The association of caregiver attitudes, information sources, and trust with HPV vaccine initiation among adolescents

This study described caregiver attitudes and the information sources they access about HPV vaccination for adolescents and determined their influence on human papillomavirus (HPV) vaccination initiation. An online survey was administered to 1,016 adults in July 2021. Participants were eligible if they were the caregiver of a child aged 9-17 residing in Mississippi, Arkansas, Tennessee, Missouri, and select counties in Southern Illinois. Multivariate logistic regression was used to estimate the association of caregiver attitudes and information sources with HPV vaccination. Information from doctors or healthcare providers (87.4%) and internet sources other than social media (31.0%) were the most used sources for HPV vaccine information. The highest proportion of caregivers trusted their doctor or healthcare providers (92.4%) and family or friends (68.5%) as sources of information. The HPV vaccine series was more likely to be initiated in children whose caregivers agreed that the vaccine is beneficial (AOR = 4.39, 95% CI = 2.05, 9.39), but less likely with caregivers who were concerned about side effects (AOR = 0.61, 95% CI = 0.42, 0.88) and who received HPV vaccination information from family or friends (AOR = 0.57, 95% CI = 0.35, 0.93). This study found that caregivers' attitudes, information sources, and trust in those sources were associated with their adolescent's HPV vaccination status. These findings highlight the need to address attitudes and information sources and suggest that tailored interventions considering these factors could increase HPV vaccination rates.

Multicomponent Strategy Improves Human Papillomavirus Vaccination Rates Among Adolescents with Sickle Cell Disease

OBJECTIVE

To evaluate the effectiveness of a vaccine strategy bundle to increase human papillomavirus (HPV) vaccine initiation and completion in a specialty clinic setting.

STUDY DESIGN

Our Hematology clinic utilized an implementation framework from October 1, 2018, to December 31, 2019, involving nurses, nursing coordinators, and clinicians in administering the HPV vaccination series to our adolescent sickle cell sample of nearly 500 patients. The bundle included education for staff on the need for HPV vaccine administration, provider incentives, vaccines offered to patients in SCD clinics, and verification of patients' charts of vaccine completion.

RESULTS

Following the implementation of the bundle, the cumulative incidence of HPV vaccination initiation and completion improved from 28% to 46% and 7% to 49%, respectively. Both rates remained higher postimplementation as well. HPV vaccination series completion was associated with a decreased distance to the health care facility, lower state deprivation rank, and increased hospitalizations.

CONCLUSION

Our clinic's implementation strategy successfully improved vaccine completion rates among adolescents with sickle cell disease (SCD) while continuing to educate staff, patients, and families on the importance of cancer prevention among people living with SCD.

Implementing interventions to start HPV vaccination at age 9: Using the evidence we have

Human papillomavirus (HPV) vaccination is routinely recommended for adolescents aged 11 or 12 years but can begin at age 9. On-time HPV vaccination by the thirteenth birthday has proven to be effective in preventing HPV cancer and pre-cancer. However, HPV coverage rates continue to lag behind other routinely recommended vaccinations for adolescents. A promising approach to improving coverage is to start HPV vaccination at age 9. This approach has been endorsed by the American Academy of Pediatrics and the American Cancer Society. Benefits of this approach include increased time to complete vaccination series by the thirteenth birthday, additional spacing of recommended vaccines, and a more concentrated focus on cancer prevention messaging. While promising, little is known about how and if existing evidence-based interventions and approaches can be used to promote starting HPV vaccination at age 9. Implementation science frameworks offer scientific direction in how to adapt current and develop new interventions to promote starting HPV vaccination at age 9 and accelerate dissemination and prevent HPV cancers.

Descriptive epidemiology of age at HPV vaccination: Analysis using the 2020 NIS-Teen

Human papillomavirus (HPV) vaccination uptake in the United States remains suboptimal, and continues to trail that of tetanus, diphtheria, and acellular pertussis (Tdap) vaccination and quadrivalent meningococcal conjugate vaccination (MCV4). This is despite these three vaccines all being recommended for routine adolescent use within the 2005-2006 time period. One strategy to improve HPV vaccination is starting the vaccine series at the first opportunity - currently as young as 9 years of age. Little is known about the epidemiology of age at HPV vaccination, and the frequency of vaccination occurring at 9-10 years of age. Using 2020 National Immunization Survey-Teen (NIS-Teen) data, we analyzed age at HPV vaccine initiation and proportion of initiators completing the HPV vaccine series relative to age at initiation. Overall, 4.0% of US adolescents initiated HPV vaccination at 9-10 years of age, with higher initiation among younger birth cohorts (4.8% for 13-year-olds and 5.1% for 14-year-olds) than older cohorts (3.1% for both 16 and 17 year-olds). Age cohorts maximized HPV vaccine completion after 3-4 years. Among those initiating at ages 9-10, 93% of 13-year-olds completed the series. Among those initiating at 11-12, completion rates rose from 66% among 13-year-olds to 90.2% among 16-year-olds. Among those initiating at age 13-14, completion rose from 61% among 15-year-olds to 84.9% among 17-year-olds. This manuscript serves as a starting point of comparison for future epidemiologic evaluations of HPV vaccination at the first opportunity.

Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningococcal vaccination on timely completion of the HPV vaccine series

To explore the impact on timely series completion of initiating the HPV vaccine series prior to other vaccines in the adolescent platform (Tdap or meningococcal vacccines), we created a cohort of children aged 9 in 2015 who were continuously enrolled through the age of 13 (2019) from a national administrative database of employee-sponsored insurance in the United States (MarketScan). Logistic regressions were used to predict the odds of HPV vaccine series completion among those who started the series prior to, concurrent with, or after receiving Tdap or meningococcal vaccination. The cohort included 100,857 eligible children. Compared with adolescents who received their HPV and Tdap or HPV and meningococcal vaccinations concurrently, those who received HPV prior to other vaccines had higher completion (aOR = 1.38 for Tdap, aOR 1.62 for meningococcal), while those who received their HPV vaccination after other vaccines had lower odds of HPV vaccine series completion (aOR = 0.68 for Tdap, aOR = 0.62 for meningococcal). Other factors associated with series completion included female sex, residing in an urban (vs. rural) area, residing in the Northeast, and receiving primary care from a pediatrician (vs. family medicine physician). These data indicate that beginning the HPV vaccine series prior to the adolescent platform may improve on-time series completion.

Community Outreach and Engagement at U.S. Cancer Centers: Notes from the Third Cancer Center Community Impact Forum

Community outreach and engagement (COE) is a fundamental activity of cancer centers as they aim to reduce cancer disparities in their geographic catchment areas. As part of COE, NCI-Designated Cancer Centers must monitor the burden of cancer in their catchment area, implement and evaluate evidence-based strategies, stimulate catchment area relevant research, support clinical trial enrollment, and participate in policy and advocacy initiatives, in addition to other responsibilities. The Cancer Center Community Impact Forum (CCCIF) is a national annual meeting of COE professionals who work at or with cancer centers across the country. CCCIF grew out of earlier discussions at American Society of Preventive Oncology (ASPO) annual meetings, where COE was often discussed, but not exclusively. The third annual CCCIF meeting-hosted by the Sidney Kimmel Cancer Center at Thomas Jefferson University-was held in June 2022 in Philadelphia, PA, where more than 200 participants listened to dynamic presentations across 12 COE-related panel sessions. CCCIF leadership and ASPO AD/PL Workshop Planners worked together on the agenda. The 12 sessions used a COE lens to focus on: Diversity, Equity, and Inclusion; Policy; State Cancer Coalitions; Evaluation and Metrics; Implementation Science; In-reach; Outreach; Training and Education; Funding, Personnel and Resources; Clinical Trials; Innovative Methods; and Lessons from the COVID-19 pandemic. This article is a summary of main points and key lessons from each session, as well as a summary of overarching themes that were evident across the sessions.

The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice

PURPOSE

The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members.

METHODS

We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation.

RESULTS

Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN's success-in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci-is attributable to: (1) its people-the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change.

CONCLUSION

CPCRN's history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.

Measuring and addressing health equity: an assessment of cancer center designation requirements

PURPOSE

By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements.

METHODS

We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes.

RESULTS

ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment.

CONCLUSION

Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Supporting implementation science and health equity in cancer prevention and control through research networks

The Cancer Prevention and Control Research Network (CPCRN) is a national network of academic, public health, and community organizational partners across multiple geographic sites who collaborate to reduce the cancer burden in diverse communities. Given key recommendations that suggest the need for cross-disciplinary collaboration in cancer prevention and control, we sought to explore the historical and contemporary evolution of health equity and disparities research as an area of focus within the CPCRN over time. We conducted 22 in-depth interviews with former and current leaders, co-investigators, and other members of the network. Several key themes emerged from data that were analyzed and interpreted using a constructivist, reflexive, thematic analysis approach. Nearly all participants reported a strong focus on studying health disparities since the inception of the CPCRN, which offered the network a distinct advantage in recent years for incorporating an intentional focus on health equity. Recent law enforcement injustices and the inequities observed during the COVID-19 pandemic have further invigorated network activities around health equity, such as development of a health equity-focused workgroup toolkit, among other cross-center activities. Several participants noted that, in terms of deep, meaningful, and impactful health equity-oriented research, there are still great strides for the network to make, while also acknowledging CPCRN as well-aligned with the national dialogue led by federal agency partners around health equity. Finally, several future directions were mentioned by the participants, including a focus on supporting a diverse workforce and engaging organizational partners and community members in equity-focused research. Findings from these interviews provide direction for the network in advancing the science in cancer prevention and control, with a strengthened focus on health equity.

Examining readiness for implementing practice changes in federally qualified health centers: A rapid qualitative study

Implementing evidence-based interventions remains slow in federally qualified health centers (FQHCs). The purpose of this study is to qualitatively examine the R = MC2 (Readiness = motivation × innovation specific capacity × general capacity) heuristic subcomponents in the context of implementing general and colorectal cancer screening (CRCS)-related practice changes in FQHCs. We conducted 17 interviews with FQHC employees to examine (1) experiences with successful or unsuccessful practice change efforts, (2) using approaches to promote CRCS, and (3) opinions about R = MC2 subcomponents. We conducted a rapid qualitative analysis to examine the frequency, depth, and spontaneity of subcomponents. Priority, compatibility, observability (motivation), intra- and interorganizational relationships (innovation-specific capacity), and organizational structure and resource utilization (general capacity) emerged as highly relevant. For example, organizational structure was described as related to an organization's open communication during meetings to help with scheduling procedures. The results contribute to understanding organizational readiness in the FQHC setting and can be helpful when identifying and prioritizing barriers and facilitators that affect implementation.

Factors Associated with College Students' Human Papillomavirus (HPV) Vaccination and Preferred Strategies for Catch-Up Vaccine Promotion: A Mixed-Methods Study

Human papillomavirus (HPV) vaccination protects against six types of cancer-cervical, anal, oropharyngeal, penile, vulvar, and vaginal. In the United States (U.S.), HPV vaccination coverage in college students remains low, especially in the Mid-South region, despite the highest risk of HPV infections and disease burden. However, few studies have assessed HPV vaccination among college students here. This study examined factors associated with HPV vaccination among college students in the Mid-South and explored preferred strategies for promoting vaccination. A mixed-methods design comprising a cross-sectional, self-report online survey and dyadic virtual interviews was conducted. Simple random sampling was performed to recruit a total of 417 undergraduate students aged 18-26 from March to May 2021; convenience sampling was performed to recruit three sex-matched dyads of a total of six (four female and two male) undergraduates from survey respondents who had not completed the HPV vaccine series in May 2021. Binary logistic regression analyses showed HPV vaccine knowledge and perceived barriers to vaccination were factors contributing to coverage for both female and male students, while perceived risks of HPV and vaccine hesitancy were factors only among female students. Findings from the qualitative content analysis identified college students' perceived barriers to the vaccination at multiple levels and preferred strategies for vaccination promotion, corroborating the findings from the survey study. The findings provide implications that benefit the development of tailored interventions aimed at facilitating catch-up vaccination among college students in the Mid-South region. There is an urgent need for further research and the implementation of effective strategies that address the identified barriers and improve HPV vaccine uptake in this population.

Influences of sociodemographic characteristics and parental HPV vaccination hesitancy on HPV vaccination coverage in five US states

BACKGROUND

In the United States (US), half of new human papillomavirus (HPV) infections occur among young people aged 15-24 years. Despite the effectiveness of HPV vaccination in protecting against HPV-associated cancers, its coverage among adolescents remains suboptimal. This study examined the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage in five US states with disproportionately low adolescent coverage rates compared to the national average.

METHODS

Responses to an online Qualtrics survey from 926 parents of children aged 9-17 years in Arkansas, Mississippi, Missouri, Tennessee, and Southern Illinois in July 2021 were analyzed using multivariate logistic regression to estimate the association of sociodemographic characteristics and HPV vaccination hesitancy with HPV vaccination coverage.

RESULTS

Of the parents, 78 % were female, 76 % were non-Hispanic White, 61.9 % lived in rural areas, 22 % were classified as HPV vaccine hesitant, and 42 % had vaccinated their oldest child between the ages of 9-17 years against HPV. Children of vaccine hesitant parents were less likely to have received any doses of the HPV vaccine than children of non-vaccine hesitant parents (AOR: 0.17, 95 % CI:0.11-0.27). Male children were less likely to have initiated the HPV vaccine series than female children (AOR: 0.70, 95 % CI:0.50-0.97). Older children (13-17 vs 9-12 years), receiving the meningococcal conjugate or most recent seasonal influenza vaccine were all associated with higher likelihoods of receiving any doses of the HPV vaccine (AOR: 6.01, 95 % CI:3.98-9.08; AOR: 2.24, 95 % CI:1.27-3.95; AOR: 2.41, 95 % CI:1.73-3.36, respectively).

CONCLUSIONS

Adolescent HPV vaccination coverage remains low in our targeted states. Children's age, sex, and parental vaccine hesitancy were significantly associated with likelihood of HPV vaccination. These findings offer the opportunity for targeted interventions among parents in regions with low vaccine uptake and underscore the importance of developing and implementing strategies to address parental HPV vaccination hesitancy to improve uptake in the US.

Medical and public health professionals' perceived facilitators and barriers of human papillomavirus (HPV) vaccination among African American adolescents in Shelby County, Tennessee

Human papillomavirus (HPV) infects nearly 85% of sexually active Americans during their lifetime, causing most cervical and five other cancers. Routine HPV vaccination is recommended for adolescents to prevent HPV-attributable cancers, but HPV vaccination coverage remains low, especially in Tennessee. In 2021, 54.6% of the population in Shelby County, Tennessee was Black or African American, reporting higher rates of new cervical cancer cases than other counties in Tennessee. While medical and public health professionals (HPs) play a critical role in promoting vaccination coverage, little is known about the factors HPs perceive to influence HPV vaccination for this population. This study sought to explore HPs' perceived facilitators and barriers of HPV vaccination among African American adolescents. Qualitative individual interviews with 26 HPs in Shelby County were conducted between October 2019 and February 2020. Interpretive content analysis of the interview data guided by the socio-ecological model revealed several important themes regarding the facilitators and barriers across the individual, interpersonal, and community levels. At the individual level, parental vaccine hesitancy emerged as a leading barrier to HPV vaccination, while appropriate education facilitated the vaccination. At the interpersonal level, a lack of strong provider recommendations impeded HPV vaccination, whereas improved communication skills with patients facilitated the vaccination. Finally, the community-level barriers included a lack of education and social/religious norms; the community-level facilitators included community outreach efforts. HPs should consider development of comprehensive community-based approaches that leverage the facilitators and barriers at multiple levels to increase HPV vaccination among African American adolescents in this region.

Human Papillomavirus (HPV) Vaccination Knowledge, Beliefs, and Hesitancy Associated with Stages of Parental Readiness for Adolescent HPV Vaccination: Implications for HPV Vaccination Promotion

The vaccination against human papillomavirus (HPV) has shown effectiveness in preventing six different types of cancer. Despite a safe, effective HPV vaccine, vaccination coverage for adolescents remains suboptimal, especially in the Memphis, Tennessee metropolitan area. Parents/Guardians have a substantial influence on adolescent vaccination, but little is known about parental cognitive factors contributing to intent on adolescent HPV vaccination in this region. Thus, this study examined factors associated with stages of parental readiness for adolescent HPV vaccination by applying the transtheoretical model. A cross-sectional, online survey was conducted to collect quantitative data on sociodemographic characteristics; health-related information; HPV vaccination knowledge, beliefs, and hesitancy; and stages of readiness for adolescent HPV vaccination among parents. Convenience sampling was performed to recruit a total of 497 parents of adolescents aged 11-17 years in Shelby and Tipton Counties in Tennessee and DeSoto County in Mississippi. Binary logistic regression analyses showed that greater knowledge of HPV vaccination, greater perceived susceptibility to HPV, and lower levels of HPV vaccination hesitancy, respectively, distinguished higher from lower stages of parental readiness for adolescent HPV vaccination after controlling for other variables. The findings provide implications for developing readiness for stage-specific interventions targeted to effectively influence the parental decision-making process regarding HPV vaccination for adolescents.

COVID-19 Vaccination: Comparison of Attitudes, Decision-Making Processes, and Communication among Vaccinated and Unvaccinated Black Americans

BACKGROUND

COVID-19 vaccination rates remain suboptimal among Black Americans who disproportionately experience higher hospitalization and death rates than White Americans.

METHODS

We conducted a multi-method (interviews and surveys) study among 30 Black Americans (n = 16 vaccinated, n = 14 unvaccinated) to explore factors related to vaccination hesitancy, decision-making processes, and communication related to uptake. Participants were recruited by using community-driven approaches, including partner collaborations. Thematic analysis was used to analyze qualitative data, and descriptive and bivariate analysis was used for quantitative data.

RESULTS

Of those unvaccinated, 79% (n = 11) stated they were delaying and 21% (n = 3) were declining vaccination indefinitely. When asked about the likelihood of vaccine initiation in 6 months and 12 months, 29% (n = 4) and 36% (n = 5), respectively, stated that they would receive the vaccine. The following themes emerged: (1) COVID-19 vaccination hesitancy exists on a continuum; (2) varied decision-making processes for COVID-19 vaccination; (3) motivators among vaccinated individuals; (4) barriers among unvaccinated individuals; (5) retrieving and navigating vaccine information within the COVID-19 infodemic; and (6) parent perspectives on child vaccination.

CONCLUSIONS

Findings suggest that vaccinated and unvaccinated participants had similar and dissimilar perspectives in decision-making processes and vaccine concerns as shown in the Decision-making Processes for the COVID-19 vaccination (DePC) model. Based on these findings, future studies should further explore how factors influencing decision-making can lead to divergent outcomes for COVID-19 vaccination.

Using cognitive interviews to improve a measure of organizational readiness for implementation

BACKGROUND

Organizational readiness is a key factor for successful implementation of evidence-based interventions (EBIs), but a valid and reliable measure to assess readiness across contexts and settings is needed. The R = MC² heuristic posits that organizational readiness stems from an organization's motivation, capacity to implement a specific innovation, and its general capacity. This paper describes a process used to examine the face and content validity of items in a readiness survey developed to assess organizational readiness (based on R = MC²) among federally qualified health centers (FQHC) implementing colorectal cancer screening (CRCS) EBIs.

METHODS

We conducted 20 cognitive interviews with FQHC staff (clinical and non-clinical) in South Carolina and Texas. Participants were provided a subset of items from the readiness survey to review. A semi-structured interview guide was developed to elicit feedback from participants using "think aloud" and probing techniques. Participants were recruited using a purposive sampling approach and interviews were conducted virtually using Zoom and WebEx. Participants were asked 1) about the relevancy of items, 2) how they interpreted the meaning of items or specific terms, 3) to identify items that were difficult to understand, and 4) how items could be improved. Interviews were transcribed verbatim and coded in ATLAS.ti. Findings were used to revise the readiness survey.

RESULTS

Key recommendations included reducing the survey length and removing redundant or difficult to understand items. Additionally, participants recommended using consistent terms throughout (e.g., other units/teams vs. departments) the survey and changing pronouns (e.g., people, we) to be more specific (e.g., leadership, staff). Moreover, participants recommended specifying ambiguous terms (e.g., define what "better" means).

CONCLUSION

Use of cognitive interviews allowed for an engaged process to refine an existing measure of readiness. The improved and finalized readiness survey can be used to support and improve implementation of CRCS EBIs in the clinic setting and thus reduce the cancer burden and cancer-related health disparities.

Human Papillomavirus Vaccination Knowledge, Barriers, and Recommendations Among Healthcare Provider Groups in the Western United States

This study compared human papillomavirus (HPV) vaccination occurrences on the same day as provider recommendations at clinics in the Western United States stratified by healthcare provider groups. In addition, the relationships between provider groups' perceived challenges associated with HPV vaccination, HPV vaccination knowledge, HPV recommendation practices, and same-day HPV vaccinations and recommendations are described. Eligible participants included pediatric healthcare providers and staff with influence on patient/parental-level decisions regarding HPV vaccination. Participants filled out a 40-question survey. Results for study participants (N = 99) showed providers reported a higher number of challenges limiting HPV vaccination, higher HPV vaccination knowledge, and more favorable HPV vaccination recommendation practices compared to other healthcare team members (OTM) suggesting providers may have a better overall understanding of the HPV vaccination climate than OTMs. Clinics should examine OTMs' training, expectations, and opportunities to increase the frequency and strength of HPV vaccination recommendations to adolescent patients and parents.

Development of a Theory-Based, Culturally Appropriate Message Library for Use in Interventions to Promote COVID-19 Vaccination Among African Americans: Formative Research

Background

Disparities in COVID-19 incidence, hospitalization, and mortality rates among African Americans suggest the need for targeted interventions. Use of targeted, theory-driven messages in behavioral and communication interventions could empower African Americans to engage in behaviors that prevent COVID-19.

Objective

To address this need, we performed a formative study that aimed to develop and design a culturally appropriate, theory-based library of messages targeting concerns around COVID-19 vaccines that could be used in behavioral and communication interventions for African Americans.

Methods

Message development occurred between January 2021 and February 2022. Initial messages were designed by a multidisciplinary team of researchers, community leaders, and community members. Kreuter’s 5 strategies (ie, linguistic, peripheral, evidential, sociocultural, and constituent-involving strategies) were used to achieve cultural appropriateness. After forming a community-academic partnership, message development occurred in 4 phases: (1) adaptation of a message library using the literature, (2) review by 6 clinical and research experts for content validation, (3) input and review by a 6-member community advisory panel (CAP), and (4) message pretesting with African Americans via semistructured interviews in a qualitative study.

Results

Themes from the semistructured interviews among 30 African Americans were as follows: (1) community reactions to the messages, (2) community questions and information needs, (3) suggestions for additional content, and (4) suggestions to improve comprehension, relevance, and trustworthiness. Feedback from the CAP, community members, and scientific experts was used by members of the community-academic partnership to iteratively update message content to maximize cultural appropriateness. The final message library had 18 message subsets for adults and 17 message subsets for parents and caregivers of children. These subsets were placed into 3 categories: (1) vaccine development, (2) vaccine safety, and (3) vaccine effectiveness.

Conclusions

We used a 4-phase, systematic process using multiple community engagement approaches to create messages for African Americans to support interventions to improve COVID-19 vaccination rates among adults and children. The newly developed messages were deemed to be culturally appropriate according to experts and members of the African American community. Future research should evaluate the impact of these messages on COVID-19 vaccination rates among African Americans.

Grounding implementation science in health equity for cancer prevention and control

BACKGROUND

The past decade of research has seen theoretical and methodological advances in both implementation science and health equity research, opening a window of opportunity for facilitating and accelerating cross-disciplinary exchanges across these fields that have largely operated in siloes. In 2019 and 2020, the National Cancer Institute's Consortium for Cancer Implementation Science convened an action group focused on 'health equity and context' to identify opportunities to advance implementation science. In this paper, we present a narrative review and synthesis of the relevant literature at the intersection of health equity and implementation science, highlight identified opportunities (i.e., public goods) by the action group for advancing implementation science in cancer prevention and control, and integrate the two by providing key recommendations for future directions.

DISCUSSION

In the review and synthesis of the literature, we highlight recent advances in implementation science, relevant to promoting health equity (e.g., theories/models/frameworks, adaptations, implementation strategies, study designs, implementation determinants, and outcomes). We acknowledge the contributions from the broader field of health equity research and discuss opportunities for integration and synergy with implementation science, which include (1) articulating an explicit focus on health equity for conducting and reviewing implementation science; (2) promoting an explicit focus on health equity in the theories, models, and frameworks guiding implementation science; and (3) identifying methods for understanding and documenting influences on the context of implementation that incorporate a focus on equity. To advance the science of implementation with a focus on health equity, we reflect on the essential groundwork needed to promote bi-directional learning between the fields of implementation science and health equity research and recommend (1) building capacity among researchers and research institutions for health equity-focused and community-engaged implementation science; (2) incorporating health equity considerations across all key implementation focus areas (e.g., adaptations, implementation strategies, study design, determinants, and outcomes); and (3) continuing a focus on transdisciplinary opportunities in health equity research and implementation science. We believe that these recommendations can help advance implementation science by incorporating an explicit focus on health equity in the context of cancer prevention and control and beyond.

Human papillomavirus (HPV) vaccination is cancer prevention for childhood cancer survivors

Childhood cancer survivors are at high risk for developing human papillomavirus (HPV)-associated subsequent neoplasms. Henderson et al., 2021 identified risk factors for subsequent HPV-associated malignant neoplasms among enrollees in the Childhood Cancer Survivor Study. The exacerbated risk of subsequent HPV cancers found in the study underscores the need for more stringent surveillance and tracking to inform intervention approaches to ensure maximal protection. In addition, HPV vaccination must be prioritized as part of transitional care and survivorship planning. Limited sources of data on survivor practices and outcomes results in limited information to develop guidelines and provide childhood cancer survivors with information on preventing subsequent HPV cancers. Improved efforts are needed to increase HPV vaccination and HPV-related surveillance among childhood cancer survivors to prevent subsequent neoplasms.

Childhood cancer survivors are at increased risk of developing a subsequent cancer caused by human papillomavirus or HPV. HPV is a very common and usually benign sexually transmitted infection. HPV vaccination and screening can prevent most HPV cancers. However, childhood cancer survivors have lower HPV vaccination rates than individuals without a cancer history. To help prevent subsequent HPV cancers among childhood cancer survivors, we must gather better information and work to improve HPV vaccination recommendations and acceptance.

Childhood cancer survivors are at high risk for developing subsequent human papillomavirus (HPV)-associated cancers; Henderson et al., 2021, examined risk factors for subsequent malignant neoplasms associated with HPV among enrollees in the Childhood Cancer Survivor Study. Improved, targeted efforts to increase HPV vaccination and HPV-related surveillance among childhood cancer survivors are needed.

How Do African-American Community Members' Perceptions About Environmental Risks of Breast Cancer Compare with the Current State of the Science?

African-American (AA) women experience higher mortality from breast cancer than any other racial group. Understanding community-held perceptions of environmental contaminants as risk factors for breast cancer can inform the development of tailored prevention and education efforts for improve health outcomes. Six focus groups were conducted with AA participants in two counties in South Carolina, and themes were identified using open and axial coding. Perceived environmental risks for breast cancer most frequently discussed by participants were compared to findings from published systematic reviews. Frequently discussed environmental risk factors by participants were deodorants containing aluminum, plastics, pesticides, and air and water pollution. While perceptions of aluminum and air pollution as risk factors did not align with the state of the science, perceived risk factors of chemicals in plastics and pesticides were found to be in alignment. There is some congruence between perceived environmental risks for breast cancer within the AA community and the current state of the science; however, there is a need to communicate information that reflects current science regarding commonly held misconceptions. Development of evidence-based, clear, and culturally appropriate messaging that reflects the current state of the science is warranted.

Successful Multi-Level HPV Vaccination Intervention at a Rural Healthcare Center in the Era of COVID-19

Objectives: To develop and test a human papillomavirus (HPV) vaccination intervention that includes healthcare team training activities and patient reminders to reduce missed opportunities and improves the rate of appointment scheduling for HPV vaccination in a rural medical clinic in the United States.

Methods: The multi-level and multi-component intervention included healthcare team training activities and the distribution of patient education materials along with technology-based patient HPV vaccination reminders for parents/caregivers and young adult patients. Missed vaccination opportunities were assessed pre- and post-intervention (n = 402 and n = 99, respectively) by retrospective chart review and compared using Pearson χ². The patient parent/caregiver and young adult patient population (n = 80) was surveyed following the reminder messages and penalized logistic regression quantified unadjusted odds of scheduling a visit.

Results: Missed opportunities for HPV vaccination declined significantly from the pre-intervention to the post-intervention period (21.6 vs. 8.1%, respectively, p = 0.002). Participants who recalled receipt of a vaccination reminder had 7.0 (95% CI 2.4–22.8) times higher unadjusted odds of scheduling a visit compared with those who did not recall receiving a reminder. The unadjusted odds of confirming that they had scheduled or were intending to schedule a follow-up appointment to receive the HPV vaccine was 4.9 (95% CI 1.51–20.59) times greater among those who had not received the vaccine for themselves or for their child.

Conclusions: Results from this intervention are promising and suggest that vaccination interventions consisting of provider and support staff education and parent/caregiver and patient education materials, and reminders can reduce missed opportunities for vaccinations in rural settings.

HPV Vaccination Champions: Evaluating a Technology-Mediated Intervention for Parents

Human papillomavirus (HPV) vaccination prevents 6 HPV-related cancers in men and women. Yet, rates of HPV vaccination among adolescents in the United States lag behind other developed nations, revealing a significant public health issue. This feasibility study tested a collaborative online learning environment to cultivate HPV vaccination champions. A 3-month training program recruited parents to serve as proponents and social media influencers to identify solutions to overcome barriers to HPV vaccination. A mixed methods study design included a pretest survey, three online asynchronous focus groups, a posttest survey, as well as a longitudinal follow-up survey at 6 months. Participants included 22 parents who self-identified as female (95.4%) and white (90.9%). Overall, there was a statistically significant difference in knowledge of HPV and HPV vaccination between pretest and posttest (p = 0.0042). This technology-mediated intervention increased parents' confidence and motivated them to speak more freely about HPV vaccination in-person and online with others in their social networks. Participants identified prevalent misinformation about HPV vaccination and learned how to effectively craft messages to address concerns related to safety and side effects, gender, understanding of risk, and sexual activity. Objective measures and qualitative open-ended assessment showed high intervention engagement and treatment satisfaction. All participants (100%) indicated that they enjoyed participating in the intervention. The effectiveness of this feasibility study suggests that social media is an appropriate platform to empower parents to counter vaccine hesitancy and misinformation through HPV vaccination information that is simple and shareable in-person and online.

Stakeholder Perspectives on Colonoscopy Navigation and Colorectal Cancer Screening Inequities

Black adults complete colonoscopies at lower rates than other groups despite increased colorectal cancer risk. Patient navigation represents a strategy to address the varied factors that influence colonoscopy completion, but few reports describe how navigation reduces racial disparities in colorectal cancer screening rates. The purpose of this study was to understand how a statewide colonoscopy navigation program addressed the challenges faced by low-income Black adults attempting to complete screening colonoscopy. A qualitative case study analysis was conducted at a participating clinical site of a statewide colonoscopy navigation program. Clinical observations, document reviews, and semi-structured interviews were conducted with patients, patient navigators, and clinical staff. Patient participants were recruited to ensure maximum variation related to gender and colonoscopy completion. Thematic coding allowed researchers to examine experiences, perceptions, and emotions related to patient navigation. In total, 31 interviews were completed between October 2014 and February 2015. Patients and patient navigators reported logistical, psychosocial, and knowledge-related barriers to colonoscopy completion. Clinical staff reports focused mostly on logistical barriers. Benefits of patient navigation also varied by participant type with clinical staff revealing positive effects on the clinic's relationships with referring specialty practices. Patient navigators address barriers that are important to patients, but often unseen by clinical staff/providers. New information about the benefits different stakeholders derive from this strategy was revealed. Together these findings provide insight into the processes associated with this strategy and novel information about the appeal of patient navigation to various stakeholders.

Development of a Clinical-Academic-Community Collaboration to Improve Health Literacy

Limited health literacy is associated with poor patient health outcomes and increased hospitalization rates. Patient-provider communication plays an important role in patient health literacy and the understanding of medical terminology. This study demonstrates how a collaboration between clinical, academic, and community partners was instrumental in the design and implementation of a clinic readiness assessment and a clinic-based pilot intervention to encourage patient-provider communication and improve patient health literacy. A state hospital association, academic research team, and community adult literacy center director collaborated to develop a 60-item clinic readiness assessment and an evidence-informed pilot intervention. The clinic readiness assessment captured clinics’ motivation and capacity for pilot implementation and providers’ current communication strategies. The intervention centered around AskMe3™ educational materials and involved 2 patient visits (initial and follow-up visits). Data collection instruments for the intervention were administered verbally and included questions about patient demographics and communication needs, and a single-item health literacy measure. Descriptive statistics (frequencies/percentages) were used to analyze results from the clinic readiness assessment and pilot intervention. Establishment of the partnership, and collaborative, iterative development of the clinic readiness assessment and pilot intervention are described. This pilot project resulted in important lessons learned which led to critical modifications that will inform future expansion of the intervention. Collaboration between healthcare leaders, researchers, and community partners is recommended for developing clinic-based health literacy initiatives.

Correcting HPV Vaccination Misinformation Online: Evaluating the HPV Vaccination NOW Social Media Campaign

The human papillomavirus (HPV) vaccine provides protection from six HPV-related cancers. Approximately half of South Carolina adolescents have not completed the vaccination series, representing a missed opportunity to prevent cancer. The HPV Vaccination NOW: This is Our Moment social media campaign is an initiative of the South Carolina Cancer Alliance (SCCA) and Hollings Cancer Center at the Medical University of South Carolina (MUSC). This statewide social media campaign aimed to increase parental awareness of and build vaccine confidence around HPV vaccination in S.C. The ten-week campaign was strategically implemented between June and August 2019 to encourage HPV vaccination at back-to-school medical appointments. A process evaluation showed that the campaign resulted in over 370,000 total impressions, reached over 33,000 individuals, and culminated with over 1122 followers. There were over 2700 engagements on Facebook and Twitter. A qualitative content analysis indicated that pro-vaccine and anti-vaccine comments were dominated by personal stories. Comments promoting misinformation about the HPV vaccine were often countered through peer-to-peer dialogue. Findings suggest that creating opportunities for the target audience to engage with campaign messages effectively corrected misinformation.

"Talk About Cancer and Build Healthy Communities": How Visuals Are Starting the Conversation About Breast Cancer Within African-American Communities

African-American (AA) women are at higher risk of breast cancer mortality than women of other races. Factors influencing breast cancer risk, including exogenous environmental exposures, and debate around timing of exposure and dose-response relationship, can cause misunderstanding. Collaboration with priority populations encourages culturally relevant health messaging that imparts source reliability, influences message adoption, and improves understanding. Through six focus groups with AA individuals in rural and urban counties in the southeastern United States, this study used a community-engaged participatory approach to design an innovative visual tool for disseminating breast cancer information. Results demonstrated that participants were generally aware of environmental breast cancer risks and were willing to share new knowledge with families and community members. Recommended communication channels included pastors, healthcare providers, social media, and the Internet. Participants agreed that a collaboratively designed visual tool serves as a tangible, focused "conversation starter" to promote community prevention and education efforts.

A narrative review of HPV vaccination interventions in rural U.S. communities

Uptake of human papillomavirus (HPV) vaccine in the United States (U.S.) is far below the Healthy People 2020 goal of 80% coverage among adolescents. In rural communities, HPV vaccination coverage is low, yet incidence and mortality rates of HPV-associated cancer are high. Much of the research focused on HPV vaccination in rural U.S. communities has involved qualitative investigations, observations, survey research, and secondary data analysis with limited implementation of interventional study designs. The purpose of this narrative review was to examine intervention studies to increase HPV vaccination in rural settings and to summarize study characteristics and associated outcomes. PubMed, PsycINFO, CINAHL, and Web of Science were searched utilizing systematic narrative review methodology for studies describing implementation of HPV vaccination interventions in rural U.S. settings from January 2006-December 2019. Using specific search criteria, 991 studies were identified. After abstract review, 30 full-text articles were assessed for eligibility, and 15 met the inclusion criteria. The 15 articles - published from 2011 to 2019 - described HPV vaccination interventions in rural settings of six states, including communities, health clinics, and schools. A range of primary and secondary outcomes were reported, including HPV vaccine receipt (series initiation, continuation, and/or completion); HPV vaccine knowledge; and/or cervical cancer knowledge. Across the studies, there was an absence of the description of rural context. As compared to the broader HPV vaccination intervention literature, interventions in rural settings were limited. More interventional research is needed in rural communities given the elevated rates of HPV-related cancer and low rates of HPV vaccine uptake.

Evaluating a Technology-Mediated HPV Vaccination Awareness Intervention: A Controlled, Quasi-Experimental, Mixed Methods Study

College-aged women and men are an important catch-up population for human papillomavirus (HPV) vaccination interventions. Limited research has explored technology-mediated HPV vaccination awareness interventions aimed at college students. The purpose was to evaluate a novel, technology-mediated, social media-based intervention to promote HPV vaccination among college students. A controlled, quasi-experimental, mixed methods study examined the feasibility of a technology-based intervention among two undergraduate classes (n = 58) at a public university in the southeastern United States of America. Classes were randomized to receive one of two cancer prevention programs (i.e., HPV vaccination (intervention) or healthy weight (control)). Both programs contained eight technology-mediated sessions, including weekly emails and private Facebook group posts. Participants completed pre-/post-test surveys and submitted weekly qualitative reflections. Data were analyzed using descriptive statistics and thematic review for qualitative data. Knowledge improved among participants in the HPV vaccination intervention relative to those in the control condition. Participants (97%) interacted on Facebook by "liking" a post or comment or posting a comment. Participants demonstrated robust engagement and high treatment satisfaction. Results suggests that social media is an effective platform to reach college students with health promotion interventions and increase HPV vaccination awareness in this important catch-up population.

Development of a comprehensive measure of organizational readiness (motivation × capacity) for implementation: a study protocol

BACKGROUND

Organizational readiness is important for the implementation of evidence-based interventions. Currently, there is a critical need for a comprehensive, valid, reliable, and pragmatic measure of organizational readiness that can be used throughout the implementation process. This study aims to develop a readiness measure that can be used to support implementation in two critical public health settings: federally qualified health centers (FQHCs) and schools. The measure is informed by the Interactive Systems Framework for Dissemination and Implementation and R = MC2 heuristic (readiness = motivation × innovation-specific capacity × general capacity). The study aims are to adapt and further develop the readiness measure in FQHCs implementing evidence-based interventions for colorectal cancer screening, to test the validity and reliability of the developed readiness measure in FQHCs, and to adapt and assess the usability and validity of the readiness measure in schools implementing a nutrition-based program.

METHODS

For aim 1, we will conduct a series of qualitative interviews to adapt the readiness measure for use in FQHCs. We will then distribute the readiness measure to a developmental sample of 100 health center sites (up to 10 staff members per site). We will use a multilevel factor analysis approach to refine the readiness measure. For aim 2, we will distribute the measure to a different sample of 100 health center sites. We will use multilevel confirmatory factor analysis models to examine the structural validity. We will also conduct tests for scale reliability, test-retest reliability, and inter-rater reliability. For aim 3, we will use a qualitative approach to adapt the measure for use in schools and conduct reliability and validity tests similar to what is described in aim 2.

DISCUSSION

This study will rigorously develop a readiness measure that will be applicable across two settings: FQHCs and schools. Information gained from the readiness measure can inform planning and implementation efforts by identifying priority areas. These priority areas can inform the selection and tailoring of support strategies that can be used throughout the implementation process to further improve implementation efforts and, in turn, program effectiveness.

Cervical cancer treatment initiation and survival: The role of residential proximity to cancer care

OBJECTIVE

To examine the role of driving time to cancer care facilities on days to cancer treatment initiation and cause-specific survival for cervical cancer patients.

METHODS

A retrospective cohort analysis of patients diagnosed with invasive cervical cancer during 2001-2016, using South Carolina Central Cancer Registry data linked to vital records. Kaplan-Meier survival curves and Cox proportional hazards models were used to examine the association of driving times to both a patient's nearest and actual cancer treatment initiation facility with cause-specific survival and time to treatment initiation.

RESULTS

Of 2518 eligible patients, median cause-specific survival was 49 months (interquartile, 17-116) and time to cancer treatment initiation was 21 days (interquartile, 0-40). Compared to patients living within 15 min of the nearest cancer provider, those living more than 30 min away were less likely to receive initial treatment at teaching hospitals, Joint Commission accredited facilities, and/or Commission on Cancer accredited facilities. After controlling for patient, clinical, and provider characteristics, no significant associations existed between driving times to the nearest cancer provider and survival/time to treatment. When examining driving times to treatment initiation (rather than simply nearest) provider, patients who traveled farther than 30 min to their actual providers had delayed initiation of cancer treatment (hazard ratio, 0.81; 95% confidence interval, 0.73-0.90), including surgery (0.82; 95% CI, 0.72-0.92) and radiotherapy (0.82, 95% CI, 0.72-0.94). Traveling farther than 30 min to the first treating provider was not associated with worse cause-specific survival.

CONCLUSIONS

For cervical cancer patients, driving time to chosen treatment providers, but not to the nearest cancer care provider, was associated with prolonged time to treatment initiation. Neither was associated with survival.

Decomposing socioeconomic disparities in the use of colonoscopy among the insured elderly population before and after the Affordable Care Act

BACKGROUND

Out-of-pocket costs may significantly dampen patients' willingness to adopt preventive procedures. This is especially true for colonoscopies, which typically involved relatively high cost-sharing requirements prior to the Affordable Care Act (ACA) implementation in 2011.

PURPOSE

We aim to examine the effects of income-related disparities in colonoscopy use in the years prior to and immediately after the implementation of the ACA. Further, we quantify the contributions of different factors in explaining the disparities in the use of colonoscopies among elderly population with health insurance coverage.

METHODS

Five cycles (2008, 2010, 2012, 2014, and 2016) of Behavioral Risk Factor Surveillance System data were utilized. To examine income-related disparities in the use of CRC, individuals aged 65-75 were included, and the concentration index (CI) was calculated before and after the implementation of ACA. To identify and quantify the contribution of different factors, a decomposition analysis of CI was conducted.

RESULTS

CIs decreased from 0.1935 in pre-ACA years to 0.1813 in the post-ACA years among the elderly, indicating that the disparities in the use of colonoscopy was relatively low and the disparities index declined after the implementation of ACA. Decomposition analyses showed that whereas decreases in disparities derived largely from income and educational level, higher level of income and educational attainment were major contributors to the observed disparities in colonoscopy use.

CONCLUSIONS

Our findings indicate that the ACA's removal of financial barriers may have contributed toward the reduction in disparities of colonoscopy use. More direct interventions, e.g., improved knowledge, better access and lower indirect cost will be helpful in improving screening among low-income and low-educational attainment households.

Expanding access to HPV vaccination in South Carolina through community pharmacies: A geospatial analysis

OBJECTIVE

Human papillomavirus (HPV)-associated cancer rates are higher in rural areas. Despite the preventive benefits of HPV vaccination, uptake is lower among rural populations. Community-based pharmacies with a strong presence in rural communities may be ideal for improving HPV vaccination access. Our objective was to determine whether spatial access to pharmacies among adolescents and young adults in South Carolina varied by rurality and geographic access to primary care providers.

METHODS

Geographic information systems methods were used to evaluate spatial access to community-based pharmacies among persons aged 10-24 years in South Carolina census tracts (CTs). CTs were categorized as metropolitan, micropolitan, or small-town and isolated rural CTs using rural-urban commuting area codes and as health provider shortage areas (HPSAs) or not. Descriptive and spatial statistics were calculated to compare access across CT groupings and to evaluate geospatial clustering.

RESULTS

Areas of highest access clustered among the metropolitan CTs. Whereas spatial access was higher in metropolitan than micropolitan CTs, there was no difference in spatial access between metropolitan and small-town and rural CTs. In general, HPSA-designated areas had lower spatial access to pharmacies than non-HPSA-designated areas. However, in micropolitan areas, there was no difference in spatial access to pharmacies based on HPSA designation.

CONCLUSION

Spatial access to pharmacies among small town and rural areas was comparable to urban areas as was HPSA-designated micropolitan areas and non-HPSA micropolitan areas. This suggests that pharmacies are equally accessible to both urban and rural populations in South Carolina, but additional research is needed to identify effective strategies to promote the uptake of and the availability of HPV vaccination in pharmacies (e.g., insurance coverage) and to ensure patients are educated on the benefits of HPV vaccinations and its availability in nonprimary care settings.

False-positive mammography and mammography screening intentions among black women: the influence of emotions and coping strategies

Introduction: Abnormal mammograms confirmed as benign are known as false-positive mammography (FPM) results. Research indicates that a history of FPM results may be linked to diagnostic delays in Black women, yet much of the research on FPM has focused on White women.Objectives: The purpose of this study was to examine: 1) The influence of FPM on breast cancer (BrCa) screening beliefs and intentions among Black women and 2) Whether emotional states, personality traits or coping behaviors altered the previously described relationships.Design: BrCa-free, Black women, aged 40 and older who completed screening mammograms in 2016 were recruited for a case-control study from 2016 to 2017. Women with FPM results were cases, and women with normal results served as matched controls. Print surveys assessing demographics, personality traits, emotions, BrCa screening history, BrCa beliefs, and africentric coping behaviors were mailed to participants. The final sample consisted of 118 respondents (55 cases, 63 controls). Ordinary least squares (OLS) models were constructed. Personality traits and emotions were tested as mediators and coping behaviors as moderators of the relationship between FPM results and BrCa beliefs.Results: FPM status was associated with a higher perception of barriers to mammography, and an elevated perception of barriers was associated with lower intentions to complete mammography. Collective coping behaviors functioned as a moderator and were associated with a decreased perception of mammography barriers in women with FPM results.Conclusions: FPM status had a detrimental impact on mammography intention indirectly through the perception of mammography barriers, but the use of africentric coping behaviors moderated the relationship between FPM status and perceived barriers to mammography. Culturally specific research focused on Black women is needed to explore influences on BrCa screening beliefs and mammography completion in this population.

Cervical cancer screening behaviors and proximity to federally qualified health centers in South Carolina

INTRODUCTION

Lack of participation in cervical cancer screening in underserved populations has been attributed to access to care, particularly among women in rural areas. Federally Qualified Health Centers (FQHCs) were created to address this need in medically underserved populations. This study observed proximity to three health centers in relation to cervical cancer screening rates in South Carolina.

METHODS

Data were obtained from FQHC patient visits (from 3 centers) between 2007-2010 and were limited to women eligible for cervical cancer screening (n = 24,393). ArcGIS was used to geocode patients addresses and FQHC locations, and distance was calculated. Modified Poisson regression was used to estimate relative risk of obtaining cervical cancer screening within one yearor ever, stratified by residential area.

RESULTS

Findings differed markedly by center and urban/rural status. At two health clinics, rural residents living the furthest away from the clinic (∼9 miles difference between quartile 4 and quartile 1) were more likely to be ever screened (RRs = 1.05 and 1.03, p-values < 0.05), while urban residents living the furthest away were less likely to be ever screened (RR = 0.85, p-value < 0.05). At the third center, only urban residents living the furthest away were more likely to be ever screened (RR = 1.02, p-value < 0.05).

CONCLUSIONS

Increased travel distance significantly increased the likelihood of cervical cancer screening at two FQHC sites while significantly decreasing the likelihood of screening at the 3rd site. These findings underscore the importance of contextual and environmental factors that impact use of cervical cancer screening services.

A Bivariate Mapping Tutorial for Cancer Control Resource Allocation Decisions and Interventions

Bivariate choropleth mapping is a straightforward but underused method for displaying geographic health information to use in public health decision making. Previous studies have recommended this approach for state comprehensive cancer control planning and similar efforts. In this method, 2 area-level variables of interest are mapped simultaneously, often as overlapping quantiles or by using other classification methods. Variables to be mapped may include area-level (eg, county level) measures of disease burden, health care use, access to health care services, and sociodemographic characteristics. We demonstrate how geographic information systems software, specifically ArcGIS, can be used to develop bivariate choropleth maps to inform resource allocation and public health interventions. We used 2 types of county-level public health data: South Carolina’s Behavioral Risk Factor Surveillance System estimates of ever having received cervical cancer screening, and a measure of availability of cervical cancer screening providers that are part of South Carolina’s Breast and Cervical Cancer Early Detection Program. Identification of counties with low screening rates and low access to care may help inform where additional resources should be allocated to improve access and subsequently improve screening rates. Similarly, identifying counties with low screening rates and high access to care may help inform where educational and behavioral interventions should be targeted to improve screening in areas of high access.

Examining Breast Cancer Screening Behavior Among Southern Black Women After the 2009 US Preventive Services Task Force Mammography Guideline Revisions

Updated United States Preventive Services Task Force (USPSTF) and American Cancer Society mammography screening recommendations push for increased age of initiation and lengthened breast cancer screening intervals. These changes have implications for the reduction of breast cancer mortality in Black women. The purpose of this study was to examine breast cancer screening behavior in a cohort of Southern Black women after the release of the 2009 USPSTF recommendations. Surveys assessing cancer screening information were collected from members of Black churches between 2006 and 2013. The sample was restricted to women aged 40 to 74 years, who did not report a breast cancer diagnosis, or a recent diagnostic mammogram (n = 789). Percentages of women ever completing a mammogram (age 40-49) and annual mammography (age 50-74) in 2006-2009 and 2010-2013 were compared using chi-square statistics. Logistic regression models were fit to determine the predictors of adherence to pre-2010 screening guidelines. No significant changes in mammography rates were found for women in the 40-49 age group (X² = 0.42, p = 0.52) nor for those in the 50-74 age group (X² = 0.67, p = 0.41). Completing an annual clinical breast exam was a significant predictor of adherence to pre-2010 screening guidelines for both age groups (OR 19.86 and OR 33.27 respectively) and participation in education sessions (OR 4.26). Stability in mammography behavior may be a result of PCP's advice, or community activities grounded pre-2010 screening recommendations. More research is needed to understand how clinical interactions and community-based efforts shape Black women's screening knowledge and practices.

A multi-site case study of community-clinical linkages for promoting HPV vaccination

Human papillomavirus (HPV) vaccination rates in the U.S. are suboptimal, requiring innovative partnerships between community and clinical entities to remedy this issue. A rigorous evaluation of HPV-related community-clinical linkages (CCLs) was conducted to understand their components, processes, and outcomes to increase HPV vaccination. Cancer Prevention and Control Research Network (CPCRN) investigators explored CCLs in their communities employing an iterative, case study approach. Information describing nine CCLs on HPV vaccination was collected from representatives from the community organization and clinical setting. Thematic content analysis was used to analyze and interpret data. Five CCLs included a federally qualified health center as the clinical partner, and five included a non-profit organization as the community partner. Five reflected clinically focused integration wherein engagement occurs in the community but vaccine delivery and follow-up occur in the clinical setting. The main impetus was the need to improve HPV vaccination and a community's strong interest in preventing cancer. Noted critical components were a designated person to support the CCL and funding. Results will guide HPV vaccination promotion, education, and intervention efforts. CCLs provide an opportunity to study the adaption, integration, and enhancement of evidence-based approaches to increase HPV vaccination.

Mentoring, Training, and Scholarly Productivity Experiences of Cancer-Related Health Disparities Research Trainees: Do Outcomes Differ for Underrepresented Scientists?

The study aims to explore variation in scholarly productivity outcomes by underrepresented status among a diverse sample of researchers in a community-engaged training program. We identified 141 trainees from a web-based survey of researchers in the National Cancer Institute-funded, Community Networks Program Centers (CNPCs) (2011-2016). We conducted a series of multiple logistic regression models to estimate the effect of National Institutes of Health (NIH)-defined underrepresented status on four, self-reported, scholarly productivity outcomes in the previous 5 years: number of publications (first-authored and total) and funded grants (NIH and any agency). Sixty-five percent (n = 92) indicated NIH underrepresented status. In final adjusted models, non-NIH underrepresented (vs. underrepresented) trainees reported an increased odds of having more than the median number of total publications (> 9) (OR = 3.14, 95% CI 1.21-8.65) and any grant funding (OR = 5.10, 95% CI 1.77-14.65). Reporting ≥ 1 mentors (vs. none) was also positively associated (p < 0.05) with these outcomes. The CNPC underrepresented trainees had similar success in first-authored publications and NIH funding as non-underrepresented trainees, but not total publications and grants. Examining trainees' mentoring experiences over time in relation to scholarly productivity outcomes is needed.

Rise Up, Get Tested, and Live: an Arts-Based Colorectal Cancer Educational Program in a Faith-Based Setting

Engaging community members in efforts to reduce cancer-related health disparities through community mini-grant programs has been shown to have meaningful impact. A predominantly African-American church in South Carolina was awarded a community mini-grant to increase awareness about colorectal cancer (CRC) screening among disproportionally high-risk African-American communities through culturally appropriate arts-based cancer education. The church's pastor, health and wellness ministry, and drama ministry created a theatrical production called Rise Up, Get Tested, and Live. Over 100 attendees viewed the play. A pre/post-test evaluation design assessed the effectiveness of the production in increasing participants' knowledge about CRC and examined their intentions to be screened. Results showed increased knowledge about CRC, increased awareness and understanding about the importance of CRC screening, and favorable intentions about CRC screening. Findings suggest that arts-based cancer education may be an effective tool for the dissemination of information about CRC screening.

A reproductive justice approach to understanding women's experiences with HPV and cervical cancer prevention

Cervical cancer is a preventable disease. HPV infection has been linked to more than 90% of cervical cancers. A vaccine to prevent the acquisition of HPV has been available since 2006. The purpose of this study was to investigate women's perceptions of cervical cancer prevention, including HPV vaccination. A reproductive justice framework guided data collection and analysis. In 2016, researchers conducted 70 in-depth, semi-structured qualitative interviews with women aged 19-78 years in South Carolina. A purposive sampling approach was employed to maximize requisite variety based on social, economic, and environmental axes of inequality. Participants self-identified as white (53%), African American (33%), and Hispanic (9%). Data analysis included an inductive constant comparative method to identify patterns and themes across the interviews. Misinformation about the prevalence and risk of HPV and cervical cancer led to "othering" of women with HPV-related diagnoses based on the flawed assumption of not being at risk. Participants described a lack of knowledge about the effectiveness and safety of the HPV vaccine. Social norms influenced participants' perceptions of HPV vaccination and cervical cancer, including concerns about sexual activity and intergenerational communication. Participants' social construction of identity, including race/ethnicity, socioeconomic position, ability, age, gender, sexual orientation, and immigration status, impacted their perceptions of cervical cancer screening and the HPV vaccine. In particular, participants believed that the HPV vaccine was "only for girls" and identified gender norms that limited uptake. Participants described barriers to accessing health care and cervical cancer screening, including cost, health insurance, and life changes (e.g., pregnancy, relocating). Many participants experienced an abnormal Papanicolaou test and described follow-up care, including biopsies and treatment for cervical dysplasia. Findings from this study offer insight into women's identity and perceptions of cervical cancer prevention. Results provide practical recommendations to increase women's agency in the development of successful public health interventions.

Policy opportunities to increase HPV vaccination in rural communities

Rural communities experience health disparities, including elevated incidence and mortality of human papillomavirus (HPV)-associated cancers and correspondingly low HPV vaccination rates. There are numerous policy strategies that are available at multiple levels - patient, provider, clinic, community, state, and national - to address geographic, clinical, and communication barriers to HPV vaccination across rural America. Examples include policy development, implementation, and evaluation of healthcare provider and clinic-based assessment and education initiatives; school entry requirements; school, pharmacy, and community-based vaccination programs; evidence-based, community-driven communication efforts; and increased interventional research in rural communities. Strategically implemented policy measures will contribute to reduction in the incidence and mortality from HPV-related cancers through increased access to HPV vaccination in our rural communities.

Evaluating centralized technical assistance as an implementation strategy to improve cancer prevention and control

PURPOSE

In 2015-2016, the Comprehensive Cancer Control National Partnership provided technical assistance workshops to support 22 cancer coalitions in increasing human papillomavirus (HPV) vaccination uptake and increasing colorectal cancer (CRC) screening in their local communities. As national efforts continue to invest in providing technical assistance, there is a current gap in understanding its use as a strategy to accelerate implementation of evidence-based interventions (EBIs) for cancer prevention. The objective of this study was to evaluate the impact of technical assistance on the participants' knowledge, attitudes, and skills for implementing EBIs in their local context and enhancing state team collaboration.

METHODS

Data were collected August-November 2017 using web-based questionnaires from 44 HPV workshop participants and 66 CRC workshop participants.

RESULTS

Both HPV vaccination and CRC screening workshop participants reported changes in knowledge, attitudes, and skills related to implementing EBIs in their local state context. Several participants reported increased abilities in communicating and coordinating with partners in their states and utilizing additional implementation strategies to increase HPV vaccination uptake and CRC screening rates.

CONCLUSIONS

Findings from this study suggest that providing technical assistance to members of comprehensive cancer control coalitions is useful in promoting collaborations and building capacity for implementing EBIs for cancer prevention and control.

"For lack of knowledge, our people will perish": Using focus group methodology to explore African-American communities' perceptions of breast cancer and the environment

Among women living in the United States, breast cancer is the second leading cause of cancer death. Disproportionate racial disparities in breast cancer exist, with African American (AA) women consistently having the highest rates of breast cancer related mortality despite lower incidence. This study attends to the Institute of Medicine's (IOM) call to action recommending the identification of effective strategies for communicating accurate and reliable breast cancer risk information to diverse audiences. Using focus group methodology, this study explores how AAs perceive and decipher information related to breast cancer and its relationship to their environment. Six focus groups were conducted. The sample (n = 50) was African American, 98% female, with an average age of 50.1 years. The focus group protocol consisted of open-ended questions designed to elicit information about participants' perceptions of their environment and its link to breast cancer. Focus groups were audio recorded and professionally transcribed. Analysis of the focus group transcripts revealed themes pertaining to these categories: (1) general knowledge and beliefs about breast cancer, (2) perceived environmental risks factors for breast cancer, (3) importance of seeking knowledge about breast cancer and the environment, and (4) recommended communication strategies. The emergent themes reflect the knowledge participants possessed about breast cancer and environmental risk factors, in addition to concerns about the importance of possessing accurate information, and how culturally appropriate health communication strategies can be used to disseminate breast cancer knowledge in the community. Findings from this study can be used for culturally appropriate communication about breast cancer and the environment with AA communities.

HPV-Related Cancer Prevention and Control Programs at Community-Based HIV/AIDS Service Organizations: Implications for Future Engagement

Background: People living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and, men who have sex with men (MSM) are disproportionately affected by genital warts and cancers caused by human papillomavirus (HPV). We assessed community-based HIV/AIDS service organizations' (ASOs) staff awareness, knowledge, attitudes, and beliefs about HPV and effective cancer prevention tools, namely HPV vaccination, Pap, and HPV tests. The potential engagement of ASO staff in future efforts to reduce the disproportionate burden of genital warts and HPV-related cancers among HIV-positive women and MSM was explored.

Methods: In May-June 2016, staff were recruited from three ASOs located in the South United States Census region—a geographical area disproportionately affected by HIV/AIDS. Participants completed a 30-min self-administered, 118-item paper and pencil survey about HPV and cancer. Data analysis was conducted using Stata/SE 14.2.

Results: ASO staff (n = 30) were 83% non-Hispanic Black, 40% lesbian/gay, and worked with people living with HIV for an average of 11.4 ± 7.7 years. All reported hearing of HPV and 77% had heard of the HPV vaccine (n = 23). While all knew HPV can cause cervical cancer, only 67% knew HPV can cause anal cancer. Most (61%) thought the HPV vaccine could prevent cervical cancer. Fewer (39–48%) thought the HPV vaccine could prevent anal, oral, penile, vaginal, and vulvar cancers. All were willing to encourage MSM and female clients to talk to a healthcare provider about HPV vaccination. Almost all were willing to promote HPV vaccination to clients (91–95%) and navigate clients to adult safety net HPV vaccine providers (86–95%). More than half (59–67%) thought they could positively influence their MSM and female clients' HPV vaccine decision-making.

Conclusion: HPV vaccination and the Pap and HPV tests are effective cancer prevention tools that can reduce the disproportionate burden of genital warts and HPV-related cancers among HIV-positive women and MSM. Engaging ASO staff in cancer prevention efforts may increase HPV vaccination rates and early detection of HPV-related cancers among HIV-positive women and MSM. Exploring ASOs as community-based settings for promoting effective cancer prevention tools may foster opportunities to reduce the disproportionate burden of genital warts and HPV-related cancers among HIV-positive women and MSM.

Abstract C69: Patient satisfaction and mammography intention among Black women: Contributions of patient-provider interactions

Background: Given rising breast cancer incidence rates and documented delays in completing follow-up testing among Black women, understanding factors that contribute to intention to complete the mammography screening process will be important for reducing the disproportionate burden of breast cancer in this population. Satisfaction with the mammography encounter has been routinely linked with mammography completion, but research describing the influence of patient-provider interactions on this relationship has been mixed.

Purpose: (1) To examine the connection between satisfaction with specific aspects of mammography experiences and Black women's intention to complete the mammography screening process, and (2) to determine whether discrimination or disrespect during the mammography encounter function as mediators or moderators of this relationship. We hypothesize that all aspects of patient satisfaction will positively influence mammography intention and that experiencing discrimination or disrespect will moderate this relationship.

Methods: Black women aged 40+, breast cancer free, who completed screening mammograms from January to August 2016 at participating mammography facilities in South Carolina were eligible for study inclusion. Demographic information, assessments of the women's recent screening mammography experience, and mammography intentions were collected via a paper survey tool. The Cockburn Mammography Satisfaction Scale was used to assess six aspects of satisfaction: general satisfaction, convenience and accessibility, provider interpersonal skills, patient-provider communication, physical surroundings, and perceived provider competence. Patient-provider interactions were measured using the discrimination and disrespectful office staff subscales of the Interpersonal Processes of Care Survey. Intention to complete future screening mammograms and follow-up tests were each assessed with a single item: 1) How likely are you get your next screening mammogram as scheduled? and 2) If you are asked to return for follow-up testing after your next screening mammogram, how likely are you to complete those additional tests? Multiple regression models linking each type of satisfaction to both types of mammography intention were created in STATA 13. All models controlled for survey respondents' age, education, income, health insurance status, marital status, geographic location, and history of abnormal mammograms. Moderation was tested using interaction terms created from satisfaction and patient-provider interactions variables.

Results: Analyses were limited to 129 eligible surveys with complete responses on variables of interest. None of the models describing the relationships between satisfaction and mammography screening was statistically significant. Intention to complete mammography follow-up was positively influenced by satisfaction with convenience and accessibility (R2=0.22, p=0.00), provider interpersonal skills (R2=0.21, p=0.00), and perceived provider competence (R2=0.17, p=0.02). Disrespect served as neither a mediator nor a moderator in any of the models. Discrimination did not function as a mediator, but it moderated intention to complete mammography follow-up in the three significant models. Among women experiencing discrimination, follow-up intentions increased as satisfaction increased. For women who did not encounter discrimination, follow-up intention remained constant regardless of satisfaction levels.

Discussion: Black women's experiences during and perceptions of their mammography encounters have consequences with respect to their desire to complete follow-up testing. More research is needed to understand influences on mammography follow-up in Black women.

Citation Format: Deeonna E. Farr, Heather M. Brandt, Daniela B. Friedman, Cheryl A. Armstead, Swann A. Adams, Jeanette Fulton, Douglas Bull,. Patient satisfaction and mammography intention among Black women: Contributions of patient-provider interactions [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C69.