance. We also examined whether avoidance was associated with more forgoing or butting out of cigarettes.

METHOD

Trial 1 randomly assigned 2149 adult U.S. smokers to receive either pictorial warnings (intervention) or text-only warnings (control) on their cigarette packs for four weeks in 2014 and 2015. Trial 2 randomly assigned 719 adult U.S. smokers to receive either messages about toxic chemicals in cigarette smoke (intervention) or messages about not littering cigarette butts (control) for three weeks in 2016 and 2017. Negative affect included fear, anxiety, disgust, sadness, and guilt. Reactance included perceived threat to freedom, anger, and counterarguing.

RESULTS

Intervention messages led to greater message avoidance in both trials (both p < .001). In Trial 1, intervention messages elicited greater negative affect, which in turn was associated with greater avoidance (mediated effect = 0.21, p < .001). In contrast, reactance explained only a small part of the effect in Trial 1 (mediated effect = 0.03, p < .001). Similarly, in Trial 2, intervention messages elicited greater negative affect, which was associated with more avoidance (mediated effect = 0.12, p < .001); reactance did not explain any of the effect. In both trials, avoidance was associated with more forgoing or butting out of cigarettes (ps < .001).

CONCLUSIONS

Smokers may avoid cigarette pack risk messages because they evoke aversive types of emotion. These studies add to a growing body of evidence that, in the context of cigarette pack messages, avoidance is not a form of defensive processing but instead a sign of deeper processing.

Increasing Effectiveness of Messages about Chemicals in Cigarette Smoke

OBJECTIVES

Federal law requires informing the public on toxic chemicals in cigarette smoke. We sought the public's advice about communicating information about these chemicals.

METHODS

Adolescents, young adults, and adults (N = 59), including smokers and non-smokers, participated in 9 focus groups that discussed inclusion of messages about toxic chemicals on cigarette packs, in media campaigns, and on a website. We transcribed, coded, and analyzed focus group audio-recordings.

RESULTS

Participants had 3 suggestions for message content to increase the impact of messages about cigarette smoke chemicals. First, they wanted to see messages rotated more frequently to increase message novelty. Second, they recommended using stories and pictures to help connect people to the abstract idea of chemicals in smoke. Third, they cautioned against making messages that might seem overblown and could appeal to the rebellious nature of adolescents. Some participants mentioned that chemical information on a website might discourage people from smoking; others mentioned that people might use it to choose which brand to smoke.

CONCLUSIONS

Legislation provides the impetus to design new chemical disclosure messages for cigarette packs and other media. Our findings can help increase the impact of these messages.

Trajectories of Responses to Pictorial Cigarette Pack Warnings

Background

Pictorial warnings on cigarette packs are a cost-effective policy-level intervention for smoking cessation; however, little research has examined changes in the impact of warnings over time, especially shortly following the first exposure to pictorial warnings. We sought to characterize the trajectories of responses to pictorial cigarette pack warnings soon after first exposure.

Methods

Participants were 2149 adult smokers in North Carolina and California, United States. In 2014-2015, we randomized smokers to have pictorial (intervention) or text-only (control) warnings on their cigarette packs for 4 weeks. Weekly surveys assessed psychosocial and behavioral outcomes.

Results

After 1 week, smokers in the intervention arm reported higher levels of most outcomes, compared with the control arm. Over subsequent weeks, smokers in both trial arms had decreases in thinking about the harms of smoking (β = -0.046), positive (β = -0.036), and negative (β = -0.042) smoking reinforcement attitudes, and increases in quit intentions (β = 0.070) and cigarette forgoing (β = 0.137) (all p < .05). Only negative affective reactions decreased more in the intervention versus control condition (pinteraction < .01).

Conclusions

The impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time. In contrast, quit intentions and cigarette forgoing may continue to increase, at least during the initial period after introduction. Rotation of pictorial warnings may help prevent warning wear-out.

Implications

Cigarette smoking is the leading cause of preventable morbidity and mortality and warnings on cigarette packs are a cost-effective policy-level intervention. Prior studies reporting on cigarette pack warning "wear out" have been limited by being short-term single-session experimental studies. Ours are the first study to experimentally examine the trajectories of several outcomes after first exposure and report that the impact of pictorial cigarette pack warnings on emotions and cognitions may wane over time while quit intentions and cigarette forgoing may continue to increase.

Trials Registration

ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Frequency and Content of Conversations About Pictorial Warnings on Cigarette Packs

Introduction

Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings.

Methods

A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits.

Results

Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05).

Conclusions

Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact.

Implications

Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.

Support for Pharmacist-Provided HPV Vaccination: National Surveys of U.S. Physicians and Parents

Background: State laws about pharmacists providing human papillomavirus (HPV) vaccines vary considerably, limiting many pharmacists' ability to provide this important cancer prevention service. We characterized physician and parent support for pharmacist-provided HPV vaccination for adolescents who are past due for vaccination.Methods: In 2014 to 2015, we conducted two national U.S. surveys of 776 primary care physicians (PCPs) and 1,504 parents of adolescents. Respondents indicated the extent to which they supported pharmacist-provided HPV vaccination for 13- to 17-year-olds who are past due. Respondents could endorse the provision unconditionally, or only if certain conditions were met, such as pharmacists receiving proper vaccination training. We used multivariable logistic regression to assess correlates of support.Results: Most physicians (79%) and parents (81%) endorsed pharmacist-provided HPV vaccination if pharmacists had received proper vaccination training, reported vaccine doses to adolescents' PCP, and referred adolescents to PCPs for other health services. Family medicine physicians were more likely than pediatricians to support trained pharmacists providing HPV vaccination [OR = 1.62; 95% confidence interval (CI) 1.17-2.22]. Support was also higher among physicians who practiced in Western states (OR = 2.11; 95% CI, 1.30-3.40). Parents' odds of endorsing trained pharmacists provision of HPV vaccine increased with higher overall satisfaction with their pharmacy's services (OR = 1.10; 95% CI, 1.02-1.19), belief in pharmacists' competence in vaccination practices (OR = 1.42; 95% CI, 1.18-1.70), and overall vaccine confidence (OR = 1.30; 95% CI, 1.15-1.48).Conclusions: To increase support for HPV vaccination services, pharmacists should raise awareness about their immunization training and standardize vaccination protocols that ensure coordination with primary care.Impact: Stakeholders' feedback and buy-in is important to help guide expansion of HPV vaccination in pharmacies. Cancer Epidemiol Biomarkers Prev; 27(8); 970-8. ©2018 AACR.

Public support for pictorial warnings on cigarette packs: an experimental study of US smokers

BACKGROUND

Understanding factors that influence public support for "nudging" policies, like pictorial cigarette pack warnings, may offer insight about how to increase such support. We sought to examine factors that influence smokers' support for requiring pictorial warnings on cigarette packs.

METHODS

In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings on their cigarette packs for 4 weeks. The outcome examined in the current study was support for a policy requiring pictorial warnings on cigarette packs in the US.

RESULTS

Support for pictorial warnings was high at baseline (mean: 3.2 out of 4). Exposure to pictorial warnings increased policy support at week 4 (β = .05, p = .03). This effect was explained by increases in perceived message effectiveness (p < .001) and reported conversations about policy support (p < .001). Message reactance (i.e., an oppositional reaction to the warning) partially diminished the impact of pictorial warnings on policy support (p < .001).

CONCLUSIONS

Exposing people to a new policy through implementation could increase public support for that policy by increasing perceived effectiveness and by prompting conversations about the policy. Reactance may partially weaken the effect of policy exposure on public support.

Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening

Background

Primary-care providers may contribute to the use of low-value cancer screening.

Objective

We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening.

Patients and methods

This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening).

Results

Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC).

Discussion

While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request.

Conclusion

More work appears to be needed to help providers to discuss and recommend screening that aligns with value.

A Decision Aid to Promote Appropriate Colorectal Cancer Screening among Older Adults: A Randomized Controlled Trial

Background. Concerns have been raised about both over- and underutilization of colorectal cancer (CRC) screening in older patients and the need to align screening behavior with likelihood of net benefit. Objective. The purpose of this study was to test a novel use of a patient decision aid (PtDA) to promote appropriate CRC screening in older adults. Methods. A total of 424 patients ages 70 to 84 y who were not up to date with CRC screening participated in a double-blinded randomized controlled trial of a PtDA targeted to older adults making decisions about whether to undergo CRC screening from March 2012 to February 2015. Intervention. Patients were randomized to a targeted PtDA or an attention control. The PtDA was designed to facilitate individualized decision making—helping patients understand the potential risks, benefits, and uncertainties of CRC screening given advanced age, health state, preferences, and values. Outcomes. Two composite outcomes, appropriate CRC screening behavior 6 mo after the index visit and appropriate screening intent immediately after the visit, were defined as completed screening or intent for patients in good health, discussion about screening with their provider for patients in intermediate health, and no screening or intent for patients in poor health. Health state was determined by age and Charlson Comorbidity Index. Results. Four hundred twelve (97%) and 421 (99%) patients were analyzed for the primary and secondary outcomes, respectively. Appropriate screening behavior at 6 mo was higher in the intervention group (55% v. 45%, P = 0.023) as was appropriate screening intent following the provider visit (61% v. 47%, P = 0.003). Limitations. The study took place in a single geographic region. The appropriate CRC screening classification system used in this study has not been formally validated. Conclusions. A PtDA for older adults promoted appropriate CRC screening behavior and intent.

Trial Registration: Clinicaltrials.gov, registration number NCT01575990. https://clinicaltrials.gov/ct2/show/NCT01575990?term=epic-d&rank=1

Predictors of Human Papillomavirus Vaccine Follow-Through Among Privately Insured US Patients

OBJECTIVES

To assess predictors of timely human papillomavirus (HPV) vaccine follow-through among privately insured individuals initiating the 3-dose series.

METHODS

Using MarketScan Commercial claims data, we identified 1 332 217 privately insured US individuals aged 9 to 26 years who initiated the bivalent or quadrivalent HPV vaccine series from 2006 to 2014, with follow-up data extending through 2015. The study outcome was receipt of third HPV dose within 12 months of the first, compared by year of initiation. Control variables were age, region, insurance plan type, provider type, and seasonal influenza vaccination.

RESULTS

Timely HPV vaccine follow-through fell over time. The trend was especially pronounced for females (from 67% in 2006 to 38% in 2014), but was also present for males (from 36% in 2011 to 33% in 2014). Similar patterns were present when we controlled for patient and provider characteristics or used alternative definitions of follow-through. Other positive predictors of timely follow-through included receipt of flu vaccine in the prior year and receipt of first HPV vaccine dose from an obstetrician/gynecologist.

CONCLUSIONS

HPV vaccine follow-through is low and has declined over time.

Why is announcement training more effective than conversation training for introducing HPV vaccination? A theory-based investigation

BACKGROUND

Improving healthcare providers' communication about HPV vaccination is critical to increasing uptake. We previously demonstrated that training providers to use presumptive announcements to introduce HPV vaccination improved uptake, whereas training them to use participatory conversations had no effect. To understand how communication training changed provider perceptions and communication practices, we evaluated intermediate outcomes and process measures from our randomized clinical trial, with a particular focus on identifying mechanisms that might explain the announcement training's impact.

METHODS

In 2015, a physician educator delivered 1-h in-clinic HPV vaccination recommendation trainings at 20 primary care clinics in North Carolina serving 11,578 patients age 11 or 12. Clinics were randomized to receive training to use "announcements" that presume parents are ready to vaccinate or "conversations" that invite dialog about vaccination. Training participants were 83 HPV vaccine providers. Pre- and post-training surveys assessed constructs from the theory of planned behavior (TPB), including providers' attitudes and subjective norms about HPV vaccination and their perceived behavioral control to recommend HPV vaccination. Surveys also assessed providers' perceptions of the announcement and conversation communication strategies.

RESULTS

Both trainings improved TPB-related constructs, including providers' positive attitudes toward HPV vaccination, subjective norms, and perceived behavioral control to recommend the vaccine (all p < .001, Cohen's d = .62-.90). Furthermore, in both trainings, the amount of time providers reported needing to discuss HPV vaccination with parents decreased from pre-training to 1-month follow-up (mean = 3.8 vs. 3.2 min, p = .01, d = .28). However, announcement trainings outperformed conversation trainings on other measures. For example, providers who received announcement training more often reported that the communication strategy saved them time, was easy to use, helped them promote HPV vaccination as routine care, and increased HPV vaccination coverage in their clinics (all p < .05; d = .44-.60).

CONCLUSIONS

Both announcement and conversation trainings improved providers' HPV vaccine-related perceptions. However, providers viewed announcements as easier to use and more effective, which may help to explain the success of this training approach. Future provider communication interventions should consider implementation outcomes, including acceptability, alongside more traditional TPB constructs.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02377843 . Registered on February 27, 2015.

Cigarette pack messages about toxic chemicals: a randomised clinical trial

Background

The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers’ cigarette packs.

Methods

Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking.

Results

In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05).

Discussion

Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges.

Trial registration number

NCT02785484.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Service quality and parents' willingness to get adolescents HPV vaccine from pharmacists

We sought to examine whether pharmacy service quality was associated with parents' willingness to have immunizing pharmacists administer human papillomavirus (HPV) vaccine to their adolescent children. Participants were a national sample of 1504 US parents of adolescents ages 11 to 17 who completed an online survey in 2014. Analyses used structural equation modeling. Parents rated service quality and feelings of satisfaction with their pharmacies as moderate to high. Many (44%) were willing to get HPV vaccine from immunizing pharmacists for their adolescent children. Compared with parents who went to chain pharmacies, parents who went to independent pharmacies gave higher ratings of service quality (professionalism, confidentiality, milieu, all p < .001). Parents who went to clinic pharmacies, compared with parents who went to chain pharmacies gave lower ratings for milieu (p < .01). Parents who went to independent pharmacies had lower willingness to get HPV vaccine from pharmacists compared to parents who went to chain pharmacies (p = .001), but there was no difference in willingness for parents who went to clinic versus chain pharmacies. Service quality and satisfaction partially mediated the effect between independent pharmacies compared to chain pharmacies and willingness (p < .05). Parents who knew their pharmacists or expressed more confidence in HPV vaccine also had higher willingness to get their children HPV vaccine from pharmacist. Many parents were willing to go to immunizing pharmacists for their children's HPV vaccination. Pharmacies that are considering offering HPV vaccine may be able to improve vaccine uptake by increasing perception of service quality.