The challenge of HPV vaccination uptake and opportunities for solutions: Lessons learned from Alabama

Human Papillomavirus Vaccination and Human Papillomavirus-Related Cancer Rates

Importance

To inform the design and implementation of targeted interventions to reduce the future burden of human papillomavirus (HPV)-related cancers in Texas, it is necessary to examine the county and health service region (HSR) levels of (1) the proportion of children and teenagers aged 9 to 17 years who initiated and were up to date for HPV vaccination series and (2) HPV-related cancer incidence rates (IRs).

Objective

To evaluate temporal trends and geospatial patterns of HPV vaccination initiation and up-to-date status as well as HPV-related cancer rates at county and HSR levels in Texas.

Design, Setting, and Participants

This population-based cross-sectional study used data from the Texas Immunization Registry, the National Cancer Institute's Surveillance, Epidemiology, and End Results Program database, and Texas Department of State Health Services annual population counts from 2006 to 2022. The analysis of HPV vaccination rates was conducted among children and teenagers aged 9 to 17 years; the analysis of HPV-related cancer rates was conducted among adults aged 20 years and older. Data were extracted between June and July 2023 and statistical analysis was performed from February to April 2024.

Main Outcomes and Measures

HPV vaccination initiation and up-to-date status rates and HPV-related cancer IR at county and HSR levels.

Results

A total of 32 270 243 children and teenagers (65.8% female individuals and 34.2% male individuals) and 22 490 105 individuals aged 20 years and older (50.7% female individuals and 49.3% male individuals) were included. The mean 2021 to 2022 county-level HPV vaccination series initiation estimates ranged from 6.3% to 69.1% for female and from 7.0% to 77.6% for male children and teenagers aged 9 to 17 years. County-level vaccination up-to-date estimates were generally lower compared with those of initiation estimates and ranged from 1.6% to 30.4% for female and from 2.1% to 34.8% for male children and teenagers. The pattern of HPV vaccination rates stratified by sex were similar across counties and HSRs. The age-adjusted annual HPV-related cancer IR by county for years 2016 to 2020 ranged from 0 to 154.2 per 100 000 for female individuals and from 0 to 60.1 per 100 000 for male individuals. The counties located in North Texas, HSRs 2/3 and 4/5N, had lower HPV vaccination rates and higher IRs of HPV-related cancers for both female and male individuals compared with other regions.

Conclusions and Relevance

In this study, the incidence of HPV-related cancers varied widely across the counties and HSRs of Texas. More counties in North Texas, HSRs 2/3 and 4/5N, had higher IRs of HPV-related cancers and a lower proportion of HPV vaccination rates than counties in other regions. Designing and implementing targeted interventions to increase uptake and completion of HPV vaccination series across counties with low HPV vaccination rates may help to reduce future the burden of HPV-related cancers.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

INTRODUCTION

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

METHODS

We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices.

RESULTS

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers' approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges.

CONCLUSION

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

HPV and HPV Vaccine Awareness Among African Americans in the Black Belt Region of Alabama

This study aims to examine the factors associated with the level of HPV infection and HPV vaccine awareness among rural African Americans living in the Black Belt region of Alabama. A cross-sectional survey on cancer screening and health behaviors was conducted in the Black Belt region of Alabama. Adults (18 years or older) recruited through convenience sampling completed the self-administered survey. Binary logistic regressions were conducted to identify factors associated with HPV infection and HPV vaccine awareness among African American participants. Slightly more than half of the participants were aware of HPV (62.5%) and HPV vaccine (62.1%). Married or partnered participants had lower awareness of HPV or HPV vaccine. Family cancer history and self-reported health status were positively associated with both HPV and HPV vaccine awareness. In addition, employment was positively associated with HPV awareness, and participation in social groups was positively associated with HPV vaccine awareness. Tailored educational interventions that consider our findings might increase HPV and HPV vaccine awareness and contribute to better vaccine uptakes.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

Introduction

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

Methods

We conducted 40 semi-structured interviews with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) model and used deductive coding approach. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities.

Results

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level), providers' approach to the HPV vaccine recommendations (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and information (practice level).

Conclusions

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Factors associated with parental human papillomavirus vaccination intentions among adolescents from socioeconomically advantaged versus deprived households: a nationwide, cross-sectional survey

Background

In the USA, HPV vaccine coverage is substantially lower among adolescents from high-income households compared to their low-income counterparts. We examined and compared the factors associated with parental HPV vaccination intentions between socioeconomically divergent groups.

Methods

Data from unvaccinated and not fully HPV-vaccinated adolescents from the 2017-2021 National Immunization Survey (NIS)-Teen were analyzed. Socioeconomically advantaged vs. deprived groups were identified based on dichotomized income (material capital) and education (social capital). Parental intent to initiate and complete the HPV vaccine series was compared using bivariable analysis and the factors associated with lacking intent were identified.

Findings

The 2017-2021 NIS-Teen included a total of 212,643 participants; the final analytical sample consisted of 105,958 adolescents (an estimated 10.3 million adolescents) who were unvaccinated or not fully vaccinated. In the advantaged group, 64.7% of parents of unvaccinated adolescents (equating to 2.4 million US adolescents) had no intention to initiate the HPV vaccine compared to 40.9% of parents in the deprived group (equating to 0.2 million adolescents) (P < 0.0001; S > 13.29). The most frequent reason for lacking intent in the advantaged group was 'safety concerns' (25.5%). In the deprived group, 'lack of knowledge', 'not recommended', and 'not needed' were common reasons (nearly 15% each). Lack of intent to complete the HPV vaccine series was higher in the advantaged group (43.9%; 1.1 million adolescents) compared to the deprived group (25.2%; 0.08 million adolescents) (P < 0.0001; S > 13.29). More than half in the advantaged group (58.4%) and over a third (37.1%) in the deprived group cited 'already up to date' as the main reason for not completing the HPV vaccine series.

Interpretation

Lack of intent to initiate and complete the HPV vaccination series, particularly among socioeconomically advantaged parents is a significant barrier to achieving the national goal in the USA.

Funding

The US National Institute on Minority Health and Health Disparities, the National Center for Advancing Translational Sciences, MUSC Hollings Cancer Center Seed funding, and the US National Cancer Institutes.

Stories to Prevent Cancer: A Pilot Study Using Cancer Survivor Narratives to Increase Human Papillomavirus Vaccine Intentions

INTRODUCTION

Human papillomavirus (HPV) vaccination rates are lower than other recommended adolescent vaccines. Cancer survivor narratives are used to promote cancer prevention and control, but little is known about their impact on adolescent HPV vaccination.

OBJECTIVE

This pilot study explored the feasibility and effects of a video education intervention using a cancer survivor narrative to improve parents' attitudes toward and intentions to get the HPV vaccine.

METHODS

This study utilized a one-group design; participants completed a pre-intervention survey, watched the video before attending their sons' wellness visits, and completed a post-intervention survey within one week of their appointment. Using the narrative persuasion framework, we developed a 4-minute video of a local HPV-related cancer survivor to promote the HPV vaccine as cancer prevention. We recruited 37 participants between June and October 2020. Participants were parents of males ages 9-17 who had not yet initiated HPV vaccination.

RESULTS

After the video, more parents agreed that HPV vaccination is safe (pre: 66% vs. post: 82%; P = .045) and that their child's chances of getting HPV-related cancer in the future are high (pre: 24% vs. post: 46%; P = .014). Overall, 91% of parents felt the cancer survivor story helped them understand the risks of HPV cancers, and 52% said the story influenced their decision to start HPV vaccination for their child.

CONCLUSIONS

Our findings suggest that cancer survivor narratives influence parents' vaccine opinions and understanding of their child's risk of HPV infection, leading to increased parental intent to get the HPV vaccine for their adolescent males.

Understanding vaccination hesitation among health professionals: a systematic review of qualitative studies

OBJECTIVES

In terms of vaccination, people trust healthcare professionals (HCPs) more than any other source of information. They are the cornerstone of vaccination as they can move undecided populations not only towards vaccination but also towards non-vaccination. The aim of this systematic review was to explore the knowledge, beliefs, attitudes, and barriers associated with own vaccination and patient recommendation in HCPs.

STUDY DESIGN

This study incorporated a systematic review.

METHODS

A systematic review of studies published from January 1, 2000, to June 1, 2020, was conducted by searching PubMed and EMBASE electronic databases. Qualitative studies reporting outcomes related to knowledge, attitudes, or barriers related to vaccination/recommendation by healthcare personnel were included. The guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed.

RESULTS

From a total of 2916 studies identified, 36 articles met the inclusion criteria. Some of the factors cited by the HCP that may contribute to vaccine hesitancy were (a) concerns regarding safety or efficacy of vaccines (23 articles); (b) time constraints (21 articles); (c) lack of knowledge about the vaccination/vaccine (19 articles); (d) costs (13 articles); (e) distrust of pharmaceutical industry (8 articles); and (f) considering oneself insusceptible (7 articles), stock shortage (7 articles), lack of personnel (5 articles), and feelings of unnecessary vaccination (5 articles).

CONCLUSIONS

Our review suggests that interventions to combat vaccine hesitancy should increase HCP education on vaccine efficacy and safety, as well as intervene on health system factors such as cost and time per visit. In this way, we could tackle the problem of vaccine hesitancy, which seriously threatens global public health.

Self-reported HPV vaccination status and HPV vaccine hesitancy in a nationally representative sample of emerging adults in Croatia

Introduction

The aim of this study was to determine self-reported human papillomavirus (HPV) vaccination status among emerging adults in Croatia, intention to get the HPV vaccine among unvaccinated individuals and correlates of HPV vaccine hesitancy.

Methods

Data were collected via a cross-sectional survey based on a probabilistic national sample. The sample included 1,197 individuals aged 18-25 years (50.6% were women) who were recruited from November 2021 to February 2022 as part of the commercial online panel. Analyses included 981 participants who correctly answered two "attention trap" questions using descriptive statistics and multivariate analyses. The data were post-hoc weighted for gender and age and adjusted for clustering effect. To adjust standard errors for the sampling design, multivariate analyses were carried out using the complex samples module in the IBM SPSS 27 statistical software package.

Results

Overall, 18.3% of participants (25.0% of women and 11.7% of men) reported that they were HPV vaccinated, while 21.9% did not know their HPV vaccination status. Of those vaccinated, 65.6% were women. The odds of being HPV-vaccinated were significantly higher among female participants. Among the unvaccinated, 35.4% expressed a willingness to get the vaccine. The odds of vaccination hesitancy were significantly lower among women, participants who reported a higher perceived risk of STIs, those who recognized that HPV could result in cervical cancer, and significantly higher among those who were more religious.

Conclusion

Our findings suggest a need to increase HPV vaccination uptake in Croatia through raising awareness about HPV vaccine effectiveness and also through the implementation of strategies to make vaccination more available.

Factors Related to the Implementation of Preconception Care Recommendations in Selected Districts of Limpopo Province: A Qualitative Study

Preconception care (PCC) is the provision of biomedical, behavioural, and social health interventions to women and couples before they fall pregnant. The World Health Organization (WHO) developed PCC recommendations in 2013, which were included in the South African maternity care guidelines in 2016. The purpose of PCC is to lessen behaviours and environmental factors leading to maternal ill-health, thus reducing maternal and perinatal mortality rates.

OBJECTIVE

To determine the implementation of PCC recommendations at health facilities in the selected districts of Limpopo Province and the associated factors.

METHODS

A qualitative exploratory design was used. Nonprobability, purposive sampling was used to sample 29 professional nurses (PNs), and 51 women of childbearing age (WCBA) (19-35 years) from clinics and community health centres (CHCs). Data were collected through in-depth interviews with the professional nurses and focus group discussions with the WCBA. Data analysis was performed through open coding. Measures of trustworthiness were adhered to. Permission to conduct the study was obtained from relevant stakeholders, participation was voluntary and participants signed a consent form prior to data collection.

RESULTS

The findings of the study revealed that there was partial implementation of the PCC recommendations in the selected districts of Limpopo Province, PCC provision was dependent on clients' initiation, a knowledge gap regarding PCC recommendations was identified from the professional nurses, and a lack of awareness regarding PCC from the WCBA.

CONCLUSION

The preconception period is an important determinant of the pregnancy outcome; therefore, focus should be redirected to the pre-pregnancy period and not only to when the woman is already pregnant. However, to achieve this, professional nurses and WCBA should be empowered regarding PCC and its benefits.

Human Papillomavirus Vaccine Hesitancy in the United States

Although the US Advisory Committee on Immunization Practices recommends vaccinating adolescents against the human papillomavirus (HPV) to prevent HPV-associated cancers, vaccine initiation and completion rates are suboptimal. Parental and provider hesitancy contributes significantly to low HPV vaccine uptake. This review describes sources of HPV vaccine hesitancy using a World Health Organization framework that categorizes determinants of vaccine hesitancy as follows: contextual factors (historical, sociocultural, environmental, or political factors), individual and group factors (personal perception or influences of the social/peer environment), and vaccine/vaccination-specific issues (directly related to vaccine or vaccination).

Examining multilevel influences on parental HPV vaccine hesitancy among multiethnic communities in Los Angeles: a qualitative analysis

BACKGROUND

Human papillomavirus (HPV) vaccine hesitancy is a growing concern in the United States, yet understudied among racial/ethnic minority parents. We conducted qualitative research to understand parental HPV vaccine hesitancy and inform community-specific, multilevel approaches to improve HPV vaccination among diverse populations in Los Angeles.

METHODS

We recruited American Indian/Alaska Native (AI/AN), Hispanic/Latino/a (HL) and Chinese parents of unvaccinated children (9-17 years) from low-HPV vaccine uptake regions in Los Angeles for virtual focus groups (FGs). FGs were conducted in English (2), Mandarin (1), and Spanish (1) between June-August 2021. One English FG was with AI/AN-identifying parents. FGs prompted discussions about vaccine knowledge, sources of information/hesitancy, logistical barriers and interpersonal, healthcare and community interactions regarding HPV vaccination. Guided by the social-ecological model, we identified multilevel emergent themes related to HPV vaccination.

RESULTS

Parents (n = 20) in all FGs reported exposure to HPV vaccine information from the internet and other sources, including in-language media (Mandarin) and health care providers (Spanish). All FGs expressed confusion around the vaccine and had encountered HPV vaccine misinformation. FGs experienced challenges navigating relationships with children, providers, and friends/family for HPV vaccine decision-making. At the community-level, historical events contributed to mistrust (e.g., forced community displacement [AI/AN]). At the societal-level, transportation, and work schedules (Spanish, AI/AN) were barriers to vaccination. Medical mistrust contributed to HPV vaccine hesitancy across the analysis levels.

CONCLUSION

Our findings highlight the importance of multilevel influences on parental HPV vaccine hesitancy and decision-making and the need for community-specific messaging to combat medical mistrust and other barriers to HPV vaccination among racial/ethnic minority communities.

An Update on Human Papillomavirus Vaccination in the United States

Cervical cancer remains a significant disease in the United States. Although the human papillomavirus (HPV) vaccine has been approved for those aged 9-26 years and for some individuals up to age 45 years, there are many circumstances in which health care professionals may not know whether the vaccine should be recommended, such as for patients with previous infection, health care workers, and those older than age 26 years. This article highlights the evidence that the HPV vaccine is a safe and highly effective way to prevent cervical cancer, with the strongest predictor of vaccine uptake being practitioner recommendation.

Digital Health Interventions to Improve Adolescent HPV Vaccination: A Systematic Review

Digital technologies are being increasingly utilized in healthcare to provide pertinent and timely information for primary prevention, such as vaccination. This study aimed to conduct a systematic review to describe and assess current digital health interventions to promote HPV vaccination among adolescents and parents of adolescents, and to recommend directions for future interventions of this kind. Using appropriate medical subject headings and keywords, we searched multiple databases to identify relevant studies published in English between 1 January 2017 and 31 July 2022. We screened and selected eligible studies for inclusion in the final analysis. We reviewed a total of 24 studies, which included interventions using text messages (4), mobile apps (4), social media and websites (8), digital games (4), and videos (4). The interventions generally improved determinants of HPV vaccination, such as HPV-related knowledge, vaccine-related conversations, and vaccination intentions. In particular, text message and social media interventions targeted improved vaccine uptake behaviors, but little meaningful change was observed. In conclusion, digital health interventions can cost-effectively provide education about HPV vaccination, offer interactive environments to alleviate parental vaccine hesitancy, and ultimately help adolescents engage in HPV vaccine uptake.

Differences in stakeholder-reported barriers and implementation strategies between counties with high, middle, and low HPV vaccine initiation rates: a mixed methods study

BACKGROUND

A greater understanding of the county-level differences in human papillomavirus (HPV) vaccination rates could aid targeting of interventions to reduce HPV-related cancer disparities.

METHODS

We conducted a mixed-methods study to compare the stakeholder-reported barriers and efforts to increase HPV vaccination rates between counties within the highest, middle, and lowest HPV vaccine initiation (receipt of the first dose) rates among 22 northern Florida counties. Between August 2018 and April 2019, we recruited stakeholders (n = 68) through purposeful and snowball sampling to identify potential participants who were most knowledgeable about the HPV vaccination activities within their county and would represent a variety of viewpoints to create a diverse picture of each county, and completed semi-structured interviews. County-level HPV vaccine initiation rates for 2018 were estimated from the Florida Department of Health's immunization registry and population counts. Implementation strategies were categorized by level of importance and feasibility using the Expert Recommendations for Implementing Change (ERIC) taxonomy. We compared the barriers and implementation strategies for HPV vaccination between tercile groups of counties by HPV vaccine initiation rates: highest (18 stakeholders), middle (27 stakeholders), and lowest (23 stakeholders).

RESULTS

The majority of the 68 stakeholders were female (89.7%), non-Hispanic white (73.5%), and represented a variety of clinical and non-clinical occupations. The mentioned barriers represented five themes: healthcare access, clinician practices, community partnerships, targeted populations, and cultural barriers. Within themes, differences emerged between county terciles. Within healthcare access, the highest rate county stakeholders focused on transportation, lowest rate county stakeholders focused on lack of clinicians, and middle county stakeholders mentioned both. The number of ERIC quadrant I strategies, higher feasibility, and importance described decreased with the tercile for HPV vaccination: highest = 6, middle = 5, and lowest =3 strategies.

CONCLUSIONS

The differing barriers and strategies between the highest, middle, and lowest vaccination rate counties suggest that a tailored and targeted effort within the lowest and middle counties to adopt strategies of the highest rate counties may reduce disparities.

Screening Awareness of HPV-Related Oropharyngeal Cancers and Attitudes and Concerns towards HPV Vaccination Among Parents : HPV and Oropharyngeal Cancer

Baseline population opinions on human papillomavirus (HPV) and HPV vaccination must be understood before physicians can address knowledge gaps in that population and encourage timely vaccination. To determine the opinions of parents of children age 9 to 18 on HPV-related oropharyngeal cancers (OPC); the associations with education level, socioeconomic status, and having a family member/friend with OPC; and the main concerns against having a vaccination., An anonymous survey was created and administered. Parents were asked to complete the survey if they met the inclusion criteria. After the survey, results were tabulated, and the answers for each question were analyzed. The target population was surveyed in the clinic. The target population was parents with children between 9 and 18 years old: the background knowledge and awareness of HPV-related OPC and associations with education level, socioeconomic status, having a family member/friend with OPC, and concerns about vaccination. Our study results showed that the age of parents, education level, marital status, personal vaccination status, and gender of the child are significant factors for background knowledge about HPV-related diseases. Similarly, the education level, the gender of the child, and personal vaccination status are significant factors towards attitudes against having children vaccinated. There is a strong correlation between background knowledge and attitudes. The main issues about vaccination are concerns about effectiveness and side effects, concerns about safe sex experiences, and the cost of vaccination. This is the first study designed to provide information on parents' knowledge of HPV-related cancers, prevalence of HPV vaccination, and attitudes and concerns about HPV vaccination in the USA. The lack of awareness of HPV-related cancers is a significant factor in attitudes against HPV vaccination.

Analysis of Perception, Reasons, and Motivations for COVID-19 Vaccination in People with Diabetes across Sub-Saharan Africa: A Mixed-Method Approach

Diabetes mellitus (DM) is associated with severe COVID-19 infection and complications. This study assesses COVID-19 vaccine acceptance and hesitancy in people with DM, and explores the reasons for not being vaccinated. This was a web-based cross-sectional survey using a mixed-method approach conducted in March–May 2021, corresponding to most sub-Saharan African (SSA) countries’ early vaccine rollout period. Participants were those aged ≥18 years with self-reported DM in 11 Sub-Saharan African (SSA) countries. Responses to comments on the reasons for vaccine hesitancy and facilitators for vaccine uptake were analyzed. Of the 73 participants with DM, 65.8% were males, older than 35 years (86.3%), had postsecondary education (90%), and a significant proportion were from South Africa (39.7%), Nigeria (28.8%) and Ghana (13.7%). At the time of this study, 64.4% experienced COVID-19 symptoms, 46.6% were tested for COVID-19, of which 19.2% tested positive. Few participants (6.8%) had received a COVID-19 vaccination, 65.8% were willing to take the vaccine when it becomes available in their country, while 26.0% either refused or remained hesitant towards taking the vaccine. The main identified reasons for not taking the vaccine were: advice from religious leaders; concerns about the safety, effects, and efficacy of the vaccines; mistrust of the pharmaceutical companies producing the vaccines and the process of production; the conspiracy theories around the vaccines; and the personal belief of the participants regarding vaccination. However, participants stated they would take the vaccine if they were more educated about it, received positive feedback from those vaccinated, were rewarded for taking the vaccine, or if vaccination became a condition for travel and employment. In conclusion, this study shows that the uptake of the COVID-19 vaccine was very low in this high-risk group. Efforts to increase the uptake of COVID-19 vaccines among people with diabetes are imperative, such as the provision of education and relevant information.

Gynecologic Oncology HPV Vaccination Practice Patterns: Investigating Practice Barriers, Knowledge Gaps and Opportunities for Maximizing Cervical Cancer Prevention

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Novel survey of gynecologic oncologists’ perspectives and practices regarding HPV vaccination.

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Higher levels of vaccine knowledge were associated with recommending the vaccine.

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Knowledge about prescribing policies and clinic factors were common barriers to HPV vaccination.

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There are modifiable patient, provider, and systemic level barriers to HPV vaccination.

Objective

HPV vaccination is an important form of cancer prevention. Gynecologic oncologists have an opportunity to improve adult vaccination rates. We aimed to describe current HPV vaccination practices and barriers to vaccination reported by gynecologic oncologists.

Methods

An online survey was developed, pilot tested and sent to U.S. members of the Society of Gynecologic Oncology.

Results

Of the 226 respondents, most were female (73%), < 45 years old (64%) and practiced in urban (60%) and academic settings (69%). Ninety percent had recommended the HPV vaccine in the past year. Nearly half (47%) had facilitated vaccination by: administering the HPV vaccine in clinic (40%), stocking the vaccine (35%), or prescribing the vaccine (30%). Recommending the vaccine was associated with higher outpatient volume, practicing in the South vs. Northeast, and having higher levels of vaccine knowledge.

Of the 90% who recommended the vaccine, 60% did not prescribe or know if they could prescribe the vaccine in their state. Prioritization of cancer treatment was the most commonly reported barrier to HPV vaccination (88%). Approximately half of providers reported other systems-level hinderances such as high cost of stocking the vaccine, clinic flow disruption, or uncertainty surrounding insurance coverage. Almost all recommenders offered the vaccine at HPV-related dysplasia (92%) or cancer (80%) visits, while only 24–50% offered it at non-HPV-related visits.

Conclusions

These survey results identify patient, provider, and systems-level barriers that could be targeted to help increase adult HPV vaccination in gynecologic oncology clinics.

mHealth video gaming for human papillomavirus vaccination among college men-qualitative inquiry for development

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Persistent infection with HPV can cause various cancers; however, HPV vaccination can prevent infections associated with high risk, cancerous strains of the virus. As it relates to HPV, college age men have been identified as one of the catch-up vaccination groups. Among college age men, gaming is an extremely popular extracurricular activity. Further, video games have emerged as a popular public health intervention tool. Therefore, this study aims to collect qualitative data on how to develop, implement and evaluate the effectiveness of a gaming intervention to increase HPV risk perceptions, improve self-efficacy and increase intention to receive the HPV vaccine among male college students (18-26 years old).

METHODS

Four focus group sessions ranging from eight to ten individuals were conducted among male college students from one large research-intensive university in the South. Using grounded theory, data from focus group interviews were coded using NVivo software to identify emergent themes.

RESULTS

Participants emphasized that although customization was not viewed as important by college aged males, the ability to tailor in game experiences or experience different things each time they played (creative freedom) was more important. They encouraged that the digital game be created on a mobile platform, incorporate health messages, and be informative to reach their population. Furthermore, they suggested innovative way to disseminate the game, which included having health department/health care providers prescribe the game to patients as an end of clinical interaction strategy.

CONCLUSIONS

College age men, are natural avid gamers, enjoy game play, and can engage in learning online or offline. While platform preference varies among gamer type, college age men in our study emphasized that mobile based gaming is the most advantageous way to increase knowledge/awareness and encourage positive in game behavior which can impact out of game behaviors such as vaccination. Because of the level of access and natural disposition of mHealth technology seen as an "extension of the self", games for health developers should consider the mobile platform as the ideal for the target demographic.

Associations Between Human Papillomavirus Vaccine Decisions and Exposure to Vaccine Information in Social Media

PURPOSE

Exposure to different types of vaccine information in social media can result in parents making disparate vaccine decisions, including not following national guidelines for human papillomavirus (HPV) vaccination. We sought to characterize parents' exposure to and engagement with information about HPV vaccination in social media, and the associations between exposure to such information and vaccine decisions for their adolescent children.

METHODS

In 2019, we conducted a web-based survey with a national sample of 1073 parents of adolescents who use social media. The survey assessed whether parents have seen information in favor, against, or mixed about HPV vaccination. Multivariable logistic regressions assessed correlates of vaccine decisions, including HPV vaccine initiation, delay, and refusal.

RESULTS

Sixty-one percent of parents reported that their children have initiated HPV vaccination. Over one-third of parents (37%) reported seeing HPV vaccine information on social media, which was either in favor (20%), against (5%), or a mix (12%). Parents exposed to information in favor were more likely than those who saw no information to have initiated HPV vaccination (OR = 1.74, 95% CI:1.24, 2.44). Parents exposed to information against vaccination were more likely to have delayed (OR = 3.29, 95% CI:1.66, 6.51) or refused (OR = 4.72, 95% CI:2.35, 9.50) HPV vaccination. Exposure to mixed information was also significantly associated with vaccine delay and refusal.

DISCUSSION

Our findings suggest that the type of information seen on social media regarding HPV vaccination may influence the decisions parents make about vaccinating their children. Efforts should be sought to increase online information in favor of HPV vaccination and combat vaccine misinformation in social media.

Human Papillomavirus Vaccination and Human Papillomavirus-Associated Cancer Rates Within Florida Counties

INTRODUCTION

To direct interventions, the Florida counties with the greatest risk of current and future human papillomavirus‒associated cancers were identified by estimating county-level (1) percentages of adolescents aged 13-17 years who initiated (≥1 dose) and were up to date (2-3 doses) for the human papillomavirus vaccine and (2) human papillomavirus‒associated cancer incidence rates.

METHODS

Records were obtained for human papillomavirus vaccinations from the Florida immunization registry (2006-2019), incident cancer cases from the Florida registry (2013-2017), and annual population counts from the Florida Department of Health (2006-2019). In 2020, annual county-level human papillomavirus vaccine initiation, human papillomavirus vaccine up-to-date, and age-adjusted human papillomavirus‒associated cancer incidence rates were estimated.

RESULTS

Among adolescents aged 13-17 years, average 2018-2019 county-specific human papillomavirus vaccine initiation ranged from 38% to 100% for females and from 34% to 96% for males. Up-to-date estimates ranged from 20% to 72% for females and from 24% to 77% for males. The majority (78%) of counties with initiation and up-to-date estimates within the lowest tercile were located in Northern Florida. County-specific 2013-2017 annualized, adjusted human papillomavirus‒associated cancer incidence rates ranged from 0 to 29.8 per 100,000 among females and from 5.4 to 24.1 per 100,000 among males. Counties within the highest tercile for human papillomavirus‒associated cancers were primarily (90% for females and 77% for males) located in Northern Florida.

CONCLUSIONS

Human papillomavirus‒associated cancer risk varies widely across Florida counties, with particularly high risk within Northern Florida. Targeting interventions toward counties with low vaccination and high cancer rates may reduce human papillomavirus‒associated cancers.

Using concept mapping to identify opportunities for HPV vaccination efforts: Perspectives from the Midwest and West Coast

Human papillomavirus (HPV) infection significantly contributes to the burden of cancer in the United States, despite the existence of a highly effective vaccine. While numerous interventions to address vaccination uptake exist, vaccination rates remain low. We conducted a concept mapping exercise to solicit perspectives on barriers and facilitators to HPV vaccination from state-level stakeholders in five states in the Midwest and West Coast of the U.S. We identified 10 clusters of barriers and facilitators based on participants' statements. For rural areas specifically, clusters rated as most important included education and provider influence; those rated as most feasible were education and coordinated/consistent messaging. Our results suggest that a combination of important (but potentially more difficult to implement) strategies, combined with those rated as most feasible (but potentially less impactful) may be beneficial. Our findings highlight similarities across diverse states, suggesting that states can learn from each other and work together to improve HPV vaccination rates. Using concept mapping proved to be an efficient way to collect information from diverse, stakeholders in different locations, and is a methodology that could be used for program planning in areas beyond HPV vaccination.

Using the Theory of Planned behavior to identify correlates of HPV vaccination uptake among college students attending a rural university in Alabama

INTRODUCTION

Humanpapillomavirus (HPV) has infected nearly 80 million people in the U.S., and is associated with most cervical cancer cases. Alabama ranks first in the country for cervical cancer mortality and third for incidence. Although the HPV vaccine can prevent HPV and reduce cancer rates, Alabama is well-below the national average for HPV vaccination. Using the Theory of Planned Behavior (TPB), this Alabama-based study aimed to examine college students' intentions to get the HPV vaccine; to examine the relationship between the relationship between religious beliefs and HPV vaccination uptake status among college students.

METHODS

Students (n = 257) from a university in rural Alabama completed the survey. Multiple regression analysis, Mann-Whitney U tests, and moderation analysis were used to examine associations among the variables of interest.

FINDINGS

Consistent with TPB, results showed that attitudes and subjective norms were significant predictors of intention to get vaccinated. Knowledge that both sexes can experience HPV-related health problems, that HPV can cause genital warts, and that the vaccine protects against HPV were each associated with higher attitude scores. The results indicated that the odds of getting at least one HPV shot were higher for females than for males for non-Caucasians than for Caucasians. Students who were not vaccinated were more likely to report that religion influenced their health beliefs. *Abstract.

CONCLUSION

TPB was helpful in understanding HPV-related intentions. Communication and education efforts are needed to increase understanding of HPV illnesses and HPV vaccination benefits among peers, parents, and other loved ones of students. in the rural areas of Alabama.

Human Papillomavirus Vaccination and Social Media: Results in a Trial With Mothers of Daughters Aged 14-17

Introduction: Parents acquire information about human papillomavirus (HPV) vaccines online and encounter vaccine-critical content, especially on social media, which may depress vaccine uptake. Secondary analysis in a randomized trial of a Facebook-delivered adolescent health campaign targeting mothers with posts on HPV vaccination was undertaken with the aims of (a) determining whether the pre–post-change occurred in self-reports of the mothers on HPV vaccination of their adolescent daughters; (b) describing the comments and reactions to vaccine posts; (c) exploring the relationship of campaign engagement of the mothers assessed by their comments and reactions to posts to change in the self-reports of the mothers of HPV vaccination.

Materials and Methods: Mothers of daughters aged 14–17 were recruited from 34 states of the US (n = 869). A social media campaign was delivered in two Facebook private groups that differed in that 16% of posts in one were focused on indoor tanning (IT) and 16% in the other, on prescription drug misuse, assigned by randomization. In both groups, posts promoted HPV vaccination (n = 38 posts; no randomization) and vaccination for other disease (e.g., influenza, n = 49). HPV and other vaccination posts covered the need for a vaccine, the number of adolescents vaccinated, how vaccines are decreasing the infection rates, and stories of positive benefits of being vaccinated or harms from not vaccinating. Guided by social cognitive theory and diffusion of innovations theory, posts were intended to increase knowledge, perceived risk, response efficacy (i.e., a relative advantage over not vaccinated daughters), and norms for vaccination. Some vaccination posts linked to stories to capitalize on identification effects in narratives, as explained in transportation theory. All mothers received the posts on vaccination (i.e., there was no randomization). Mothers completed surveys at baseline and 12- and 18-month follow-up to assess HPV vaccine uptake by self-report measures. Reactions (such as sad, angry) and comments to each HPV-related post were counted and coded.

Results: Initiation of HPV vaccination (1 dose) was reported by 63.4% of mothers at baseline, 71.3% at 12-month posttest (pre/post p < 0.001), and 73.3% at 18-month posttest (pre/post p < 0.001). Completion of HPV vaccination (two or three doses) was conveyed by 50.2% of mothers at baseline, 62.5% at 12-month posttest (pre/post p < 0.001), and 65.9% at 18-month posttest (pre/post p < 0.001). For posts on HPV vaccines, 8.1% of mothers reacted (n = 162 total), and 68.4% of posts received a reaction (63.2% like; 13.2% love, 7.9% sad). In addition, 7.6% of mothers commented (n = 122; 51 unfavorable, 68 favorable, 1 neutral), and 50.0% of these posts received a comment. There were no differences in pre–post change in vaccine status by the count of reactions or comments to HPV vaccine posts (Ps > 0.05). Baseline vaccination was associated with the valence of comments to HPV vaccine posts (7.2% of mothers whose daughters had completed the HPV series at baseline made a favorable comment but 7.6% of mothers whose daughters were unvaccinated made an unfavorable comment).

Conclusion: Effective strategies are needed in social media to promote HPV vaccines and counter misinformation about and resistance to them. Mothers whose daughters complete the HPV vaccine course might be recruited as influencers on HPV vaccines, as they may be predisposed to talk favorably about the vaccine. Comments from mothers who have not been vaccinated should be monitored to ensure that they do not spread vaccine-critical misinformation. Study limitations included lack of randomization and control group, relatively small number of messages on HPV vaccines, long measurement intervals, inability to measure views of vaccination posts, reduced generalizability related to ethnicity and social media use, and use of self-reported vaccine status.

Clinical Trial Registration:www.clinicaltrials.gov, identifier NCT02835807.

Parental acceptability of COVID-19 vaccination for children under the age of 18 years among Chinese doctors and nurses: a cross-sectional online survey

This study investigated parental acceptability of COVID-19 vaccination for children under the age of 18 years among Chinese parents who are healthcare workers. A closed online survey among full-time doctors or nurses employed by the five collaborative hospitals who had access to smartphones was conducted. Facilitated by the hospital administrators, prospective participants received an invitation sent by the research team via the existing WeChat/QQ groups to complete an online questionnaire. A total of 2,281 participants completed the survey. This study was a sub-analysis of 1332 participants who had at least one child under the age of 18 years. Among the participants, 44.5% reported that they would likely or very likely to have their children under the age of 18 years take up COVID-19 vaccination in the next six months. After adjusting for significant background characteristics, perceived higher vaccine efficacy, longer protection duration, perceived high/very high chance for China to prevent another wave of COVID-19 outbreak with vaccines in place and willingness to receive a COVID-19 vaccination for themselves were associated with higher parental acceptability of COVID-19 vaccination. At interpersonal level, higher frequency of information exposure through social media and direct interpersonal communication were associated with higher parental acceptability of COVID-19 vaccination, while knowing some people who experienced serious side effects following COVID-19 vaccination were associated with lower parental acceptability of COVID-19 vaccination. Despite their important roles in vaccination promotion, Chinese doctors and nurses showed low parental acceptability of COVID-19 vaccination. Effective health promotion is needed when COVID-19 vaccination become available.

Examining Associations between Knowledge and Vaccine Uptake Using the Human Papillomavirus Knowledge Questionnaire (HPV-KQ)

Objectives: Understanding the relationship between human papillomavirus (HPV) knowledge and vaccination behavior is important to inform public health interventions, yet few validated HPV knowledge scales exist. This study describes development of the Human Papillomavirus Knowledge Questionnaire (HPV-KQ) and its validation with parents residing in the southern United States (US). Methods: Drawing on previously published measures, we developed the 13-item HPV-KQ and administered the scale via Web-based survey to parents (N=1105) of adolescents ages 9 to 17 years. Dimensionality, internal consistency, model fit, and predictive validity were assessed. Results: The scale was bidimensional. One factor captured general HPV knowledge, and the second factor captured perceptions of gender differences in HPV infection and vaccine recommendations. The 13-item scale and 2-factor solution displayed strong internal consistency and good model fit. Parents of vaccinated adolescents scored higher on the 13-item HPV-KQ (Mean = 8.56) than parents of unvaccinated adolescents (Mean = 6.43) (p < .001). In regression models, controlling for key covariates, parents' performance on the HPV-KQ predicted adolescent HPV vaccination (p < .001). Conclusions: Evaluation indicates the HPV-KQ is a reliable and valid tool for measuring knowledge of HPV and the HPV vaccine among parents residing in the southern US. We recommend further efforts to validate the scale with other populations.

Challenges related to human papillomavirus (HPV) vaccine uptake in Minnesota: clinician and stakeholder perspectives

Background

Human papillomavirus (HPV) vaccination rates among adolescents are increasing in Minnesota (MN) but remain below the Healthy People 2020 goal of 80% completion of the series. The goal of this study was to identify messaging and interventions impacting HPV vaccine uptake in MN through interviews with clinicians and key stakeholders.

Methods

We conducted semi-structured key participant interviews with providers and stakeholders involved in HPV vaccination efforts in MN between 2018 and 2019. Provider interview questions focused on messaging around the HPV vaccine and clinic-based strategies to impact HPV vaccine uptake. Stakeholder interview questions focused on barriers and facilitators at the organizational or state level, as well as initiatives and collaborations to increase HPV vaccination. Responses to interviews were recorded and transcribed. Thematic content analysis was used to identify themes from interviews.

Results

14 clinicians and 13 stakeholders were interviewed. Identified themes were grouped into 2 major categories that dealt with messaging around the HPV vaccine, direct patient–clinician interactions and external messaging, and a third thematic category involving healthcare system-related factors and interventions. The messaging strategy identified as most useful was promoting the HPV vaccine for cancer prevention. The need for stakeholders to prioritize HPV vaccination uptake was identified as a key factor to increasing HPV vaccination rates. Multiple providers and stakeholders identified misinformation spread through social media as a barrier to HPV vaccine uptake.

Conclusion

Emphasizing the HPV vaccine’s cancer prevention benefits and prioritizing it among healthcare stakeholders were the most consistently cited strategies for promoting HPV vaccine uptake. Methods to combat the negative influence of misinformation about HPV vaccines in social media are an urgent priority.

Understanding primary care physician perspectives on recommending HPV vaccination and addressing vaccine hesitancy

HPV vaccination rates have improved in recent years, but remain suboptimal in the United States. Physician recommendation is associated with increased uptake; however, specific strategies used by physicians to recommend the vaccine and address hesitancy are underexplored. We iteratively conducted qualitative in-depth interviews with family medicine and pediatrics/adolescent medicine physicians recruited from four primary care settings (federally qualified health centers and hospital-affiliated practices) within a large academic-hospital system in New Jersey. Interviews aimed to understand factors influencing physician recommendations. Transcripts were analyzed iteratively using a team-based, thematic content analysis approach. All physicians reported strong support for HPV vaccination, intention to recommend for target age groups, and providing factsheets to parents. Many physicians used electronic medical records and/or the state immunization registry for monitoring vaccinations, but few were able to report their own clinic-level rates. The majority said they needed to overcome both hesitancy for at least 10-30% of parents and misinformation from the internet. Most cited having their own children vaccinated for HPV as a first-line strategy for addressing parental hesitancy. Other strategies included using data or professional authority to address safety concerns, linking HPV to cervical cancer, highlighting only needing two doses if vaccinated younger, and normalizing the vaccine. While our findings indicate physicians are knowledgeable about HPV vaccination and recommend it to parents, strategies to overcome parental hesitancy varied. Physician, clinic, and health-system-based strategies need to be adopted to overcome parental hesitancy for HPV vaccination.

Timeliness of Early Childhood Vaccinations and Undervaccination Patterns in Montana

INTRODUCTION

Early childhood vaccination rates are lower in rural areas than those in urban areas of the U.S. This study's objective is to quantify vaccine timeliness and the prevalence of undervaccination patterns in Montana and to measure the associations between timeliness and series completion by age 24 months.

METHODS

Using records from January 2015 to November 2019 in Montana's centralized immunization information system, days undervaccinated were calculated for the combined 7-vaccine series. Undervaccination patterns indicative of certain barriers to vaccination, including parental vaccine hesitancy, were identified. Using multivariable log-linked binomial regression, the association between timing of vaccine delay and not completing the combined 7-vaccine series by age 24 months was assessed. Analyses were conducted in March 2020-August 2020.

RESULTS

Among 31,422 children, 38.0% received all vaccine doses on time; 24.3% received all doses, but some were received late; and 37.7% had not completed the combined 7-vaccine series. Approximately 18.7% had an undervaccination pattern suggestive of parental vaccine hesitancy, and 19.7% started all series but were missing doses needed for multidose series completion. Although falling behind on vaccinations at any age was associated with failing to complete the combined 7-vaccine series, being late at age 12-15 months had the strongest association (adjusted prevalence ratio=3.73, 95% CI=3.56, 3.91) compared with being on time at age 12-15 months.

CONCLUSIONS

Fewer than 2 in 5 Montana children were fully vaccinated on time for the combined 7-vaccine series. To increase vaccination rates, initiatives to increase vaccine confidence and remind parents to complete vaccine series are needed.

Quality over quantity: human papillomavirus vaccine information on social media and associations with adult and child vaccination

Human Papillomavirus (HPV) vaccination is recommended for adults aged 27-45 as a shared clinical decision with their healthcare provider. With the rise of social media as a vaccine information source, this study examined the extent of exposure to HPV vaccine content by social media platform and evaluated associations between HPV vaccine content on social media and HPV vaccine intent among both 27-45 year olds and their eligible children. U.S. participants (51% women, 9% Black, 8% Hispanic/Latinx), aged 27-45, were cross-sectionally surveyed online from April to May 2020 (n = 691). Outcomes included HPV vaccination intention (intend/do not intend) for themselves and, among participants with unvaccinated children aged 9-17 (n = 223), their eligible children. Adjusted odds ratios for HPV vaccine content and both outcomes were calculated. Extent of HPV vaccination exposure on social media was not associated with intention to vaccinate for HPV. Seeing mostly negative/mixed information about the HPV vaccine on social media was associated with lower odds of vaccination intention for adults (aOR = 0.34, 95% CI 0.15, 0.79) and adolescents (aOR = 0.34, 95% CI 0.21, 0.53). Viewing HPV vaccine information from social media as not credible was associated with lower odds of vaccine intent for adults (aOR = 0.17, 95% CI 0.07, 0.41) and adolescents (aOR = 0.16, 95% CI 0.10, 0.29). Although extent of HPV vaccine exposure on social media was not associated with vaccination outcomes, findings support developing quality social media strategies that increase the dissemination of positive and credible information in favor of HPV vaccination.

Misinformation and public opinion of science and health: Approaches, findings, and future directions

A summary of the public opinion research on misinformation in the realm of science/health reveals inconsistencies in how the term has been defined and operationalized. A diverse set of methodologies have been employed to study the phenomenon, with virtually all such work identifying misinformation as a cause for concern. While studies completely eliminating misinformation impacts on public opinion are rare, choices around the packaging and delivery of correcting information have shown promise for lessening misinformation effects. Despite a growing number of studies on the topic, there remain many gaps in the literature and opportunities for future studies.

The role of trust in HPV vaccine uptake among racial and ethnic minorities in the United States: a narrative review

Despite the clinically proven benefits of the human papillomavirus (HPV) vaccine in preventing cervical and other HPV-associated cancers, vaccination coverage has been suboptimal among adolescents and young adults in the United States (US), particularly among racial and ethnic minority adolescents. Historical legacies, combined with current racial/ethnic disparities in healthcare, may contribute to suboptimal uptake and completion of the HPV vaccine in part through differing levels of trust in doctors and healthcare institutions. The purpose of this narrative review was to characterize trust and its role in decision making about HPV vaccine uptake among US racial and ethnic minorities. We conducted a literature search using the PubMed database, and our search terms yielded 1176 articles. We reviewed 41 full-text articles for eligibility and included 20 articles in this review. These studies used varied measures of trust or mistrust and assessed trust in not only doctors/healthcare providers, but also other sources including pharmaceutical companies, media, and clergy. Our review findings revealed generally high levels of trust in doctors and healthcare providers, but less so in pharmaceutical companies. Mistrust of either healthcare providers, government agencies or pharmaceutical companies was consistently associated with less favorable attitudes and lower vaccine uptake. The downstream effects of mistrust may occur through selected health beliefs regarding the perceived efficacy and safety of the vaccine. Minority groups were more likely to report trust in family members, religious organizations, and media sources compared to their white counterparts. Decision making about vaccine uptake is a multilayered process that involves comparing the perceived benefits of the vaccine against its perceived risks. Understanding how trusted sources can effectively harness the tools of social and traditional media to increase knowledge and awareness may help combat misinformation about the HPV vaccine and improve engagement with diverse communities.

Behavioral Intention to Receive a COVID-19 Vaccination Among Chinese Factory Workers: Cross-sectional Online Survey

BACKGROUND

COVID-19 vaccines will become available in China soon. Understanding communities' responses to the forthcoming COVID-19 vaccines is important. We applied the theory of planned behavior as the theoretical framework.

OBJECTIVE

This study investigates the prevalence of and factors associated with behavioral intention to receive self-financed or free COVID-19 vaccinations among Chinese factory workers who resumed work during the pandemic. We examined the effects of factors including sociodemographics, perceptions related to COVID-19 vaccination, exposure to information about COVID-19 vaccination through social media, and COVID-19 preventive measures implemented by individuals and factories.

METHODS

Participants were full-time employees 18 years or older who worked in factories in Shenzhen. Factory workers in Shenzhen are required to receive a physical examination annually. Eligible workers attending six physical examination sites were invited to complete a survey on September 1-7, 2020. Out of 2653 eligible factory workers, 2053 (77.4%) completed the online survey. Multivariate two-level logistic regression models and ordinal logistic regression models were fitted.

RESULTS

The prevalence of behavioral intention to receive a COVID-19 vaccination was 66.6% (n=1368, conditional on 80% vaccine efficacy and market rate) and 80.6% (n=1655, conditional on 80% vaccine efficacy and free vaccines). After adjusting for significant background characteristics, positive attitudes toward COVID-19 vaccination (adjusted odds ratio [AOR] 1.20, 95% CI 1.15-1.25 and AOR 1.24, 95% CI 1.19-1.30), perceived support from significant others for getting a COVID-19 vaccination (AOR 1.43, 95% CI 1.32-1.55 and AOR 1.37, 95% CI 1.25-1.50), and perceived behavioral control to get a COVID-19 vaccination (AOR 1.51, 95% CI 1.32-1.73 and AOR 1.28, 95% CI 1.09-1.51) were positively associated with both dependent variables (conditional on 80% vaccine efficacy and market rate or free vaccines, respectively). Regarding social media influence, higher frequency of exposure to positive information related to COVID-19 vaccination was associated with a higher intention to receive a COVID-19 vaccination at market rate (AOR 1.53, 95% CI 1.39-1.70) or a free vaccination (AOR 1.52, 95% CI 1.35-1.71). Higher self-reported compliance with wearing a face mask in the workplace (AOR 1.27, 95% CI 1.02-1.58 and AOR 1.67, 95% CI 1.24-2.27) and other public spaces (AOR 1.80, 95% CI 1.42-2.29 and AOR 1.34, 95% CI 1.01-1.77), hand hygiene (AOR 1.21, 95% CI 1.00-1.47 and AOR 1.52, 95% CI 1.19-1.93), and avoiding social gatherings (AOR 1.22, 95% CI 1.01-1.47 and AOR 1.55, 95% CI 1.23-1.95) and crowded places (AOR 1.24, 95% CI 1.02-1.51 and AOR 1.73, 95% CI 1.37-2.18) were also positively associated with both dependent variables. The number of COVID-19 preventive measures implemented by the factory was positively associated with the intention to receive a COVID-19 vaccination under both scenarios (AOR 1.08, 95% CI 1.04-1.12 and AOR 1.06, 95% CI 1.01-1.11).

CONCLUSIONS

Factory workers in China reported a high behavioral intention to receive a COVID-19 vaccination. The theory of planned behavior is a useful framework to guide the development of future campaigns promoting COVID-19 vaccination.

Rural Caregivers' Willingness for Community Pharmacists to Administer the HPV Vaccine to Their Age-Eligible Children

Human papillomavirus (HPV) vaccination uptake varies by geographic regions with rural, often medically underserved areas, lagging behind more urban regions in terms of vaccine initiation and completion. In these regions, pharmacies may serve as an additional location for HPV vaccine administration. Little is known about rural caregivers' willingness to have their HPV vaccine age-eligible children obtain this vaccine from their local pharmacist. First and second authors conducted 26 in-depth interviews with caregivers of HPV vaccine age-eligible children living in rural regions of a southwestern state to explore their perceptions of the HPV vaccine and their willingness for pharmacist-administered HPV vaccination. They analyzed interview data using an inductive qualitative content analyses approach. The majority of caregivers were unaware that pharmacists could offer adolescent vaccines. However, most were willing to allow their children to receive the vaccine from this non-traditional source. Comments related to obtaining vaccinations from pharmacists related mostly to concerns about proper training and their certification to vaccinate against HPV. Caregivers believed that having a pharmacist administer the HPV vaccine would not affect their relationship with their primary care provider. Caregivers preferred print health education resources and were interested in also receiving health information via social media to learn more about the HPV vaccine and pharmacists' role in HPV vaccine administration. Pharmacies may serve as an additional site to increase HPV vaccine initiation and completion. Rural regions need additional health information about the HPV vaccine and pharmacists' abilities to administer this cancer prevention resource.

HPV and HPV Vaccination Knowledge and Attitudes Among Medical Students in Alabama

In addition to being the most common sexually transmitted infection, the human papillomavirus (HPV) is associated with six types of cancer in men and women. The HPV vaccine provides long-lasting, effective protection from high-risk HPV infection, thus serving as a means of cancer prevention. An effective healthcare provider recommendation is well-established as the most significant influence on HPV vaccine uptake, and, as emerging providers, it is critical that medical students receive comprehensive training in this area. However, the type and extent of such training for current medical students in the USA is unclear. An online survey assessing HPV and HPV vaccine knowledge, attitudes, and vaccine status was distributed to all medical students at an Alabama university. Scales were developed to assess composite HPV and HPV knowledge scores and HPV vaccination intentions. Of those age-eligible, 32.1% reported completion of the HPV vaccine series while 15.2% reported partial completion. Knowledge of both HPV and HPV vaccination significantly increased with program year (p < 0.0001 and p = 0.0069, respectively); however, there were knowledge gaps across all years regarding HPV-associated cancers. Attitudes and intentions showed a similar association, with more advanced students demonstrating more positive attitudes toward HPV vaccination (p = 0.0003). There is a need within the current curriculum to include more education and training on HPV, HPV vaccination, and counseling-particularly for students in the first 2 years of their program. Implementation of a classroom module or interactive workshop would likely improve knowledge and attitudes, better preparing students for their future role as potential immunizers.

Utilizing Theories and Evaluation in Digital Gaming Interventions to Increase Human Papillomavirus Vaccination Among Young Males: Qualitative Study

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. HPV attributes to most cancers including anal, oral, cervical, and penile. Despite infection rates in the United States, recommendations and communication campaigns have traditionally focused on females. Because of this, males lack knowledge about reasons for vaccination, the benefits of being vaccinated, and their HPV risk, overall. Gaming as a health education strategy can be beneficial as mechanism that can promote behavior change for this key demographic because of the popularity of gaming.

OBJECTIVE

We sought to explore the relationship between gamification and HPV vaccine uptake.

METHODS

Interviews were conducted with experts (n=22) in the fields of cancer prevention, sexual and reproductive health, public health, game design, technology, and health communication on how a game should be developed to increase HPV vaccination rates among males.

RESULTS

Overwhelmingly, theoretical models such as the health belief model were identified with key constructs such as self-efficacy and risk perception. Experts also suggested using intervention mapping and logic models as planning tools for health promotion interventions utilizing a digital game as a medium. In game and out of game measures were discussed as assessments for quality and impact by our expert panel.

CONCLUSIONS

This study shows that interventions should focus on whether greater utilization of serious games, and the incorporation of theory and standardized methods, can encourage young men to get vaccinated and to complete the series of HPV vaccinations.

Practice-, provider- and patient-level facilitators of and barriers to HPV vaccine promotion and uptake in Georgia: a qualitative study of healthcare providers' perspectives

Georgia experiences higher human papillomavirus (HPV)-associated cancer burden and lower HPV vaccine uptake compared with national estimates. Using the P3 model that concomitantly assesses practice-, provider- and patient-level factors influencing health behaviors, we examined facilitators of and barriers to HPV vaccine promotion and uptake in Georgia. In 2018, we conducted six focus groups with 55 providers. Questions focused on multilevel facilitators of and barriers to HPV vaccine promotion and uptake. Our analysis was guided by the P3 model and a deductive coding approach. We found that practice-level influences included organizational priorities of vaccinations, appointment scheduling, immunization registries/records, vaccine availability and coordination with community resources. Provider-level influences included time constraints, role, vaccine knowledge, self-efficacy to discuss HPV vaccine and vaccine confidence. Patient-level influences included trust, experiences with vaccine-preventable diseases, perceived high costs, perceived side effects and concerns with sexual activity. Findings suggest that interventions include incentives to boost vaccine rates and incorporate appointment scheduling technology. An emphasis should be placed on the use of immunization registries, improving across-practice information exchange, and providing education for providers on HPV vaccine. Patient-provider communication and trust emerge as intervention targets. Providers should be trained in addressing patient concerns related to costs, side effects and sexual activity.

Adherence to Pulmonary Rehabilitation in COPD: A QUALITATIVE EXPLORATION OF PATIENT PERSPECTIVES ON BARRIERS AND FACILITATORS

PURPOSE

Adherence to pulmonary rehabilitation (PR) is low. This qualitative study used the PRECEDE model to identify predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors acting as barriers or facilitators of adherence to PR, and elicit recommendations for solutions from patients with chronic obstructive pulmonary disease (COPD).

METHODS

Focus groups with COPD patients who had attended PR in the past year were conducted. Sessions were recorded, transcribed verbatim, and coded independently by 2 coders, who then jointly decided on the final coding scheme. Data were summarized across groups, and analysis was used a thematic approach with constant comparative method to generate categories.

RESULTS

Five focus groups with 24 participants each were conducted. Participants (mean age 62 yr) were 54% male, and 67% black. More than half had annual income less than $20 000, 17% were current smokers, and 54% had low adherence (less than 35% of prescribed PR sessions). The most prominent barriers included physical ailments and lack of motivation (intrapersonal), no support system (interpersonal), transportation difficulties, and financial burden (structural). The most prominent facilitators included health improvement, personal determination (intrapersonal), support from peers, family, and friends (interpersonal), and program features such as friendly staff and educational component of sessions (structural). Proposed solutions included incentives to maintain motivation, tobacco cessation support (intrapersonal), educating the entire family (interpersonal), transportation assistance, flexible program scheduling, and financial assistance (structural).

CONCLUSION

Health limitations, social support, transportation and financial difficulties, and program features impact ability of patients to attend PR. Interventions addressing these interpersonal, intrapersonal, and structural barriers are needed to facilitate adherence to PR.

Human papillomavirus vaccination practices and perceptions among Ghanaian Healthcare Providers: A qualitative study based on multi-theory model

BACKGROUND

Healthcare providers' (HCPs) recommendations for the Human Papillomavirus (HPV) vaccine are likely to increase the vaccination uptake. However, little is known about Ghanaian HCPs' general practices regarding HPV vaccination. We used Multi-Theory Model (MTM) constructs (i.e. participatory dialogue, behavioral confidence, environment, social and emotional transformation) to examine Ghanaian HCPs' attitudes towards HPV vaccination and their vaccination recommendation practices.

METHODS

We conducted three, 60-minute focus group discussions (FGDs) with HCP in the second-largest government hospital in Ghana. Sixteen semi-structured open-ended questions based on MTM constructs were used to guide the FGDs. We explored HCPs' general knowledge about HPV, vaccination recommendation behavior, physical environment, and socio-cultural factors associated with the HPV vaccination. Data from the FGDs were transcribed and thematically coded using NVivo software.

RESULTS

The sample of (n = 29) HCPs consisting of males (n = 15) and females (n = 14) between the ages of 29 and 42 years participated in the FGDs. Our analyses showed that HCPs (a) rarely offered HPV vaccination recommendations, (b) showed varied understanding about who should be vaccinated regarding age eligibility, gender, and infection status. Perceived barriers to HPV vaccination include (a) low urgency for vaccination education due to competing priorities such as malaria and HIV/AIDS; (b) lack of data on HPV vaccination; (c) lack of awareness about the vaccine safety and efficacy; (c) lack of HPV vaccine accessibility and (d) stigma, misconceptions and religious objections. HCPs expressed that their motivation for counseling their clients about HPV vaccination would be increased by having more knowledge about the vaccine's efficacy and safety, and the involvement of the parents, chiefs, churches, and opinion leaders in the vaccination programs.

CONCLUSION

The study's findings underscore the need for a comprehensive HPV vaccination education for HCPs in Ghana. Future HPV vaccination education programs should include information about the efficacy of the vaccine and effective vaccination messages to help mitigate HPV vaccine-related stigma.

A Mixed-Methods Analysis of Barriers to and Facilitators of Human Papillomavirus Vaccination Among Adolescents in Montana

OBJECTIVES

Human papillomavirus (HPV) vaccination rates among adolescents are lower in rural areas than in urban areas of the United States. The objective of this study was to identify barriers to and facilitators of adolescent HPV vaccination in Montana, a large, primarily rural state.

METHODS

Using a mixed-methods design, we integrated quantitative analyses of Montana's National Immunization Survey-Teen (NIS-Teen) data from 2013-2017 with qualitative data collected at a statewide meeting in October 2018 and from stakeholder interviews conducted from October 2018 through June 2019. Using NIS-Teen data, we identified trends and estimated adjusted prevalence ratios (aPRs) to identify factors associated with vaccine uptake. Using directed content analysis of qualitative data, we identified themes related to vaccine uptake.

RESULTS

In Montana, initiation of the HPV vaccine series among adolescents aged 13-17 increased from 34.4% in 2013 to 65.5% in 2017. We identified 6 themes related to HPV vaccination from qualitative analyses, including medical providers' recommendation style as a facilitator of vaccination and parental vaccine hesitancy as a barrier to vaccination. In NIS-Teen 2017 data (n = 326 adolescents), receiving a medical provider recommendation was significantly associated with series initiation (aPR = 2.3; 95% CI, 1.5-3.6). Among parents who did not intend to initiate the vaccine series for their adolescent within 12 months (n = 71), vaccine safety was the top concern (aPR = 24.5%; 95% CI, 12.1%-36.9%).

CONCLUSIONS

HPV vaccination rates have increased in Montana but remain lower than rates for other adolescent vaccines. Future work should focus on reducing missed opportunities, increasing parents' knowledge of and confidence in vaccination, and training medical providers on addressing common vaccine concerns.

Tobacco smoke exposure in pediatric cystic fibrosis: A qualitative study of clinician and caregiver perspectives on smoking cessation

OBJECTIVE

Tobacco smoke exposure has negative impacts on the lung health of children with cystic fibrosis (CF), yet evidence-based strategies for smoking cessation have not been tested with or tailored to CF caregivers. This qualitative study identified barriers and facilitators of smoking cessation in this population and outlined potential interventional approaches.

METHODS

We conducted semi-structured interviews with CF familial caregivers who were current or former smokers, and with members of the CF care team. We asked about experiences, practices, and prerequisites for a successful program. Interviews were recorded, transcribed verbatim, and coded by two investigators. Analysis used a thematic approach guided by the PRECEDE model, which identifies predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors relevant to health behaviors and programs.

RESULTS

Seventeen interviews were conducted-eight with familial caregivers and nine with CF team members. Whereas caregivers provided greater insight into internal difficulties and motivators to quit smoking, clinicians offered more extensive input on barriers and solutions related to the clinical environment. Based on study recommendations, a successful tobacco cessation program should include (a) family education about the harms of smoke exposure for children with CF; (b) screening for exposure, ideally with biochemical verification; (c) access to trained tobacco counselors; (d) affordable pharmacotherapy; and (e) outpatient follow-up of those undergoing tobacco treatment.

CONCLUSION

This qualitative study revealed intrapersonal, interpersonal, and structural barriers to eliminating tobacco smoke exposure in children with CF, outlined opportunities to address these barriers, and made recommendations for a comprehensive tobacco cessation strategy.

Human papillomavirus vaccine series follow-through: comparison of four clinics in an academic medical center

Objective The Centers for Disease Control & Prevention (CDC) recommends that the human papillomavirus (HPV) vaccine series be initiated at ages 11-12 years, but many children never follow-through with the series. By examining differences in clinic-specific vaccine series follow-through rates across four clinics, we aimed to identify best practices related to communication around the vaccine and pathways to follow-through. Methods We used the electronic medical record (EMR) to retrospectively analyze HPV vaccine follow-through at four clinic settings. We limited the sample to children ages 11-17 who received a dose of the vaccine series at any of the clinics between January 2015 and June 2018. The primary outcome was follow-through of the HPV vaccine series within 18 months of initiation. Results A total of 3,813 patients were included in this study, 29% of which followed through with the HPV vaccine series. There was significant variability of vaccine follow-through among the clinics (p<0.001), with the Med/Peds clinic having the highest rate of follow-through (32%). After adjusting for confounding variables, multivariable analysis found that Med/Peds and Family Medicine had higher odds of HPV vaccine series follow-through than the Pediatrics clinic. Conclusions We found that the likelihood of vaccine series follow-through was highest when the series was started in the Med/Peds and Family Medicine clinics, compared to Pediatrics and Adolescent Medicine. These results suggest that further qualitative research is needed to understand what communication strategies are most effective at facilitating HPV vaccine uptake among adolescents, and how the most effective strategies can be shared among clinics.

HPV vaccine uptake among daughters of Latinx immigrant mothers: Findings from a cluster randomized controlled trial of a community-based, culturally relevant intervention

OBJECTIVE

We examined the efficacy of a culturally relevant, community-based HPV vaccination intervention among Latinx immigrant mothers with daughters aged 9-12 in Alabama.

METHODS

We conducted a cluster-randomized controlled trial with "place of residence" (e.g., apartment complexes, trailer parks) as the unit of randomization that evaluated two interventions: 1) promotion of HPV vaccination and 2) promotion of healthy eating and appropriate nutrition label interpretation. Identical baseline/post/7-month follow up questionnaires were completed by all participants and both interventions consisted of four group sessions and one individual session. A total of 40 locations were randomized with 317 mother-daughter dyads enrolled in the study between May 2013 and October 2017.

RESULTS

A total of 278 mother-daughter dyads met full eligibility and initiated the intervention/control participation. Retention rate overall was 93.2% (92.6% for the intervention arm and 93.7% for the control arm). Daughters in the intervention arm were significantly more likely to receive one, two, and three doses of HPV vaccine than daughters in the control arm p < 0.001). In multivariate analyses, mothers in the intervention arm had a six times greater odds of vaccinating daughters with the first dose (OR = 5.96, 95% CI: 3.38, 10.49), eight times greater odds of vaccinating daughters with the second dose (OR = 8.09, 95% CI: 4.0, 16.35), and more than 16 times greater odds of completing the three-dose HPV vaccine series than mothers in the control arm after adjusting for mother's age, time in the U.S., income, and daughter's health insurance status (OR = 16.5, 95% CI: 5.73, 47.48). Only perceived risk of their daughters' future HPV infection remained significant as a predictor of three-dose HPV vaccination completion (OR = 0.69, 95% CI: 0.23, 2.1).

CONCLUSIONS

A theory-driven, culturally-relevant intervention developed through extensive formative assessments in collaboration with community members can effectively promote HPV vaccination among 9-12 years of age daughters of Latina immigrants.

The incidence of oropharyngeal cancer and rate of human papillomavirus vaccination coverage in Florida, 2011 through 2015

OBJECTIVES

The authors aimed to compare the incidence of oropharyngeal cancer (OPC) from 2011 through 2015 and the rate of human papilloma virus (HPV) vaccination from 2015 through 2017 in the United States overall and in Florida.

METHODS

Using SEER*Stat software (Surveillance Research Program, National Cancer Institute), the authors calculated age-specific OPC incidence rates for various age groups and age-adjusted rates by sex and race to analyze Surveillance, Epidemiology, and End Results program and National Program of Cancer Registries data. The authors used Joinpoint software (Surveillance Research Program, National Cancer Institute) to model time trends of OPC incidence. They estimated the rate of HPV vaccination among teenagers in Florida and explored the main reasons parents gave for not getting their children vaccinated by means of analyzing data from the National Immunization Survey-Teen. The authors used the χ² test to determine the association between sociodemographic factors and HPV vaccination and to compare the rate of HPV vaccination in the United States overall with that in Florida.

RESULTS

The incidence of OPC was higher and the rate of HPV vaccination was lower in Florida than in the United States overall. The OPC incidence rate was highest in those who were aged 50 through 70 years, non-Hispanic white, and male. The rate of being up-to-date on HPV vaccination in Florida was higher among female teenagers than male teenagers but did not differ significantly by other sociodemographic characteristics. The top reason for not getting an HPV vaccination in Florida was that it had not been recommended.

CONCLUSIONS

The authors found relatively higher and increasing incidence rate of OPC in Florida and lower rate of HPV vaccination among adolescents in Florida than in the nation overall.

PRACTICAL IMPLICATIONS

The trends illustrated may stimulate policy changes to increase HPV vaccination for children and enhance the understanding of its benefits.

Using photovoice to explore social determinants of obesity in two underserved communities in the southeast

Over the past 25 years, the adult obesity rate in the U.S. has increased 70%, with obesity placing a disproportionate chronic disease burden on African Americans. Using Photovoice methodology, this study aimed to: (1) explore the social determinants contributing to obesity from the perspectives of residents of two low-income municipalities in Birmingham, Alabama with varying levels of segregation, (2) better understand residents' perceptions of contributors to obesity in their communities, and (3) examine residents' perceptions of interventions that might be effective in promoting positive change. Focus groups (N=10) segmented by race and community were conducted by trained moderators. Transcriptions were analyzed by theoretical thematic analysis. The study design and data analysis analyses were guided by a conceptual framework based on the Social Determinants of Obesity model. Findings from this study lend support to the efficacy of the conceptual framework as a multilevel approach describing obesity disparities in the south. Regardless of community and race, participants believed that elements of their built environment, such as fast food restaurants and unsafe walking conditions, contributed to obesity, and that schools and churches should play an active role in addressing the issue.

Factors associated with not receiving HPV vaccine among adolescents by metropolitan statistical area status, United States, National Immunization Survey-Teen, 2016-2017

The 2016 and 2017 National Immunization Surveys-Teen (NIS-Teen) highlighted disparities in human papillomavirus (HPV) vaccination coverage by metropolitan statistical area (MSA) status. Coverage with ≥1 dose of HPV vaccine was significantly lower among teens in suburban and mostly rural areas than it was among those in mostly urban areas. Reasons underlying this disparity are poorly understood; this analysis sought to identify sociodemographic factors associated with not initiating the HPV vaccine series and to determine whether these factors differed by MSA status. Using NIS-Teen data for a sample of 41,424 adolescents from the 2016 and 2017 survey years, multivariate logistic regression was utilized to assess associations between various sociodemographic factors and non-initiation of the HPV vaccine series by MSA status. Adjusted prevalence ratios and 95% confidence intervals are reported. A secondary analysis assessed missed opportunities for HPV vaccination by MSA status and estimated what coverage could be if these missed opportunities had not occurred. Most factors associated with not receiving HPV vaccine were similar across all three MSAs, including living in the South, having a mother with some college education, not having an 11–12-year-old well-child visit, and not receiving a provider recommendation for vaccination. Others were associated with non-initiation of the HPV vaccine series in only specific MSAs. Teens in suburban areas (82.2%) were more likely to miss opportunities for HPV vaccination than those in mostly urban (79.3%) areas. Coverage with ≥1 dose of HPV vaccine in all three MSAs would be substantially higher if these missed opportunities had been eliminated.

Small area estimation of human papillomavirus vaccination coverage among school-age children in Alabama counties

OBJECTIVES

This study estimated county-level human papillomavirus (HPV) vaccination initiation rates in Alabama and determined whether disparities existed between counties in the Mississippi Delta region (MDR) and Appalachian region (AR).

STUDY DESIGN

This study used an observational cross-sectional design.

METHODS

We used small area estimation methodology to estimate rates of medical provider-verified HPV vaccine initiation among school-age children in Alabama. Data for the study were retrieved from the 2015 National Immunization Survey (n = 22,205) and the US Census Bureau.

RESULTS

The predictive model results showed that older age (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.16, 1.29) was positively associated with vaccination initiation and black (OR = 0.79, 95% CI = 0.71, 0.87), white (OR = 0.56, 95% CI = 0.52, 0.60), and 'other' race/ethnicities (OR = 0.78, 95% CI = 0.70, 0.86), compared with Hispanics, and was negatively associated with vaccination initiation. The median (x̃)-modeled HPV vaccination initiation rate for all Alabama counties was 50.83% (interquartile range = 5.00%). Modeled HPV vaccination initiation rates were lowest in AR counties (x̃ = 49.81%), followed by counties not in the AR or MDR (x̃ = 53.26%) and MDR counties (x̃ = 54.90%).

CONCLUSIONS

Culturally sensitive school-based HPV vaccine delivery programs are needed for children living in AR counties in Alabama.