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.

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life.

METHODS

We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors.

RESULTS

A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.

CONCLUSIONS

In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.

Black women's perspectives on bladder health: Social-ecological and life course contexts

AIMS

This paper explores Black women's perspectives on bladder health using a social-ecological conceptual framework and life course perspective.

METHODS

We conducted a directed content analysis of data from the Study of Habits, Attitudes, Realities, and Experiences (SHARE), a focus group study by the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium. Analysis was conducted on data from five focus groups and a member-checking session where all participants self-identified as Black or African American.

RESULTS

Forty-two participants aged 11-14 or 45+ years reported life course experiences with their bladder. The intersection of race and gender was the lens through which participants viewed bladder health. Participants' accounts of their perspectives on bladder health explicitly and implicitly revealed structural racism as an explanatory overarching theme. Participants described (a) historically-rooted and still pervasive practices of discrimination and segregation, engendering inequitable access to quality medical care and public facilities, (b) institutional barriers to toileting autonomy in educational and occupational settings, promoting unhealthy voiding habits, (c) internalized expectations of Black women's stereotyped role as family caregiver, compromising caregiver health, (d) lack of reliable information on bladder health, leading to unhealthy bladder behaviors, and (e) potentially stress-related comorbid chronic conditions and associated medication use, causing or exacerbating bladder problems.

CONCLUSIONS

Bladder health promotion interventions should address social-ecological and life course factors shaping Black women's bladder health, including social and structural barriers to accessing equitable health information and medical care.

Asthma morbidity measures across Black ethnic subgroups

BACKGROUND

Black adults are disproportionately affected by asthma and are often considered a homogeneous group in research studies despite cultural and ancestral differences.

OBJECTIVE

We sought to determine if asthma morbidity differs across adults in Black ethnic subgroups.

METHODS

Adults with moderate-severe asthma were recruited across the continental United States and Puerto Rico for the PREPARE (PeRson EmPowered Asthma RElief) trial. Using self-identifications, we categorized multiethnic Black (ME/B) participants (n = 226) as Black Latinx participants (n = 146) or Caribbean, continental African, or other Black participants (n = 80). African American (AA/B) participants (n = 518) were categorized as Black participants who identified their ethnicity as being American. Baseline characteristics and retrospective asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids [SCs], emergency department/urgent care [ED/UC] visits, hospitalizations) were compared across subgroups using multivariable regression.

RESULTS

Compared with AA/B participants, ME/B participants were more likely to be younger, residing in the US Northeast, and Spanish speaking and to have lower body mass index, health literacy, and <1 comorbidity, but higher blood eosinophil counts. In a multivariable analysis, ME/B participants were significantly more likely to have ED/UC visits (incidence rate ratio [IRR] = 1.34, 95% CI = 1.04-1.72) and SC use (IRR = 1.27, 95% CI = 1.00-1.62) for asthma than AA/B participants. Of the ME/B subgroups, Puerto Rican Black Latinx participants (n = 120) were significantly more likely to have ED/UC visits (IRR = 1.64, 95% CI = 1.22-2.21) and SC use for asthma (IRR = 1.43, 95% CI = 1.06-1.92) than AA/B participants. There were no significant differences in hospitalizations for asthma among subgroups.

CONCLUSIONS

ME/B adults, specifically Puerto Rican Black Latinx adults, have higher risk of ED/UC visits and SC use for asthma than other Black subgroups.

Association Between Maternal Depression and Lower Urinary Tract Symptoms in Their Primary School-Age Daughters: A Birth Cohort Study

PURPOSE

Although maternal depression is associated with adverse outcomes in women and children, its relationship with lower urinary tract symptoms (LUTS) in offspring is less well-characterized. We examined the association between prenatal and postpartum maternal depression and LUTS in primary school-age daughters.

DESIGN

Observational cohort study.

SUBJECTS AND SETTING

The sample comprised 7148 mother-daughter dyads from the Avon Longitudinal Study of Parents and Children.

METHOD

Mothers completed questionnaires about depressive symptoms at 18 and 32 weeks' gestation and 21 months postpartum and their children's LUTS (urinary urgency, nocturia, and daytime and nighttime wetting) at 6, 7, and 9 years of age. Multivariable logistic regression models were used to estimate the association between maternal depression and LUTS in daughters.

RESULTS

Compared to daughters of mothers without depression, those born to mothers with prenatal and postpartum depression had higher odds of LUTS, including urinary urgency (adjusted odds ratio [aOR] range = 1.99-2.50) and nocturia (aOR range = 1.67-1.97) at 6, 7, and 9 years of age. Additionally, daughters born to mothers with prenatal and postpartum depression had higher odds of daytime wetting (aOR range = 1.81-1.99) and nighttime wetting (aOR range = 1.63-1.95) at 6 and 7 years of age. Less consistent associations were observed for depression limited to the prenatal or postpartum periods only.

CONCLUSIONS

Exposure to maternal depression in the prenatal and postpartum periods was associated with an increased likelihood of LUTS in daughters. This association may be an important opportunity for childhood LUTS prevention. Prevention strategies should reflect an understanding of potential biological and environmental mechanisms through which maternal depression may influence childhood LUTS.

Preference for and impact of telehealth vs in-person asthma visits among Black and Latinx adults

BACKGROUND

Black and Latinx adults experience disproportionate asthma-related morbidity and limited specialty care access. The severe acute respiratory syndrome coronavirus 2 pandemic expanded telehealth use.

OBJECTIVE

To evaluate visit type (telehealth [TH] vs in-person [IP]) preferences and the impact of visit type on asthma outcomes among Black and Latinx adults with moderate-to-severe asthma.

METHODS

For this PREPARE trial ancillary study, visit type preference was surveyed by e-mail or telephone post-trial. Emergency medical record data on visit types and asthma outcomes were available for a subset (March 2020 to April 2021). Characteristics associated with visit type preferences, and relationships between visit type and asthma outcomes (control [Asthma Control Test] and asthma-related quality of life [Asthma Symptom Utility Index]), were tested using multivariable regression.

RESULTS

A total of 866 participants consented to be surveyed, with 847 respondents. Among the participants with asthma care experience with both visit types, 42.0% preferred TH for regular checkups, which associated with employment (odds ratio [OR] = 1.61; 95% confidence interval [CI], 1.09-2.39; P = .02), lower asthma medication adherence (OR = 1.06; 95% CI, 1.01-1.11; P = .03), and having more historical emergency department and urgent care asthma visits (OR = 1.10 for each additional visit; 95% CI, 1.02-1.18; P = .02), after adjustment. Emergency medical record data were available for 98 participants (62 TH, 36 IP). Those with TH visits were more likely Latinx, from the Southwest, employed, using inhaled corticosteroid-only controller therapy, with lower body mass index, and lower self-reported asthma medication adherence vs those with IP visits only. Both groups had comparable Asthma Control Test (18.4 vs 18.9, P = .52) and Asthma Symptom Utility Index (0.79 vs 0.84, P = .16) scores after adjustment.

CONCLUSION

TH may be similarly efficacious as and often preferred over IP among Black and Latinx adults with moderate-to-severe asthma, especially for regular checkups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02995733.

HPV Vaccination among College Students in the South: The Role of HPV Knowledge on Vaccine Initiation and Completion

BACKGROUND

The purpose of this study was to examine factors related to HPV vaccination initiation and completion, especially the role of health knowledge, among college students in a southern state.

METHODS

College students ages 17-45 (n=1,708) were analyzed in this study. Primary outcomes were HPV vaccine series initiation and completion; binary logistic regressions were performed to identify associated factors.

RESULTS

Among total participants, students who were aware that HPV could be transmitted even without symptoms were less likely to initiate HPV vaccination. However, among students who have initiated the vaccine series, those who were aware that HPV could be transmitted without symptoms and that men should receive the HPV vaccine were more likely to complete the vaccine series. Other significant variables included age, gender, race, and international student status.

CONCLUSION

Future studies are needed to investigate students' concerns regarding initiating HPV vaccination and how to effectively motivate students to initiate and complete the HPV vaccine series.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data

PURPOSE

We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women.

METHODS

We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates.

RESULTS

Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17.

DISCUSSION

We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

Recommending HPV vaccination at age 9 to reduce health disparities: Communication challenges and opportunities

The HPV vaccine is approved for children as young as age nine and recommended by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices routinely for ages 11-12. However, many U.S. adolescents do not complete the vaccine series until middle to late adolescence, if at all, leaving them vulnerable to future HPV infection and attributable cancers. Health disparities exist for both vaccination coverage and most HPV-associated cancers. A strategy for improving vaccination rates for all populations and reducing disparate gaps in protection and health disparities from HPV-associated cancers is to shift the routine recommendation to an earlier age, that is, to start the vaccine series at age nine instead of ages 11-12. Challenges, opportunities, and suggestions for communicating this recommendation are outlined alongside considerations of social determinants of health.

Health Equity and the Impact of Racism on Adolescent Health

Racism is woven within the fabric of the United States culture, structures, and systems, including its healthcare system. There is extensive research on adults demonstrating racial discrimination's physical and mental health impacts, and the evidence showing similar disproportionate effects for adolescents of color continues to grow. Furthermore, the devastation of the coronavirus pandemic has paralleled the resurgence of white nationalism movements and adverse outcomes associated with the over-policing of Black and Brown communities. Scientific evidence continues to illustrate how sociopolitical determinants of health and experiencing vicarious racism amplify overt racism and implicit bias actions individually and within health care structures. Therefore, evidence-based strategic interventions are desperately needed to ensure the health and well-being of adolescents and young adults.

Leveling the Playing Field: Promoting Vaccine Equity for Adolescents and Young Adults

Immunization is one the greatest prevention tools in the skillset of the general pediatrician. Ensuring that all patients, particularly adolescents and young adults, have the opportunity and access to age-appropriate vaccines should be an integral part of pediatric practice. Equitable immunization access and allocation should be afforded to adolescents and young adults to foster the health and well-being of America's next generation. This article will focus on select inequities that create health disparities disproportionately affecting adolescents and young adults of color. We seek to highlight inequities in adolescents and young adult vaccination and explore strategies for improving equity among this unique group. [Pediatr Ann. 2023;52(3):e102-e105.].

"Sex. Maybe We Should Do Things to be Healthy About It." Adolescent-Caregiver Discussions About Sex

PURPOSE

Adolescents are disproportionately burdened with HIV. Numerous barriers limit adolescent pre-exposure prophylaxis (PrEP) use for HIV prevention. We explored adolescent-caregiver perspectives on discussing sexual health and PrEP to inform future caregiver interventions as a possible strategy to promote PrEP use.

METHODS

We conducted separate in-depth interviews with adolescents aged 14-18 living in Alabama and their parent/guardian (caregiver). Interviews explored attitudes about sex, knowledge and attitudes about HIV prevention and PrEP, and attitudes about PrEP communication within adolescent-caregiver groups. Thematic analysis of adolescent and caregiver interviews was conducted independently and then triangulated to compare shared themes.

RESULTS

Nine adolescents and seven caregivers contributed to five dyads and two triads. Adolescents had a median age of 16 years (range 14-18); five were girls (55%), and five were non-Hispanic Black (55%). Most caregivers were mothers (5, 71%), non-Hispanic Black (5, 71%), with a median age of 41 (36-56) years. All adolescents expressed willingness to involve their caregiver around PrEP use. Major themes included as follows: 1) caregiver efforts to overcome cultural taboos about sex and sexuality foster adolescents' willingness to talk with caregivers about sex; 2) evolving societal norms and reflections on their own upbringings motivate caregivers to discuss and support adolescents with sexual health; and 3) caregivers desire to engage in sexual health discussions with providers and support their teens with PrEP.

DISCUSSION

As socio-cultural norms around sex evolve, adolescent-caregiver discussions about sexual health and PrEP may be an opportunity to increase PrEP use and reduce HIV infections among select adolescent sub-populations.

A community-engaged approach to the design of a population-based prospective cohort study to promote bladder health

INTRODUCTION

Community engagement is increasingly recognized as a critical component of research, but few studies provide details on how to successfully incorporate community perspectives in urological research. This manuscript describes the community engagement strategy used by the Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS) to design RISE FOR HEALTH (RISE), a multicenter, population-based, prospective cohort study to promote bladder health.

METHODS AND RESULTS

The PLUS Community Engagement Subcommittee, guided by a set of antiracist community engagement principles and practices, organized, implemented, and communicated findings for all RISE community engagement activities. Community engagement was conducted through a diverse network of community partners at PLUS clinical research centers called Rapid Assessment Partners (RAPs). Via online surveys (4), virtual discussion groups (14), and one-on-one interviews (12), RAPs provided input on RISE processes and materials, including in-person visit procedures, specimen collection instructions, survey data collection instruments, recruitment materials, the study website, and the study name. This process resulted in significant changes to these aspects of the study design with reciprocal benefits for the community partners.

DISCUSSION

Meaningful community engagement improved the design and implementation of RISE. PLUS will continue to engage community partners to interpret the RISE study results, disseminate RISE findings, and inform other PLUS studies toward the development of interventions to promote bladder health. Future urological studies would also benefit from community participation in determining priority research questions to address.

Socioeconomic status associates with worse asthma morbidity among Black and Latinx adults

BACKGROUND

Asthma disproportionately affects African American/Black (AA/B) and Hispanic/Latinx (H/L) patients and individuals with low socioeconomic status (SES), but the relationship between SES and asthma morbidity within these racial/ethnic groups is inadequately understood.

OBJECTIVE

To determine the relationship between SES and asthma morbidity among AA/B and H/L adults with moderate to severe asthma using multidomain SES frameworks and mediation analyses.

METHODS

We analyzed enrollment data from the PeRson EmPowered Asthma RElief randomized trial, evaluating inhaled corticosteroid supplementation to rescue therapy. We tested for direct and indirect relationships between SES and asthma morbidity using structural equation models. For SES, we used a latent variable defined by poverty, education, and unemployment. For asthma morbidity, we used self-reported asthma exacerbations in the year before enrollment (corticosteroid bursts, emergency room/urgent care visits, or hospitalizations), and Asthma Control Test scores. We tested for mediation via health literacy, perceived stress, and self-reported discrimination. All models adjusted for age, sex, body mass index, ethnicity, and comorbidities.

RESULTS

Among 990 AA/B and H/L adults, low SES (latent variable) was directly associated with hospitalizations (β = 0.24) and worse Asthma Control Test scores (β = 0.20). Stress partially mediated the relationship between SES and increased emergency room/urgent care visits and worse asthma control (β = 0.03 and = 0.05, respectively). Individual SES domains were directly associated with asthma morbidity. Stress mediated indirect associations between low educational attainment and unemployment with worse asthma control (β = 0.05 and = 0.06, respectively).

CONCLUSIONS

Lower SES is directly, and indirectly through stress, associated with asthma morbidity among AA/B and H/L adults. Identification of stressors and relevant management strategies may lessen asthma-related morbidity among these populations.

Food Insecurity Screening of Hospitalized Patients: A Descriptive Analysis

OBJECTIVES

The purpose of this study is to describe an advocacy effort to implement a food insecurity (FI) screening during hospital admission and describe characteristics of hospitalized patients with household FI.

METHODS

This is a descriptive study after the implementation of FI screening at a quaternary-care children's hospital in the Southeastern United States between August 2020 and April 2021. The Hunger Vital Sign, a 2-question screening tool for FI, was added to the intake questionnaire performed on inpatient admissions. A positive screen triggered a social work consult to connect patients with resources. Chart review and statistical analyses were performed on patients with household FI.

RESULTS

There were 7751 hospital admissions during the study period, of which 4777 (61.6%) had an FI screen completed. Among those with a completed screen, 233 patients (4.9%) were positive for household FI. Patients with household FI were more likely to be Black (P <.001) and have Medicaid (P <.001). Social work documented care specific to FI in 125 of the 233 (56%) FI patients, of which 39 (31%) were not enrolled in the Women, Infants, and Children Program/Supplemental Nutrition Assistance Program.

CONCLUSIONS

This initiative highlights hospitalization as an opportunity to screen for FI using a multidisciplinary approach. Our findings underscore the importance of identifying FI with the goal of reducing FI and mitigating the adverse effects of FI on child health outcomes.

Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma

BACKGROUND

Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations.

METHODS

In this pragmatic, open-label trial, we randomly assigned Black and Latinx adults with moderate-to-severe asthma to use a patient-activated, reliever-triggered inhaled glucocorticoid strategy (beclomethasone dipropionate, 80 μg) plus usual care (intervention) or to continue usual care. Participants had one instructional visit followed by 15 monthly questionnaires. The primary end point was the annualized rate of severe asthma exacerbations. Secondary end points included monthly asthma control as measured with the Asthma Control Test (ACT; range, 5 [poor] to 25 [complete control]), quality of life as measured with the Asthma Symptom Utility Index (ASUI; range, 0 to 1, with lower scores indicating greater impairment), and participant-reported missed days of work, school, or usual activities. Safety was also assessed.

RESULTS

Of 1201 adults (603 Black and 598 Latinx), 600 were assigned to the intervention group and 601 to the usual-care group. The annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P = 0.048). ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and by 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group (difference, 0.9; 95% CI, 0.5 to 1.2); ASUI scores increased by 0.12 points (95% CI, 0.11 to 0.13) and 0.08 points (95% CI, 0.07 to 0.09), respectively (difference, 0.04; 95% CI, 0.02 to 0.05). The annualized rate of missed days was 13.4 in the intervention group and 16.8 in the usual-care group (rate ratio, 0.80; 95% CI, 0.67 to 0.95). Serious adverse events occurred in 12.2% of the participants, with an even distribution between the groups.

CONCLUSIONS

Among Black and Latinx adults with moderate-to-severe asthma, provision of an inhaled glucocorticoid and one-time instruction on its use, added to usual care, led to a lower rate of severe asthma exacerbations. (Funded by the Patient-Centered Outcomes Research Institute and others; PREPARE ClinicalTrials.gov number, NCT02995733.).

01. Serum Bactericidal Activity Against Circulating and Reference Strains of Meningococcal Serogroup B in the United States: A Review of Meningococcal Serogroup B (MenB) Vaccines in Adolescents and Young Adults

Background

US adolescents and young adults are at particular risk of invasive meningococcal disease (IMD). In 2018, menincococcal serogroup B was responsible for 36% of IMD cases in the US overall and for 66% of cases in adolescents and young adults. This age group is at high risk of IMD during outbreaks, which result in significant response-related costs. MenB vaccine efficacy against IMD relies on its ability to provide broad protection against diverse disease-causing strains. MenB-FHbp (Trumenba) and MenB-4C (Bexsero) are MenB vaccines licensed in the US as 2-dose series with an interval of 6 mo or 1 mo, respectively, recommended in healthy adolescents and young adults. We review available data on vaccine coverage of serogroup B strains.

Methods

A literature review identified relevant information from peer-reviewed publications, congress presentations, and ClinicalTrials.gov. Previously presented but unpublished data from phase 2/3 studies were included.

Results

After 2 MenB-FHbp doses, percentages of adolescents and young adults achieving serum bactericidal activity assay using human complement (hSBA) titers ≥1:8 were 79%–99% for 4 heterologous representative test strains and 71%–97% for 10 additional strains, confirming cross-protection against a diverse strain panel (Figure 1; unpublished data). These 14 heterologous strains collectively represent ~80% of disease-causing strains in the US and Europe. In a published study with limited sample size, 44%–78% of subjects had hSBA titers ≥1:8 against strains from 4 US college outbreaks after 2 MenB-FHbp doses. After 2 MenB-4C doses, percentages of 10–25-year-olds achieving hSBA titers ≥1:5 against 3 reference strains homologous to the vaccine antigen were 82%–93% (published data); 15%–100% of adolescents achieved hSBA titers ≥1:4 against a panel of 14 strains (unpublished data). Of college students who received 2 MenB-4C doses, 53%–93% achieved hSBA titers ≥1:4 against 5 US outbreak strains (4/5 strains had antigenic similarity to MenB-4C; published data).

Conclusion

MenB-FHbp and MenB-4C protect against various serogroup B strains. As for the breadth of coverage provided by these vaccines, available data show that MenB-FHbp elicits robust immune responses to a wide variety of disease-causing strains prevalent in the US (Figure 2).

Disclosures

Tamera Coyne-Beasley, MD, MPH, Pfizer Inc and GlaxoSmithKline (Advisor or Review Panel member) Joseph Bocchini, MD, Pfizer Inc and Dynavax (Advisor or Review Panel member) Alejandro Cane, M.D., Pfizer Inc (Employee, Shareholder) Cindy Burman, PharmD, Pfizer Inc (Employee, Shareholder) Maria J. Tort, PhD, Pfizer Inc (Employee, Shareholder) Jessica Presa, MD, Pfizer Inc (Employee, Shareholder)

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

Non-invasive bladder function measures in healthy, asymptomatic female children and adolescents: A systematic review and meta-analysis

BACKGROUND

Lower urinary tract symptoms (LUTS) are common in children and adolescents. Non-invasive tests evaluating bladder function are generally preferred over invasive tests, yet few studies have explored the range of normative values for these tests in healthy, asymptomatic children.

OBJECTIVE

To define normative reference ranges for non-invasive tests of bladder function in healthy, asymptomatic girls and adolescents.

STUDY DESIGN

A comprehensive search strategy was performed in seven electronic databases through October 2019. English-language studies reporting data on voiding frequency, voided and postvoid residual volumes (PVR) and uroflowmetry results in healthy, asymptomatic girls (mean age ≥ 5 years) were included. Two independent reviewers performed study review, data extraction, and quality assessment. Overall mean estimates and 95% confidence intervals for each bladder function parameter were calculated using random effects models, and 95% normative reference values were estimated.

RESULTS

Ten studies met eligibility criteria for the meta-analysis (n = 2143 girls, age range: 3-18). Mean estimates of maximum voided volume and PVR were 233.4 ml (95% CI 204.3-262.6; n = 1 study) and 8.6 ml (95% CI 4.8-12.4; n = 2 studies) respectively. Pooled mean estimates for uroflowmetry parameters were: 21.5 ml/s (95% CI 20.5-2.5) for maximum flow rate (n = 6 studies), 12.5 ml/s (95% CI 11.2-13.8) for mean flow rate (n = 6 studies), 6.8 s (95% CI 4.4-9.3) for time to maximum flow (n = 3 studies), 15.7 s (95% CI 13.0-18.5) for flow time (n = 3 studies), and 198.7 ml (95% CI 154.2-234.2) for voided volume (n = 9 studies). No studies reported estimates of voiding frequency. Between-study heterogeneity was high (89.0-99.6%).

CONCLUSIONS

Although we were able to calculate pooled mean estimates for several parameters, the small number of included studies and the wide age ranges of participants preclude generalization of reference values to all healthy girls. Further research is needed to determine normative reference values within specific age groups.

Enrolling a rural community pharmacy as a Vaccines for Children provider to increase HPV vaccination: a feasibility study

Background

Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. with over 80 million infected individuals. High-risk strains are associated with 6 different cancers. Although infection is preventable, U.S. vaccination rates remain suboptimal and there are noted disparities between urban and rural communities due to economic barriers, lack of access, and low awareness and education.

Methods

The current pilot study sought to overcome these barriers through an interprofessional collaborative enrolling a community pharmacy in a rural, medically underserved Alabama county as a Vaccines for Children (VFC) provider to provide free vaccines to eligible adolescents. Program evaluation was conducted to determine the intervention’s feasibility. Potential efficacy was assessed by analyzing county-level HPV vaccination uptake and completion rates using state immunization registry data.

Results

Over the 8-month study, 166 total vaccines were administered to 89 adolescents ages 10–18, including 55 doses of HPV vaccine, 53 doses of Tdap vaccine, 45 doses of meningococcal vaccine, and 13 doses of influenza vaccine. Among these adolescents, mean age was 12.6 years old, and 64 (71.9%) were VFC patients. The pharmacy recorded an increase in total vaccine administration of 158.8%, an increase in prescription revenue of 34.8%, and an increase in total revenue by 24.4% during the course of the study, compared to the previous year.

Conclusions

Findings from the current work demonstrate the potential of this strategy and can serve as a blueprint for statewide and national dissemination and implementation to ultimately increase access to vaccination services, increase vaccination rates, and reduce urban-rural vaccine disparities.

School Toileting Environment, Bullying, and Lower Urinary Tract Symptoms in a Population of Adolescent and Young Adult Girls: Preventing Lower Urinary Tract Symptoms Consortium Analysis of Avon Longitudinal Study of Parents and Children

OBJECTIVES

To examine whether the school toilet environment at age 13, including bullying at toilets, is associated with female lower urinary tract symptoms (LUTS) at ages 13 and 19, as little is known about the association among school toilet environment, voiding behaviors, and LUTS in adolescent girls.

METHODS

The sample comprised 3962 female participants from the Avon Longitudinal Study of Parents and Children. At age 13, participants reported on 7 school toilet environment characteristics and a range of LUTS items. At age 19, participants completed the Bristol Female Lower Urinary Tract Symptoms questionnaire.

RESULTS

All toilet environmental factors were associated with at least 1 LUTS outcome at age 13. Holding behavior was associated with all school toilet environmental factors, with odds ratios ranging from 1.36 (95% confidence interval [CI]: 1.05, 1.76) for dirty toilets to 2.38 (95% CI: 1.60, 3.52) for feeling bullied at toilets. Bullying was associated with all daytime LUTS symptoms and nocturia; odds ratios ranged from 1.60 (95% CI: 1.04, 2.07) for nocturia to 2.90 (95% CI: 1.77, 4.75) for urgency. Associations between age 13 school toilets and age 19 LUTS were in the same direction as age 13 LUTS.

CONCLUSION

This is the first examination of associations between school toilets and LUTS. Toileting environments were cross-sectionally associated with LUTS in adolescent girls. While further work is needed to determine whether these associations are causal, school toilet environments are modifiable and thus a promising target for LUTS prevention.

A randomized, open-label, pragmatic study to assess reliever-triggered inhaled corticosteroid in African American/Black and Hispanic/Latinx adults with asthma: Design and methods of the PREPARE trial

BACKGROUND

Asthma prevalence, morbidity, and mortality disproportionately impact African American/Black (AA/B) and Hispanic/Latinx (H/L) communities. Adherence to daily inhaled corticosteroid (ICS), recommended by asthma guidelines in all but the mildest cases of asthma, is generally poor. As-needed ICS has shown promise as a patient-empowering asthma management strategy, but it has not been rigorously studied in AA/B or H/L patients or in a real-world setting. Design and Aim The PeRson EmPowered Asthma RElief (PREPARE) Study is a randomized, open-label, pragmatic study which aims to assess whether a patient-guided, reliever-triggered ICS strategy called PARTICS (Patient-Activated Reliever-Triggered Inhaled CorticoSteroid) can improve asthma outcomes in AA/B and H/L adult patient populations. In designing and implementing the study, the PREPARE research team has relied heavily on advice from AA/B and H/L Patient Partners and other stakeholders. Methods PREPARE is enrolling 1200 adult participants (600 AA/Bs, 600H/Ls) with asthma. Participants are randomized to PARTICS + Usual Care (intervention) versus Usual Care (control). Following a single in-person enrollment visit, participants complete monthly questionnaires for 15 months. The primary endpoint is annualized asthma exacerbation rate. Secondary endpoints include asthma control; preference-based quality of life; and days lost from work, school, or usual activities. Discussion The PREPARE study features a pragmatic design allowing for the real-world assessment of a patient-centered, reliever-triggered ICS strategy in AA/B and H/L patients. Outcomes of this study have the potential to offer powerful evidence supporting PARTICS as an effective asthma management strategy in patient populations that suffer disproportionately from asthma morbidity and mortality.

Evaluation of a Serious Video Game to Facilitate Conversations About Human Papillomavirus Vaccination for Preteens: Pilot Randomized Controlled Trial

Background

In the United States, the most common sexually transmitted infection, human papillomavirus (HPV), causes genital warts and is associated with an estimated 33,700 newly diagnosed cancer cases annually. HPV vaccination, especially for preteens aged 11 to 12 years, is effective in preventing the acquisition of HPV and HPV-associated cancers. However, as of 2018, completion of the 2- or 3-dose HPV vaccination series increased only from 48.6% to 51.1% in teens aged 13 to 17 years, and this increase was observed only in boys. By comparison, 88.7% of teens had more than one dose of the recommended vaccine against tetanus, diphtheria, and acellular pertussis (Tdap), and 85.1% of teens had more than one dose of meningococcal vaccine. Immunizations for Tdap, meningococcal disease, and HPV can occur at the same clinical visit but often do not.

Objective

Vaccination against HPV is recommended for routine use in those aged 11 to 12 years in the United States, yet it is underutilized. We aimed to develop an educational video game to engage preteens in the decision to vaccinate.

Methods

Land of Secret Gardens is a metaphor for protecting seedlings (body) with a potion (vaccine). We screened 131 dyads of parents and preteens from 18 primary practices in North Carolina who had not initiated HPV vaccination. We measured vaccination intentions, story immersion, and game play and documented HPV vaccination rates. A total of 55 dyads were enrolled, and we randomly assigned 28 (21 completed) to play the game and 27 (26 completed) to the comparison group.

Results

In total, 18 preteens reported playing the game. The vaccination self-efficacy score was higher in the comparison group than the intervention group (1.65 vs 1.45; P=.05). The overall mean decisional balance score trended toward greater support of vaccination, although differences between the groups were not significant.. Vaccine initiation and completion rates were higher in the intervention group (22% vs 15%; P=.31) than in the comparison group (9% vs 2%; P=.10), although the difference was not significant.

Conclusions

Video games help preteens in the decision to pursue HPV vaccination. A serious video game on HPV vaccination is acceptable to parents and preteens and can be played as intended. Gamification is effective in increasing preteen interest in HPV vaccination, as game features support decision making for HPV vaccination.

Trial Registration

ClinicalTrials.gov NCT04627298; https://www.clinicaltrials.gov/ct2/show/NCT04627298

Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake

OBJECTIVES

We sought to prioritize interventions for increasing human papillomavirus (HPV) vaccination coverage based on cost-effectiveness from a US state perspective to inform decisions by policy makers.

METHODS

We developed a dynamic simulation model of HPV transmission and progression scaled to a medium-sized US state (5 million individuals). We modeled outcomes over 50 years comparing no intervention to a one-year implementation of centralized reminder and recall for HPV vaccination, school-located HPV vaccination, or quality improvement (QI) visits to primary care clinics. We used probabilistic sensitivity analysis to assess a range of plausible outcomes associated with each intervention. Cost-effectiveness was evaluated relative to a conservative willingness-to-pay threshold; $50 000 per quality-adjusted life-year (QALY) .

RESULTS

All interventions were cost-effective, relative to no intervention. QI visits had the lowest cost and cost per QALY gained ($1538 versus no intervention). Statewide implementation of centralized reminder and recall cost $28 289 per QALY gained versus QI visits. School-located vaccination had the highest cost but was cost-effective at $18 337 per QALY gained versus QI visits. Scaling to the US population, interventions could avert 3000 to 14 000 future HPV cancers. When varying intervention cost and impact over feasible ranges, interventions were typically preferred to no intervention, but cost-effectiveness varied between intervention strategies.

CONCLUSIONS

Three interventions for increasing HPV vaccine coverage were cost-effective and offered substantial health benefits. Policy makers seeking to increase HPV vaccination should, at minimum, dedicate additional funding for QI visits, which are consistently effective at low cost and may additionally consider more resource-intensive interventions (reminder and recall or school-located vaccination).

Toward Optimal Communication About HPV Vaccination for Preteens and Their Parents: Evaluation of an Online Training for Pediatric and Family Medicine Health Care Providers

OBJECTIVE

Health care provider recommendation is a key determinant of human papillomavirus (HPV) vaccination. We developed an online training program for providers that addressed vaccine guidelines, hesitancy to strongly recommend the vaccine, and reluctance to discuss HPV infection as a sexually transmitted infection.

DESIGN

Single-group evaluation with 3 waves. Providers completed a 29-item electronic survey with closed and open-ended response options after course completion.

SETTING

Pediatric and family medicine practices in North Carolina.

PARTICIPANTS

Prescribing clinicians (MD, DO, family nurse practitioner, physician assistant) who serve preteens aged 11 to 12 years. In wave 3, we expanded our communities to include nursing and medical staff.

INTERVENTION

An asynchronous online course to promote preteen HPV vaccination. Topics included HPV epidemiology, vaccine recommendations from the Advisory Committee on Immunization Practices (ACIP), preteen-provider-parent communication, topics about hesitancy to seek vaccination, subjects related to sexual health, and practice-level strategies to increase vaccination rates. The course, approved for 12 CME and CNE credits, was live for 4 weeks and available on-demand for 3 additional months.

MAIN OUTCOME MEASURES

Provider-reported change in vaccine communication, perceptions of course content in improving practice, and satisfaction with materials.

RESULTS

A total of 113 providers from 25 practices enrolled in the course and 69 (61%) completed an evaluation. Providers spent an average of 6.3 hours on the course and rated the CDC (Centers for Disease Control and Prevention)-ACIP Web site and multiple resources on hesitancy and communication about sexually transmitted infection vaccines most highly of all materials across the 3 waves. Almost all (96%) agreed the course will improve their practice. About half of all participants said they were either "much more likely" (28%) or "more likely" (19%) to recommend the vaccine after course participation.

CONCLUSIONS

An online format offers a highly adaptable and acceptable educational tool that promotes interpersonal communication and practice-related changes known to improve providers' vaccine uptake by their patients.

What types of dissemination of information occurred between researchers, providers and clinical staff while implementing an asthma shared decision-making intervention: a directed content analysis

OBJECTIVE

To qualitatively analyse different types of dissemination of information during monthly group calls between researchers, providers and clinical staff used to establish best practices for implementing an asthma shared decision-making (SDM) intervention. Evaluating dissemination of information can provide a better understanding of how best practices are shared, informing implementation approaches to improve the uptake of new evidence and overcome barriers.

SETTING

10 primary care practices in North Carolina.

PARTICIPANTS

Providers and clinical staff participated in monthly group phone calls with researchers to share best practices during implementation of a SDM intervention for asthma patients.

DESIGN

The research team transcribed and coded statements using content analysis into three different knowledge types: Knowledge Position, Knowledge Form and Knowledge Object. Knowledge Objects were further classified using directed content analysis where the research team interpreted the content objects through a classification process of identifying themes or patterns to describe three different types of dissemination of information: (A) Confirmation of Existing Knowledge, (B) Generation of New Knowledge and (C) Spreading of New Knowledge.

RESULTS

Across the 8 transcripts, 4 Knowledge Positions, 7 Knowledge Forms and 18 types of Knowledge Objects were identified. From the Knowledge Objects, Confirmation of Existing Knowledge occurred during the training of participating practices. The review also identified Generation of New Knowledge by providers and clinical staff raised in these calls. This Generation of New Knowledge was later documented being used by other practices with the identification of Spreading of New Knowledge.

CONCLUSION

The research team described the types of dissemination of information that occurred between researchers, providers and clinical staff during implementation of an asthma SDM intervention. Both Confirmation of Existing Knowledge and Generation of New Knowledge in response to barriers occurred. These exploratory dissemination of information results provide additional mechanisms for evaluating implementation science.

TRIAL REGISTRATION NUMBER

NCT02047929; Post-results.

Adherence to adding inhaled corticosteroids to rescue therapy in a pragmatic trial with adults with asthma: A pilot study

BACKGROUND

Underuse of guideline-recommended inhaled corticosteroids (ICS) controller therapy is a risk factor for greater asthma burden. ICS concomitantly used with rescue inhalers (Patient-Activated Reliever-Triggered ICS ['PARTICS']) reduced asthma exacerbations in efficacy trials, but whether PARTICS is effective in pragmatic trials is unknown.

OBJECTIVE

We conducted this pilot to determine the feasibility of executing a large-scale pragmatic PARTICS trial and to improve study protocols.

METHODS

Four sites recruited 33 Hispanic or black adults with persistent asthma, randomized them approximately 3:1 to intervention or usual care, and followed them for 12 weeks. All participants received asthma guideline-based educational videos; intervention participants received video-based instructions on implementing PARTICS plus usual medications. The study involved 1 randomization visit and monthly questionnaires. Timely questionnaire responses (±2 weeks) were monitored. Participants underwent qualitative phone interviews to assess self-reported adherence to PARTICS and understand barriers to completing study procedures.

RESULTS

Timely questionnaire response rates were 61%, 64%, and 70% at 4, 8, and 12 weeks, respectively. Self-reported adherence to PARTICS was 76% (95% confidence interval [CI], 58%-94% [n = 21]), 88% (95%CI, 72%-100% [n = 16]), and 62% (95%CI, 36%-88% [n = 13]) at weeks 1, 6, and 12, respectively. Barriers to completing study procedures included difficulties with questionnaire access, remembering to use ICS and rescue inhalers together, and obtaining refills. Only 22% of participants recognized their short-acting bronchodilator as "reliever" or "rescue."

CONCLUSION

Recruitment was feasible within the allocated period. Adherence to PARTICS was incomplete, questionnaire completion was suboptimal, and common rescue inhaler nomenclature usage was limited. We have modified the full study protocol to attempt to improve adherence to PARTICS and minimize barriers to study procedures.

CLINICAL TRIALS REGISTRATION

pilot study for 'PeRson EmPowered Asthma Relief' (PREPARE, NCT02995733).

Black Pastors' Views on preaching about sex: barriers, facilitators, and opportunities for HIV prevention messaging

OBJECTIVES

Despite the disproportionately high rates of heterosexually transmitted HIV infection among US Blacks and ongoing need for effective inexpensive behavioral interventions, the use of sermons as an HIV prevention tool in Black churches has received little research attention. The Black church plays an important role in Black communities and is a potential ally in development and delivery of sexual risk prevention messages. The objective of this study was to examine Black pastors' thoughts about whether sermons should address issues related to heterosexual relationships - and the barriers and facilitators to discussing these topics in a sermon setting.

DESIGN

We conducted in-depth semi-structured, individual interviews among 39 pastors of Black churches in North Carolina and analyzed the interview data using thematic analysis strategies based on grounded theory.

RESULTS

Pastors expressed widely ranging opinions, especially about discussion of condom use, but generally agreed that sermons should discuss marriage, abstinence, monogamy, dating, and infidelity - behaviors that impact sexual networks and HIV transmission. The major barriers to incorporation of these subjects into sermons include the extent to which a concept undermines their religious beliefs and uncertainty about how to incorporate it. However, scriptural support for a prevention message and the pastor's perception that the message is relevant to the congregation facilitate incorporation of related topics into sermons.

CONCLUSIONS

These findings have implications for the potential utility of sermons as an HIV prevention tool and suggest that it is possible for public health professionals and pastors of Black churches to form partnerships to develop messages that are consonant with pastors' religious convictions as well as public health recommendations.

A systematic literature review to examine the potential for social media to impact HPV vaccine uptake and awareness, knowledge, and attitudes about HPV and HPV vaccination

This article summarizes the findings from a systematic literature review to examine how social media may impact HPV vaccine uptake and HPV and HPV vaccine related awareness, knowledge, and attitudes. Study inclusion criteria was original data collection of at least one data point about social media and HPV and/or HPV vaccination, such that the study provided insight into how social media content may influence HPV and HPV vaccine related knowledge, attitudes, and/or behaviors. A total of 44 relevant articles were identified using the following databases: PubMed, PsycINFO, Communication Source, Sociological Abstracts, Business Source Elite, and the Educational Resources Information Center (ERIC). Most studies analyzed the valence, type, and frequency of social media content about HPV vaccination, and some found associations between potential exposure to negative, anti-vacc`11qine content and lower vaccination rates. Some studies that included primary human subject data collection found that engagement with HPV related social media content was associated with improved awareness and knowledge but not with increased vaccine uptake. The literature overall is lacking in systematic and rigorous research examining the effects of social media on HPV related knowledge, attitudes, and behaviors and needs further examination as social media increasingly becomes a source of health information.

"What I wish my doctor knew about my life": Using photovoice with immigrant Latino adolescents to explore barriers to healthcare

BACKGROUND

Latinos in the USA have reported more frequent discriminatory treatment in healthcare settings when compared to their White counterparts. In particular, foreign-born Latinos report discrimination more than Latinos born in the USA. Such patient-reported racial/ethnic discrimination appears to contribute to specific health consequences, including treatment seeking delays, interruptions in care, and medical mistrust. Immigrant Latino adolescents in the USA experience a variety of health disparities, yet little is known about their views of the healthcare experience, their perceptions of discriminatory treatment, or ways in which they would like their relationships with healthcare providers to be different.

METHODS

This work, based in a larger interdisciplinary social work-led initiative, used photovoice with two groups of immigrant Latino adolescents to explore the topic "what I wish the doctor knew about my life." The findings were used to engage healthcare stakeholders as part of a pilot intervention aimed at decreasing provider bias toward immigrant Latino youth.

RESULTS/DISCUSSION

Findings illuminated ways that the immigrant experience affects the lives and health of Latino adolescents in North Carolina. To improve their health, it is critical to understand, from their perspectives, the ways their lives can be complicated by experiences of migration, stereotypes, and cross-cultural communication challenges and how their interactions with authority figures in one sector, such as education, influence interactions in health care. Understanding the healthcare barriers faced by immigrant Latino youth is critical to any effort to improve the system of care for immigrant Latino populations.

Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management

Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57-1.04]; 0.83[0.66-1.07]), hospitalizations (OR [95%CI] = 1.30[0.59-2.89]; 1.40 [0.68-3.06]), or oral steroids (OR [95%CI] =0.95[0.79-1.15]; 1.03[0.81-1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.

Development and Evaluation of a Social Media Health Intervention to Improve Adolescents' Knowledge About and Vaccination Against the Human Papillomavirus

This study describes the formative research, execution, and evaluation of a social media health intervention to improve adolescents’ knowledge about and vaccination against human papillomavirus (HPV). Based on the results from formative focus groups with adolescents (N = 38) to determine intervention feasibility, parameters, and message preferences, we developed and conducted a pretest/posttest evaluation of a 3-month social media health intervention for adolescents who had not completed the HPV vaccine series (N = 108). Results revealed that adolescents who fully engaged with the intervention improved in their knowledge compared with a control group, and many were also likely to have interpersonal discussions with others about what they learned. Adolescents are generally interested in receiving information about HPV and the vaccine, along with other relevant health information, through social media channels if messages are considered interesting, their privacy is protected, and the source is credible.

Determinants of the receipt of the 9-valent human papillomavirus vaccine in the first year after introduction in North Carolina

OBJECTIVES

The objective of this study was to describe the transition from bi- and quadrivalent HPV vaccines to 9vHPV in aggregate and identify determinants of the receipt of 9vHPV among youth following the introduction of 9vHPV in North Carolina.

METHODS

The study used a retrospective cohort design with data from the North Carolina Immunization Registry (NCIR). Our sample included all doses of HPV vaccine administered between July 2015 and October 2016 to age-eligible youth (ages 9-17). We used a logistic regression model to associate individual child-level and ZIP Code Tabulation Area (ZCTA)-level characteristics with an indicator variable for receiving 9vHPV (vs. other HPV vaccines).

RESULTS

Youth receiving the HPV vaccine were more likely to receive 9vHPV if they lived in a ZCTA with a larger age-eligible (i.e., 9-17) population, a health professional shortage area, or a higher number of annual outpatient visits per capita. They were less likely to receive 9vHPV if they were older, received a publicly-funded dose, or lived in a ZCTA with a higher percentage of the population with less than a high-school education or a higher number of religious organizations.

CONCLUSIONS

While the transition from other HPV vaccines to 9vHPV was relatively quick, there were disparities in the diffusion of 9vHPV across North Carolina.

Developing a Serious Videogame for Preteens to Motivate HPV Vaccination Decision Making: Land of Secret Gardens

INTRODUCTION

Vaccination against human papillomavirus (HPV) is routinely recommended for ages 11-12, yet in 2016 only 49.5% of women and 37.5% of men had completed the three-dose series in the United States. Offering information and cues to action through a serious videogame for preteens may foster HPV vaccination awareness, information seeking, and communication.

MATERIALS AND METHODS

An iterative process was used to develop an interactive videogame, Land of Secret Gardens. Three focus groups were conducted with 16 boys and girls, ages 11-12, for input on game design, acceptability, and functioning. Two parallel focus groups explored parents' (n = 9) perspectives on the game concept. Three researchers identified key themes.

RESULTS

Preteens wanted a game that is both entertaining and instructional. Some parents were skeptical that games could be motivational. A back-story about a secret garden was developed as a metaphor for a preteen's body and keeping it healthy. The goal is to plant a lush secret garden and protect the seedlings by treating them with a potion when they sprout to keep them healthy as they mature. Points to buy seeds and create the potion are earned by playing mini-games. Throughout play, players are exposed to messaging about HPV and the benefits of the vaccine. Both boys and girls liked the garden concept and getting facts about HPV. Parents were encouraged to discuss the game with their preteens.

CONCLUSION

Within a larger communication strategy, serious games could be useful for engaging preteens in health decision making about HPV vaccination.

Impact of introduction of the 9-valent human papillomavirus vaccine on vaccination coverage of youth in North Carolina

OBJECTIVES

The objective of this study was to evaluate the impact of introduction of 9vHPV vaccine on HPV vaccination uptake (doses per capita) and initiation (≥1 doses), completion (≥3 doses) and compliance (≥3 doses within 12 months) by adolescents.

METHODS

We used a retrospective cohort analysis using North Carolina Immunization Registry (NCIR) data from January 2008 through October 2016. The sample included Vaccines for Children eligible adolescents aged 9 to 17 years in 2016, for whom the NCIR contains complete vaccination history. We applied an interrupted time series design to measure associations between ZIP Code Tabulation Area (ZCTA)-level HPV vaccination outcomes over time with the introduction of 9vHPV in North Carolina (NC) in July 2015.

RESULTS

Each outcome displayed a linear upward trend over time with large seasonal spikes near August of each year, corresponding to the time when adolescents often receive other vaccines required for school entry. After accounting for these underlying trends, introduction of 9vHPV was not associated with a change in publicly funded HPV vaccination rates in NC.

CONCLUSIONS

Our results indicate that 9vHPV substituted for 4vHPV in the first year after release in NC, but the release of 9vHPV was not associated with an overall change in HPV vaccination.

Making a difference in medical trainees' attitudes toward Latino patients: A pilot study of an intervention to modify implicit and explicit attitudes

Negative attitudes and discrimination against Latinos exist in the dominant U.S. culture and in healthcare systems, contributing to ongoing health disparities. This article provides findings of a pilot test of Yo Veo Salud (I See Health), an intervention designed to positively modify attitudes toward Latinos among medical trainees. The research question was: Compared to the comparison group, did the intervention group show lower levels of implicit bias against Latinos versus Whites, and higher levels of ethnocultural empathy, healthcare empathy, and patient-centeredness? We used a sequential cohort, post-test design to evaluate Yo Veo Salud with a sample of 69 medical trainees. The intervention setting was an academic medical institution in a Southeastern U.S. state with a fast-growing Latino population. The intervention was delivered, and data were collected online, between July and December of 2014. Participants in the intervention group showed greater ethnocultural empathy, healthcare empathy, and patient-centeredness, compared to the comparison group. The implicit measure assessed four attitudinal dimensions (pleasantness, responsibility, compliance, and safety). Comparisons between our intervention and comparison groups did not find any average differences in implicit anti-Latino bias between the groups. However, in a subset analysis of White participants, White participants in the intervention group demonstrated a significantly decreased level of implicit bias in terms of pleasantness. A dose response was also founded indicating that participants involved in more parts of the intervention showed more change on all measures. Our findings, while modest in size, provide proof of concept for Yo Veo Salud as a means for increasing ethno-cultural and physician empathy, and patient-centeredness among medical residents and decreasing implicit provider bias toward Latinos.

Patient reminder and recall interventions to improve immunization rates

BACKGROUND

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population-based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient-oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.

OBJECTIVES

To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.

SELECTION CRITERIA

We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization-focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no-intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media-based activities aimed at promoting immunizations, or simple practice-based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before-after studies. We present pooled results for randomized trials using the random-effects model.

MAIN RESULTS

The 75 included studies involved child, adolescent, and adult participants in outpatient, community-based, primary care, and other settings in 10 countries.Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.Three types of single-method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single-method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non-influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).

AUTHORS' CONCLUSIONS

Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.

Community Advisory Boards Guiding Engaged Research Efforts within a Clinical Translational Sciences Award: Key Contextual Factors Explored

BACKGROUND

Engaging stakeholders in research carries the promise of enhancing the research relevance, transparency, and speed of getting findings into practice. By describing the context and functional aspects of stakeholder groups, like those working as community advisory boards (CABs), others can learn from these experiences and operationalize their own CABs. Our objective is to describe our experiences with diverse CABs affiliated with our community engagement group within our institution's Clinical Translational Sciences Award (CTSA). We identify key contextual elements that are important to administering CABs.

METHODS

A group of investigators, staff, and community members engaged in a 6-month collaboration to describe their experiences of working with six research CABs. We identified the key contextual domains that illustrate how CABS are developed and sustained. Two lead authors, with experience with CABs and identifying contextual domains in other work, led a team of 13 through the process. Additionally, we devised a list of key tips to consider when devising CABs.

RESULTS

The final domains include (1) aligned missions among stakeholders (2) resources/support, (3) defined operational processes/shared power, (4) well-described member roles, and (5) understanding and mitigating challenges. The tips are a set of actions that support the domains.

CONCLUSIONS

Identifying key contextual domains was relatively easy, despite differences in the respective CAB's condition of focus, overall mission, or patient demographics represented. By contextualizing these five domains, other research and community partners can take an informed approach to move forward with CAB planning and engaged research.