County-Level Factors Associated With Influenza and COVID-19 Vaccination in Indiana, 2020‒2022

Objectives. To assess COVID-19 and influenza vaccination rates across Indiana's 92 counties and identify county-level factors associated with vaccination. Methods. We analyzed county-level data on adult COVID-19 vaccination from the Indiana vaccine registry and 2021 adult influenza vaccination from the Centers for Disease Control and Prevention. We used multiple linear regression (MLR) to determine county-level predictors of vaccinations. Results. COVID-19 vaccination ranged from 31.2% to 87.6% (mean = 58.0%); influenza vaccination ranged from 33.7% to 53.1% (mean = 42.9%). In MLR, COVID-19 vaccination was significantly associated with primary care providers per capita (b = 0.04; 95% confidence interval [CI] = 0.02, 0.05), median household income (b = 0.23; 95% CI = 0.12, 0.34), percentage Medicare enrollees with a mammogram (b = 0.29; 95% CI = 0.08, 0.51), percentage uninsured (b = -1.22; 95% CI = -1.57, -0.87), percentage African American (b = 0.31; 95% CI = 0.19, 0.42), percentage female (b = -0.97; 95% CI = -1.79, ‒0.15), and percentage who smoke (b = -0.75; 95% CI = -1.26, -0.23). Influenza vaccination was significantly associated with percentage uninsured (b = 0.71; 95% CI = 0.22, 1.21), percentage African American (b = -0.07; 95% CI = -0.13, -0.01), percentage Hispanic (b = -0.28; 95% CI = -0.40, -0.17), percentage who smoke (b = -0.85; 95% CI = -1.06, -0.64), and percentage who completed high school (b = 0.54; 95% CI = 0.21, 0.87). The MLR models explained 86.7% (COVID-19) and 70.2% (influenza) of the variance. Conclusions. Factors associated with COVID-19 and influenza vaccinations varied. Variables reflecting access to care (e.g., insurance) and higher risk of severe disease (e.g., smoking) are notable. Programs to improve access and target high-risk populations may improve vaccination rates. (Am J Public Health. 2024;114(4):415-423. https://doi.org/10.2105/AJPH.2023.307553).

Enhancing Uterine Fibroid Care: Clinician Perspectives on Diagnosis, Disparities, and Strategies for Improving Health Care

Objective

To explore clinicians' perspectives on diagnosing, treating, and managing uterine fibroids, identifying gaps and challenges in health care delivery, and offering recommendations for improving care.

Materials and Methods

A qualitative design was used to conduct 14 semistructured interviews with clinicians who treat fibroid patients in central Indiana. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis techniques. Constant comparative analysis was used to identify emergent themes.

Results

Four themes emerged. (1) Lack of patient fibroid awareness: Patients lacked fibroid awareness, leading to challenges in explaining diagnoses and treatment. Misconceptions and emotional distress highlighted the need for better education. (2) Inequities in care and access: Health care disparities affected Black women and rural patients, with transportation, scheduling delays, and financial constraints hindering access. (3) Continuum of care: Clinicians prioritized patient-centered care and shared decision-making, tailoring treatment based on factors like severity, location, size, cost, fertility goals, and recovery time. (4) Coronavirus disease 2019 (COVID-19) impact: The pandemic posed challenges and opportunities, prompting telehealth adoption and consideration of nonsurgical options.

Conclusions

Clinician perspectives noted patient challenges with fibroids, prompting calls for enhanced education, interdisciplinary collaboration, and accessible care to address crucial aspects of fibroid management and improve women's well-being.

Practice Implications

Clinicians identified a lack of patient awareness and unequal access to fibroid care, highlighting the need for improved education and addressing disparities. Findings also emphasized the importance of considering multidimensional aspects of fibroid care and adapting to challenges posed by the COVID-19 pandemic, recommending broader education, affordability, interdisciplinary collaboration, and research for better fibroid health care.

Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status

Providers' recommendation is among the strongest predictors to patients engaging in preventive care. Therefore, the aim of this study was to compare providers' Hepatitis C Virus (HCV) screening recommendation quality between high-risk and average-risk patients to determine if providers are universally recommending HCV screening, regardless of risk behaviors. This cross-sectional survey of 284 Indiana providers in 2020 assessed provider characteristics, HCV screening recommendation practices (strength, presentation, frequency, timeliness), self-efficacy, and barriers to recommending HCV screening. T-test and Chi-square compared recommendation practices for high-risk and average-risk patients. Prevalence ratios were calculated for variables associated with HCV recommendation strength comparing high-risk and average-risk patients. Logistic regression analyses examined factors associated with HCV recommendation strength for high- and average-risk patients, with odds ratios. Compared to average-risk patients, high-risk patients received higher proportion of HCV recommendations that were strong (70.4 % v. 42.4 %), routine (61.9 % v. 55.6 %), frequent (37.7 % v. 28 %), and timely (74.2 % v. 54.9 %) (P-values < 0.001). Compared to average-risk patients, providers with high-risk patients had a lower percentage of giving a strong recommendation if they were nurse practitioner (PR = 0.49). For high-risk patients, providers with higher self-efficacy (aOR = 2.16;95 %CI = 0.99-4.69) had higher odds, while those with higher perceived barriers (aOR = 0.19;95 %CI = 0.09-0.39) and those with an internal medicine specialty compared to family medicine (aOR = 0.22;95 %CI = 0.08-0.57) had lower odds of giving a strong recommendation. These data suggest providers are not universally recommending HCV screening for all adults regardless of reported risk. Future research should translate these findings into multilevel interventions to improve HCV screening recommendations regardless of patient risk status.

County-level correlates of completed HPV vaccination in Indiana

The Healthy People 2030 goal is for 80% of all adolescents to complete their HPV vaccination series. Per the 2021, National Immunization Survey-Teen (NIS-Teen), 61.7% of adolescents have completed the series, and Indiana lags below the national average (55.2%). The present study estimated the 2-dose HPV vaccine series completion rates across Indiana counties among individuals aged 9-14 years who received their first dose of vaccine and determined what factors were associated with series completion at the county level. The association of county-level sociodemographic and health measures with series completion was also examined. Data were extracted from the Indiana Immunization Information System (IIS), administered by the Indiana Department of Health. All vaccine providers are required to report all immunizations to the system for any patient under age 19 years. All Indiana children ages 9-14 years at the time of first dose who had initiated HPV vaccination in 2017 or 2018 were included. Two-dose series completion was evaluated through October of 2020, allowing a minimum gap of 22 months from first dose administration. All statistical analyses were conducted at the county-level. The Indiana HPV vaccination series completion rate among individuals that received the first dose was on average 73% across counties, ranging from 55.7% to 90.4%. Higher series completion was positively associated with primary care providers per capita, participation in mammography screening among Medicare enrollees, median household income, life expectancy, percentage of residents with some college, percentage of adults up-to-date with colonoscopy screening, and percentage of adults with flu vaccine. There was wide variability in series completion across Indiana counties. HPV series completion was associated with county-level sociodemographic and health measures, particularly variables reflecting difficulties with access to care and lack of financial resources.

Factors related to human papillomavirus vaccine uptake and intentions among adults aged 18-26 and 27-45 years in the United States: A cross-sectional study

BACKGROUND

The current study examined self-reported human papillomavirus (HPV) vaccination uptake and intentions, and associations with psychosocial constructs among United States adults aged 18 to 26 and 27 to 45 years.

METHODS

Data were collected via an online survey from participants recruited from a research panel. Outcomes were HPV vaccination uptake and intentions. Multivariable binary and ordered logistic regression models were used to examine associations between HPV vaccination outcomes and psychosocial constructs, sociodemographics, and previous health behaviors.

RESULTS

HPV vaccination uptake in both age cohorts (N =  2722) was associated with multiple variables, including but not limited to: provider recommendation (adjusted odds ratio [aOR], 11.63 [95% CI, 7.70-17.56] and aOR, 14.26 [95% CI, 9.52-21.38], for those aged 18 to 26 and 27 to 45 years, respectively) and positive HPV vaccine attitudes (aOR, 2.40 [95% CI, 1.70-3.40] and aOR, 1.46 [95% CI,1.06-2.02]). Among those who did not report or were unsure of prior HPV vaccination (N =1894), only 4.6% and 8.1% (aged 18-26 and 27-45 years, respectively) reported being very likely to receive the HPV vaccine in the next year. Increased intentions were associated with more positive vaccine attitudes (aOR, 2.45 [95% CI, 1.91-3.15] and aOR, 2.19 [95% CI, 1.72-2.78]) and provider recommendation (yes vs no; aOR, 1.97 [95% CI, 1.38-2.83] and aOR, 1.82 [95% CI, 1.31-2.52]; don't know/can't remember vs no; aOR, 1.38 [95% CI, 1.03-1.84] and aOR, 1.60 [95% CI, 1.17-2.18]). Sociodemographics and health behaviors associated with increased intentions differed for each age cohort.

CONCLUSIONS

Individual and interpersonal factors were associated with HPV vaccination uptake and intentions. Findings reveal the need for targeted interventions to improve HPV vaccination rates among these age groups.

Development and Feasibility Testing of a Multilevel Intervention to Increase Hepatitis C Virus Screening Among Baby Boomers in Primary Care

Chronic infection with hepatitis C virus (HCV) results in an increased risk of cirrhosis and hepatocellular carcinoma (HCC). Only 15% of baby boomers (born 1945-1965) have ever been screened. We aimed to develop a multilevel intervention to increase HCV screening for baby boomers in a primary care setting. This study included two phases: intervention development (phase 1) and feasibility testing (phase 2). In phase 1, we partnered with a Community Advisory Board and a Provider Advisory Board to develop a multilevel intervention to increase HCV screening to be delivered to both providers and patients in primary care. Phase 2 assessed intervention feasibility, acceptability, and usability by conducting Concurrent Think Aloud (CTA) interviews and surveys using previously validated scales with patients (n = 8) and providers (n = 7). Phase 1 results: The patient-level intervention included a mailed reminder letter and CDC pamphlet and a 7-min in-clinic educational video. The provider-level intervention included a 30-min educational session and monthly performance feedback e-mails. Phase 2 results: Qualitatively, both the patient and provider-level intervention were feasible, acceptable, and usable by the target audiences. Quantitatively, on a 1-4 scale, the range of patient-level scores was 3.00-4.00 and provider level was 3.50-4.00 for feasibility, acceptability, and usability. This intervention could improve HCV screening among a high-risk population and therefore reduce HCV-related morbidity and mortality. This project developed a feasible, acceptable, and usable multilevel intervention aimed at increasing HCV screening in primary care.

Factors associated with parental COVID-19 vaccine attitudes and intentions among a national sample of United States adults ages 18-45

PURPOSE

This study explored factors associated with parents' attitudes and intentions to seek information about the COVID-19 vaccine for their children (ages 0-18) and intentions to vaccinate their age-eligible children.

DESIGN AND METHODS

As part of an anonymous online cross-sectional survey, parents' vaccine attitudes, COVID-19 vaccine intentions for their children, health literacy, health numeracy, and sociodemographic variables were assessed. Multivariable ordered logistic regression models identified factors associated with parents' COVID-19 vaccine intentions for their children.

RESULTS

Parents/guardians (n = 963) were mostly White (82.3%), insured (88.0%), and college graduates (57.3%). Men reported higher intentions than women to seek information about the COVID-19 vaccine for their children (p = 0.003) and higher intentions to vaccinate their children (p = 0.049). Parental characteristics associated with increased intentions to have their children vaccinated included higher educational attainment (p < 0.001), more positive general vaccine attitudes (p < 0.001), preference for health information in a language other than English (p = 0.006), higher income (p = 0.048), having health insurance (p = 0.05), health literacy (p = 0.024), and health numeracy (p = 0.049).

CONCLUSIONS

Multiple sociodemographic characteristics including male gender, higher health literacy and numeracy, and language preference are noteworthy factors associated with parental COVID-19 vaccine intentions that could inform the planning and implementation of educational interventions.

PRACTICE IMPLICATIONS

Nurses are important sources of trusted information and play an important role in parent/family health education and in understanding myriad factors that may improve attitudes and enhance readiness toward vaccine uptake. Our findings emphasize the potential value of examining tailored/targeted COVID-19 vaccine education according to key influencing factors.

Impact of the COVID-19 pandemic on human papillomavirus (HPV) vaccination among a national sample of United States adults ages 18-45: A cross-sectional study

To assess how the COVID-19 pandemic affected catch-up HPV vaccination among age-eligible adults (ages 18-45). The current study leverages a national, cross-sectional sample of US adults ages 18-45 years to assess the prevalence and determinants of COVID-19 pandemic-related disruptions to catch-up HPV vaccination in 2021. The sample was restricted to adults intending to receive the HPV vaccine. Multinomial logistic regression analysis was conducted to assess the probability of 1) pandemic-related HPV vaccination disruption and 2) uncertainty about pandemic-related HPV vaccination disruption. Report of 'no pandemic-related HPV vaccination disruption' served as the reference category. Among adults intending to get the HPV vaccine (n = 1,683), 8.6 % reported pandemic-related HPV vaccination disruption, 14.7 % reported uncertainty about vaccination disruption, and 76.7 % reported no disruption. Factors associated with higher odds of pandemic-related vaccination disruption included non-English language preference (OR: 3.20; 95 % CI: 1.99-5.13), being a parent/guardian (OR: 1.77; 95 % CI: 1.18-2.66), having at least one healthcare visit in the past year (OR: 1.97; 95 % CI: 1.10-3.53), being up-to-date on the tetanus vaccine (OR: 1.81; 95 % CI: 1.19-2.75), and being a cancer survivor (OR: 2.57; 95 % CI: 1.52-4.34). Catch-up HPV vaccination for age-eligible adults is a critical public health strategy for reducing HPV-related cancers. While a small percentage of adults reported pandemic-related disruptions to HPV vaccination, certain adults (e.g., individuals with a non-English language preference and cancer survivors) were more likely to report a disruption. Interventions may be needed that increase accessibility of catch-up HPV vaccination among populations with reduced healthcare access during the pandemic.

Clinician practices, knowledge, and attitudes regarding primary human papillomavirus testing for cervical cancer screening: A mixed-methods study in Indiana

Primary human papillomavirus (HPV) testing, in which a high-risk HPV test is administered without cytology, was first included in 2018 US cervical cancer screening guidelines. Subsequent guidelines endorsed primary HPV testing as the preferred method for cervical cancer screening following evidence of its clinical and economic benefits, although many sources still indicate it as an option along with cytology and HPV/Pap co-testing. Primary HPV testing could be key to improving the declining cervical cancer screening rates in the US; however its adoption has been slow as clinicians are hesitant to make the change. Indiana ranks in the top ten states for cervical cancer mortality, with marked race-ethnic disparities in cervical cancer screening and low HPV vaccination rates. To examine clinician practices, knowledge, and attitudes regarding primary HPV testing, in 2021 we conducted an online cross-sectional survey (n = 224) and in-depth interviews (n = 20) with Indiana clinicians practicing cervical cancer screening. Only 3 % reported using primary HPV testing for eligible patients, and only 50 % were willing to adopt it as the preferred cervical cancer screening method for the recommended patient group. In a multivariable logistic regression model, knowledge of the effectiveness (aOR 2.58 [1.41-4.72]) and perceived benefit (aOR 7.35 [3.65-14.81]) of primary HPV testing predicted willingness to adopt. In-depth interviews revealed knowledge gaps, uncertainty, and perceived limitations of this method as the reasons for limited uptake of primary HPV testing. Targeted messages about the benefits and effectiveness may enhance clinician knowledge, acceptance, and adoption.

"I think people should be more aware:" Uterine fibroid experiences among women living in Indiana, USA

OBJECTIVE

To understand healthcare experiences among patients with uterine fibroids (fibroids) across the continuum of care, from early symptoms through diagnosis, treatment, and management, while also investigating health disparities.

METHODS

We conducted 20 semi-structured interviews with patients with fibroids. Interviews were transcribed verbatim and qualitatively analyzed using thematic analysis. Eligible participants were women aged 18 and over, residing within 75 miles of one of the two recruitment locations (Tippecanoe or Marion County) in Indiana, USA.

RESULTS

Women experienced myriad physical symptoms, which often manifested into psychological and sexual disturbances and infiltrated all aspects of daily life. Internet searches were frequently mentioned as their main information source. Fertility became a prominent factor in deciding treatment options. However, health disparities prevented some from receiving quality fibroids healthcare. Some women reported staying home during COVID-19 pandemic facilitated the management of physical symptoms. Overall, participants advocated for greater fibroids awareness and education.

CONCLUSION

Results highlight barriers and facilitators to fibroids-related decisions, behaviors, and outcomes. Translation of research to practice was guided by a combined Social-Ecological Model and social determinants of health framework for development of strategic interventions.

PRACTICE IMPLICATIONS

Interventions should aim to improve fibroids healthcare access, education and awareness, and patient-provider communication for minority, rural, and low socioeconomic status communities disproportionately impacted by fibroids.

Impact of the COVID-19 Pandemic on Women's Health Care Access: A Cross-Sectional Study

Background: There has been limited study of how the COVID-19 pandemic has affected women's health care access. Our study aims to examine the prevalence and correlates of COVID-19-related disruptions to (1) primary care; (2) gynecologic care; and (3) preventive health care among women. Materials and Methods: We recruited 4,000 participants from a probability-based online panel. We conducted four multinomial logistic regression models, one for each of the study outcomes: (1) primary care access; (2) gynecologic care access; (3) patient-initiated disruptions to preventive visits; and (4) provider-initiated disruptions to preventive visits. Results: The sample included 1,285 women. One in four women (28.5%) reported that the pandemic affected their primary care access. Sexual minority women (SMW) (odds ratios [OR]: 1.67; 95% confidence intervals [CI]: 1.19-2.33) had higher odds of reporting pandemic-related effects on primary care access compared to women identifying as heterosexual. Cancer survivors (OR: 2.07; 95% CI: 1.25-3.42) had higher odds of reporting pandemic-related effects on primary care access compared to women without a cancer history. About 16% of women reported that the pandemic affected their gynecologic care access. Women with a cancer history (OR: 2.34; 95% CI: 1.35-4.08) had higher odds of reporting pandemic-related effects on gynecologic care compared to women without a cancer history. SMW were more likely to report patient- and provider-initiated delays in preventive health care. Other factors that affected health care access included income, insurance status, and having a usual source of care. Conclusions: The COVID-19 pandemic disrupted women's health care access and disproportionately affected access among SMW and women with a cancer history, suggesting that targeted interventions may be needed to ensure adequate health care access during the COVID-19 pandemic.

Factors Associated With the Intention to Receive the COVID-19 Vaccine: Cross-sectional National Study

BACKGROUND

The COVID-19 pandemic is an unprecedented public health crisis, and vaccines are the most effective means of preventing severe consequences of this disease. Hesitancy regarding vaccines persists among adults in the United States, despite overwhelming scientific evidence of safety and efficacy.

OBJECTIVE

The purpose of this study was to use the Health Belief Model (HBM) and reasoned action approach (RAA) to examine COVID-19 vaccine hesitancy by comparing those who had already received 1 vaccine to those who had received none.

METHODS

This study examined demographic and theory-based factors associated with vaccine uptake and intention among 1643 adults in the United States who completed an online survey during February and March 2021. Survey items included demographic variables (eg, age, sex, political ideology), attitudes, and health belief variables (eg, perceived self-efficacy, perceived susceptibility). Hierarchical logistic regression analyses were used for vaccine uptake/intent. The first model included demographic variables. The second model added theory-based factors to examine the association of health beliefs and vaccine uptake above and beyond the associations explained by demographic characteristics alone.

RESULTS

The majority of participants were male (n=974, 59.3%), White (n=1347, 82.0%), and non-Hispanic (n=1518, 92.4%) and reported they had already received a COVID-19 vaccine or definitely would when it was available to them (n=1306, 79.5%). Demographic variables significantly associated with vaccine uptake/intent included age (adjusted odds ratio [AOR] 1.05, 95% CI 1.04-1.06), other race (AOR 0.47, 95% CI 0.27-0.83 vs White), and political ideology (AOR 15.77, 95% CI 7.03-35.35 very liberal vs very conservative). The theory-based factors most strongly associated with uptake/intention were attitudes (AOR 3.72, 95% CI 2.42-5.73), self-efficacy (AOR 1.75, 95% CI 1.34-2.29), and concerns about side effects (AOR 0.59, 95% CI 0.46-0.76). Although race and political ideology were significant in the model of demographic characteristics, they were not significant when controlling for attitudes and beliefs.

CONCLUSIONS

Vaccination represents one of the best tools to combat the COVID-19 pandemic, as well as other possible pandemics in the future. This study showed that older age, attitudes, injunctive norms, descriptive norms, and self-efficacy are positively associated with vaccine uptake and intent, whereas perceived side effects and lack of trust in the vaccine are associated with lower uptake and intent. Race and political ideology were not significant predictors when attitudes and beliefs were considered. Before vaccine hesitancy can be addressed, researchers and clinicians must understand the basis of vaccine hesitancy and which populations may show higher hesitancy to the vaccination so that interventions can be adequately targeted.

Hepatitis C Virus Screening: Factors Associated With Test Completion in a Large Academic Health Care System

OBJECTIVES

In 2012, onetime hepatitis C virus (HCV) screening was recommended for all baby boomers (people born during 1945-1965) in the United States, but only 4.0%-12.9% of baby boomers have ever had a screening ordered by a health care provider. This study examined the HCV screening prevalence among adult patients in a large academic health care system and assessed factors associated with the completion of screening when ordered for baby boomers.

METHODS

We defined HCV screening completion as the completion of an HCV antibody test when it was ordered. We used electronic health records to examine HCV screening completion rates among adults (N = 106 630) from August 1, 2015, through July 31, 2020, by birth cohort. Among baby boomers whose health care provider ordered HCV screening, we examined frequency and percentages of HCV screening completion by sociodemographic and clinical characteristics. We conducted univariate and multivariable logistic regression analyses to assess factors associated with HCV screening completion among baby boomers.

RESULTS

During the study period, 73.0% of baby boomers completed HCV screening when it was ordered. HCV completion did not differ by sex or race and ethnicity among baby boomers. Baby boomers with Medicare supplemental health insurance compared with commercial health insurance (adjusted odds ratio [aOR] = 1.87) and those seeing only advanced practice professionals compared with specialty care physicians (aOR = 2.24) were more likely to complete HCV screening when it was ordered.

CONCLUSIONS

Noncompletion of HCV screening is one of many barriers along the HCV treatment continuum. Our findings suggest a need for interventions targeting systems, health care providers, and patients to increase HCV screening rates in the United States.

COVID-19 vaccine behaviors and intentions among a national sample of United States adults ages 18-45

BACKGROUND

Vaccination for SARS-CoV-2, the virus that causes COVID-19 illness, is an important public health tool to reduce hospitalizations and deaths.

PURPOSE

This report focuses on intentions and behaviors related to COVID-19 vaccination among United States (U.S.) adults ages 18-45.

METHODS

From February 25-March 24, 2021, we conducted an online survey assessing COVID-19 vaccine intentions and behaviors, health beliefs, vaccine attitudes, and sociodemographic characteristics. Participants were adults aged 18-45, living throughout the U.S. with oversampling in Florida, panelists of a research panel company directly or via verified partners, and able to read, write, and understand English. Associations between COVID-19 vaccination uptake, intentions, and other study variables were examined through multivariable logistic and proportional odds regression analyses.

RESULTS

Among participants in the final analytic sample (n = 2722), 18% reported having received at least one dose of a COVID-19 vaccine. Approximately 31% of unvaccinated participants reported strong intentions to receive a COVID-19 vaccine in the next year, whereas 35% reported strong intentions to receive a COVID-19 vaccine if it were strongly recommended by a healthcare provider. All COVID-19 vaccination outcomes were associated with male gender, sexual minority status, higher levels of education, and previous influenza vaccination. All vaccination intention outcomes were associated with vaccine attitudes and geographic region. Vaccination status and intentions were differentially associated with multiple additional sociodemographic, attitudinal, and/or healthcare experience variables.

CONCLUSIONS

Several demographic variables, vaccine attitudes, and healthcare experiences were found to contribute to COVID-19 vaccine receipt and intentions. Targeted efforts are necessary to increase uptake of the vaccine in the U.S.

Perceptions of the ethical permissibility of strict travel restrictions to mitigate transmission of SARS-CoV-2

Although there has been extensive exploration of public opinion surrounding many non-pharmaceutical interventions (NPIs) aimed at mitigating transmission of SARS-CoV-2 (e.g. mask-wearing and social distancing), there has been less discussion of the public's perception of the ethical appropriateness other NPIs. This paper presents the results of a survey of U.S. adults' opinions of the ethical permissibility of both state-to-state and international travel restrictions to mitigate transmission of SARS-CoV-2. Our research revealed overall high agreement with the ethical permissibility of both state-to-state and international travel restrictions, though we saw significant difference across political party affiliation and conservative/liberal ideologies. Other factors associated with agreement with state-to-state travel restrictions included increasing education, increasing income, and both high and low commitment altruism. When considering international travel restrictions, income, education, and low commitment altruism were associated with increased agreement with the ethical permissibility of international travel restrictions. Ethical analysis and implications are explored.

Obstetrician/gynecologists' HPV vaccination recommendations among women and girls 26 and younger

Background

Obstetrician/gynecologists (OB/GYNs) are well poised to vaccinate girls and young women against HPV, however little is known about if and how they recommend the HPV vaccine. This study aims to understand factors associated with strong and frequent HPV vaccine recommendations among OB/GYNs for patients 26 years and younger.

Methods

224 practicing U.S. OB/GYNs were surveyed for how strongly and frequently they recommend the HPV vaccine to patients 26 and younger. Provider beliefs, knowledge, and preferences surrounding the vaccine, as well as clinic and patient-level variables were examined as covariates. We then examined the relationships using multivariable logistic regression analyses.

Results

Of the 224 respondents, 205 were included in the analysis, with 57% (n = 116) reporting strongly and frequently recommending the HPV vaccination to eligible patients 26 and younger. The regression showed two provider beliefs and two clinic-level attributes to be strongly associated with strong and frequent recommendations. Being a strong and frequent recommender was positively associated with believing other gynecologists frequently recommend the vaccine (aOR 24.33 95%CI[2.56-231.14]) and believing that 50% or more of their patients are interested in receiving the vaccine (aOR 2.77 95%CI[1.25-6.13]). The clinic-level attributes were having the vaccine stocked (aOR 2.66 95%CI[1.02-6.93]) and suburban (aOR 3.31 95%CI[1.07-10.19]) or urban (aOR 3.54 95%CI[1.07-11.76]) location versus rural.

Conclusions

These findings suggest that OB/GYN peer support and educating OB/GYN about patients' interest in HPV vaccination may improve HPV vaccination. This work can inform clinic-level interventions including stocking the vaccine and focusing improvement efforts on rural clinics.

Association between patient characteristics and HPV vaccination recommendation for postpartum patients: A national survey of Obstetrician/Gynecologists

Human papillomavirus (HPV) vaccination rates in the U.S. are relatively low. Provider recommendation rates for HPV vaccination often vary by patient age and relationship status. Obstetrician/gynecologists (OB/GYNs) represent a key provider group that can recommend the HPV vaccine. This study examined differences in OB/GYN recommendation of HPV vaccination for inpatient postpartum patients by age, parity, and marital status. Data were collected from OB/GYNs nationally via a cross-sectional survey. Participants were randomized to two vignette groups (23-year-old patient or 33-year-old patient). Within each group, participants received 4 vignettes that were identical except for patient marital status (married/not in a committed relationship) and number of children (first/third child), and were asked to indicate HPV vaccination recommendation likelihood on a scale of 0 (definitely would not) to 100 (definitely would). A 2 × 2 × 2 general linear model with repeated measures was used to examine main and interaction effects of patient age, relationship status, and parity. 207 OB/GYNs were included in the final analyses. Recommendation was high for 23-year-old patients (range: 64.5–84.6 out of 100). When marital status and parity were held constant, recommendation likelihood was higher for the younger vs. older patient and was also higher for patients not in a committed relationship, compared to married patients (all p-values < 0.001). Differences in recommendation exist when considering age and relationship status, which provides insight into OB/GYN clinical decision-making. Findings highlight the need to address barriers to HPV vaccination recommendation, including awareness of risk factors to consider when recommending the vaccine.

Removal of medicaid restrictions were associated with increased hepatitis C virus treatment rates, but disparities persist

Despite the release of a growing number of direct-acting antivirals and evolving policy landscape, many of those diagnosed with hepatitis C virus (HCV) have not received treatment. Those from vulnerable populations are at particular risk of being unable to access treatment, threatening World Health Organization (WHO) HCV elimination goals. The aim of this study was to understand the association between direct-acting antivirals approvals, HCV-related policy changes and access to HCV virus treatment in Indiana, and to explore access to treatment by race, birth cohort and insurance type. We performed a retrospective cohort study of adults with HCV from 05/2011-03/2021, using statewide electronic health data. Nine policy and treatment changes were defined a priori. A Lowess curve evaluated treatment trends over time. Monthly screening and treatment rates were examined. Multivariable logistic regression explored predictors of treatment. The population (N = 10,336) was 13.4% Black, 51.8% was born after 1965 and 44.7% was Medicaid recipients. Inflections in the Lowess curve defined four periods: (1) Interferon + DAA, (2) early direct-acting antivirals, (3) Medicaid expansion/optimization and (4) Medicaid restrictions (fibrosis/prescriber) removed. The largest increase in monthly treatment rates was during period 4, when Medicaid prescriber and fibrosis restrictions were removed (2.4 persons per month [PPM] in period 1 to 72.3 PPM in period 4, p < 0.001; 78.0% change in slope). Multivariable logistic regression analysis showed being born after 1965 (vs. before 1945; OR 0.69; 95% 0.49-0.98) and having Medicaid (vs. private insurance; OR 0.47; 95% CI 0.42-0.53), but not race was associated with lower odds of being treated. In conclusion, DAAs had limited impact on HCV treatment rates until Medicaid restrictions were removed. Additional policies may be needed to address HCV treatment-related age and insurance disparities.

Financial hardship is associated with lower uptake of colorectal, breast, and cervical cancer screenings

PURPOSE

Cancer screening uptake differs between groups in ways that cannot be explained by socioeconomic status alone. This study examined associations between material, psychosocial, and behavioral aspects of financial hardship and cancer screening behaviors.

METHODS

Surveys were mailed to 7,979 people ages 18-75 who were seen in the statewide health system in Indiana. Participants reported SES, feelings about finances, and whether they had to forgo medical care due to cost. This was compared to uptake of mammogram, colonoscopy/sigmoidoscopy, and Pap testing in best-fit multivariable logistic regression analyses controlling for demographic and healthcare characteristics.

RESULTS

A total of 970 surveys were returned; the majority of respondents were female (54%), non-Hispanic White (75%), and over 50 years old (76%). 15% reported forgoing medical care due to cost; this barrier was higher among Black than White participants (24% vs. 13%; p = 0.001). In a best fit regression model for colonoscopy/sigmoidoscopy, those who reported they had to forgo medical care due to cost had lower odds of screening (aOR 0.41; 95% CI 0.22-0.74). Forgoing medical care due to cost was not significantly associated with Pap testing in bivariate analyses. For mammogram, forgoing medical care due to cost was significant in bivariate analyses (OR 0.44; 95% CI 0.22-0.88), but was not significant in the multivariable model.

CONCLUSION

Associations between financial hardship and cancer screening suggest the need to reduce barriers to cancer screening even among patients who have access to healthcare. Future research should explore barriers related to both healthcare and personal costs.

Attitudinal Correlates of HPV Vaccination in College Women

This study examined associations between general attitudes toward seeking medical care, attitudes about vaccines/fear of shots, and human papillomavirus (HPV) vaccine uptake and intentions in college women. Hypothesized associations were framed by the Theory of Planned Behavior (TPB). Participants (N = 330, mean age = 18.9 years, 75% White) completed a one-time survey. The majority (61%; n = 201) had received ≥1 HPV vaccine dose. Hierarchical logistic regression examined relationships between attitudes and vaccine uptake. Pearson correlation coefficients and Kruskal-Wallis tests examined associations between attitudes and vaccine intentions. Results were partially consistent with the TPB. In the final model, perceived benefits, but not fear of shots, were associated with vaccine uptake. Among the unvaccinated, perceived benefits, but not fear of shots, were associated with vaccine intentions. Provider recommendation was the strongest predictor of vaccine uptake. Findings suggest interventions incorporating discussion of perceived benefits and provider recommendation may improve HPV vaccine receipt among college women.

Shared decision-making among non-physician healthcare professionals: Enhancing patient involvement in women's reproductive health in community healthcare settings

OBJECTIVE

Shared decision-making (SDM) is an important approach to patient-centered care in women's reproductive healthcare. This study explored SDM experiences and perceptions among non-physician healthcare professionals.

METHODS

We completed 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women's reproductive healthcare. Interviews were audio-recorded, transcribed, and analyzed using an expanded grounded theory framework. Constant comparative analysis identified emergent themes.

RESULTS

Professionals noted community-based healthcare required contextualized decision-making approaches. Results identified listening, decisional ownership, and engagement strategies that enhanced SDM involvement. Findings suggested outcome-oriented SDM concepts, including decisional ownership and investigative listening to enhance SDM. Providers redefined 'challenging' patients as engaged in their healthcare and discussed ways SDM improved healthcare experience beyond one visit.

CONCLUSION

Findings offered insight into actionable and practical strategies for enhancing SDM in community-based women's reproductive healthcare. The findings offer strategies to improve SDM by addressing barriers and facilitators among professionals. This extends SDM beyond the patient-physician dyad and supports broader application of SDM.

PRACTICE IMPLICATIONS

Incorporating professionals' experiences into SDM concepts can enhance SDM in community-based women's healthcare practice, offering opportunities to support a culture of SDM across settings.

Influenza vaccination in the time of COVID-19: A national U.S. survey of adults

Introduction

Decisions about influenza vaccination for fall-winter 2020 were made against the backdrop of the COVID-19 pandemic. During May 2020, the authors examined intended vaccination in the next 12 months in relationship to demographic variables, healthcare attitudes, and personal COVID-19 experiences for two samples of adults--those who did not receive influenza vaccine during the prior 12 months, and those who did.

Methods

In May 2020, a cross-sectional online survey was conducted with a national US sample. Participants reported prior influenza vaccination (yes/no during prior 12 months) and anticipated vaccination (yes/no during next 12 months). Covariates included demographic characteristics (e.g., gender, race-ethnicity, political ideology), general beliefs (e.g., benefits of vaccines, altruistic attitudes), and COVID-19 health beliefs and experiences (COVID-19 worry and severity, perception of COVID-19 as a community threat, knowing someone with COVID-19). For each group, hierarchical multivariable logistic regression was conducted with intent to vaccinate as the outcome.

Results

Among participants (n = 3502), 47% did not receive influenza vaccine in the prior 12 months and 53% had; 25.5% of non-vaccinators and 91.9% of vaccinators intended future vaccination. For non-vaccinators, odds of intending vaccination was associated with race/ethnicity (Hispanics were more likely to intend than white-NH; AOR = 1.74; 95% CI = 1.23–2.4), greater perceived benefits of vaccination (AOR = 2.19; 95% CI = 1.88–2.54), and perception of COVID-19 as a community threat (AOR = 1.91; 95% CI = 1.49–2.45). For vaccinators, odds of intending vaccination was associated with age (AOR = 1.04; 95% CI = 1.03–1.05), race/ethnicity (Black-NH and Other-NH were less likely to intend than white-NH, AOR = 0.60; 95% CI = 0.36–0.999; and AOR = 0.45; 95% CI = 0.24–0.84, respectively), greater perceived benefits of vaccination (AOR = 1.88; 95% CI = 1.45–2.45) and greater perception of collective benefits of vaccines (AOR = 1.48; 95% CI = 1.15–1.90).

Conclusions

The COVID-19 pandemic may have served as a cue to action for influenza vaccination intention among some prior non-vaccinators whereas intention among prior vaccinators is more related to positive attitudes toward vaccination.

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

There's just not enough time: a mixed methods pilot study of hepatitis C virus screening among baby boomers in primary care

BACKGROUND

Liver cancer rates are rising and hepatitis C virus (HCV) is the primary cause. The CDC recommends a one-time HCV screening for all persons born 1945-1965 (baby boomers). However, 14% of baby boomers have been screened. Few studies have examined primary care providers' (PCP) perspectives on barriers to HCV screening. This study examines current HCV screening practices, knowledge, barriers, and facilitators to HCV screening recommendation for baby boomers among PCPs.

METHODS

We conducted a mixed methods pilot study of PCPs. Quantitative: We surveyed PCPs from 3 large academic health systems assessing screening practices, knowledge (range:0-9), self-efficacy to identify and treat HCV (range:0-32), and barriers (range:0-10). Qualitative: We conducted interviews assessing patient, provider, and clinic-level barriers to HCV screening for baby boomers in primary care. Interviews were audio recorded, transcribed, and analyzed with content analysis.

RESULTS

The study sample consisted of 31 PCPs (22 survey participants and nine interview participants). All PCPs were aware of the birth cohort screening recommendation and survey participants reported high HCV testing recommendation, but qualitative interviews indicated other priorities may supersede recommending HCV testing. Provider knowledge of viral transmission was high, but lower for infection prevalence. While survey participants reported very few barriers to HCV screening in primary care, interview participants provided a more nuanced description of barriers such as lack of time.

CONCLUSIONS

There is a need for provider education on both HCV treatment as well as how to effectively recommend HCV screening for their patients. As HCV screening guidelines continue to expand to a larger segment of the primary care population, it is important to understand ways to improve HCV screening in primary care.

Human Papillomavirus Vaccination Prevalence Among Adults Aged 19-45 Years: An Analysis of the 2017 National Health Interview Survey

INTRODUCTION

In 2018, the U.S. Food and Drug Administration extended the licensure for human papillomavirus vaccination to include everyone aged 27-45 years. In 2019, the Advisory Committee on Immunization Practices issued a recommendation that adults aged 27-45 years and their providers engage in shared clinical decision making about human papillomavirus vaccination. In addition, in 2019, the Advisory Committee on Immunization Practices reiterated that all previously unvaccinated individuals receive catch-up vaccination through age 26 years. This study estimates the pre-recommendation prevalence of human papillomavirus vaccination and factors associated with vaccination in 2 age groups (19-26 years [young adults] and 27-45 years [mid-adults]), forming a baseline to monitor future coverage among U.S. adults.

METHODS

The final sample included 9,744 individuals (2,522 young adults and 7,222 mid-adults) who participated in the 2017 National Health Interview Survey. The main outcomes were receipt of 1 or more human papillomavirus vaccination and whether the participant had been vaccinated as an adult. Demographic characteristics and healthcare factors were included as covariates in statistical analyses.

RESULTS

Population estimate of receiving 1 or more human papillomavirus vaccine doses among young adults was 36.3% (female: 51.5%, male: 21.2%; p<0.001) and 9.7% for mid-adults (females: 15.8%, males: 3.2%; p<0.001). In the best-fit model, age was inversely associated with vaccination for mid-adults (female: OR=0.84, 95% CI=0.81, 0.86; male: OR=0.86; 95% CI=0.82, 0.90) and male young adults (OR=0.79, 95% CI=0.71, 0.88). Of the entire vaccinated sample aged 19-45 years, 26.6% had received their first vaccination as an adult (95% CI=23.9, 29.4).

CONCLUSIONS

These data emphasize the continued need for vaccinating adolescents aged 11-12 years given that few adults were vaccinated against human papillomavirus.

Public perceptions of the effectiveness of recommended non-pharmaceutical intervention behaviors to mitigate the spread of SARS-CoV-2

Background

The COVID-19 pandemic is an unprecedented public health threat, both in scope and response. With no vaccine available, the public is advised to practice non-pharmaceutical interventions (NPI) including social distancing, mask-wearing, and washing hands. However, little is known about public perceptions of the effectiveness of these measures, and high perceived effectiveness is likely to be critical in order to achieve widespread adoption of NPI.

Methods

In May 2020, we conducted a cross-sectional survey among U.S. adults (N = 3,474). The primary outcome was a six-item measure assessing perceived effectiveness of recommended behaviors to prevent SARS-CoV-2 infection from 1 (not at all effective) to 5 (extremely effective). The sample was divided into “higher” and “lower” perceived effectiveness groups. Covariates included demographics, healthcare characteristics, and health beliefs. Variables that were significant at p<0.01 in bivariate analyses were entered into a multivariable logistic regression and a best-fit model was created using a cutoff of p<0.01 to stay in the model.

Results

Mean age was 45.5 years and most participants were non-Hispanic White (63%) and female (52.4%). The high perceived effectiveness group was slightly larger than the low perceived effectiveness group (52.7% vs. 47.3%). Almost all health belief variables were significant in the best-fit regression model. COVID-19-related worry (aOR = 1.82; 95% CI = 1.64–2.02), and perceived threat to physical health (aOR = 1.32; 95% CI = 1.20–1.45) were positively associated with perceived effectiveness while perceived severity of COVID-19 (0.84; 95% CI = 0.73–0.96) and perceived likelihood of infection (0.85; 95% CI = 0.77–0.94) switched directions in the adjusted model and were negatively associated with perceived effectiveness.

Conclusions

This research indicates people generally believe NPI are effective, but there was variability based on health beliefs and there are mixed rates of engagement in these behaviors. Public health efforts should focus on increasing perceived severity and threat of SARS-CoV-2-related disease, while promoting NPI as effective in reducing threat.

A National Survey Assessing SARS-CoV-2 Vaccination Intentions: Implications for Future Public Health Communication Efforts

With SARS-CoV-2 vaccines under development, research is needed to assess intention to vaccinate. We conducted a survey (N = 3,159) with U.S. adults in May 2020 assessing SARS-CoV-2 vaccine intentions, intentions with a provider recommendation, and sociodemographic and psychosocial variables. Participants had high SARS-CoV-2 vaccine intentions (M = 5.23/7-point scale), which increased significantly with a provider recommendation (M = 5.47). Hierarchical linear regression showed that less education and working in health care were associated with lower intent, and liberal political views, altruism, and COVID-19-related health beliefs were associated with higher intent. This work can inform interventions to increase vaccine uptake, ultimately reducing COVID-19-related morbidity and mortality.

A Framework for Pilot Testing Health Risk Video Narratives

Narrative messages may be superior to didactic messages when providing educational information due to their natural format for information sharing, ability to engage audiences, and engender positive thoughts about the message. Although narrative messages are gaining popularity in health promotion, little guidance exists regarding the development phase. Our team created a psychosocial narrative video intervention grounded in the Health Belief Model to increase breast cancer survivors' attendance at genetic counseling after treatment. Here we report the use of Learner Verification (LV) during an iterative video development process. Using LV, we conducted individual semi-structured interviews with patients and providers, after they viewed the video. Demographic information was analyzed using descriptive statistics, and verbatim interview transcripts were used to conduct a two-phase qualitative content analysis. Patient and provider participants (n = 30) believed the video was attractive, relatable, and informative, and they identified areas for improvement including narrative coherence, changes to text and graphical information, and including more specific information. LV framework elicited audience feedback on the video intervention relevant to theoretical principles of narrative interventions, and highlighted audience preferences. In this study, LV interviews tapped into theoretical constructs of narratives and facilitated the iterative intervention design process.

The big reveal: Family disclosure patterns of BRCA genetic test results among young Black women with invasive breast cancer

Despite higher incidence and mortality of breast cancer among younger Black women, genetic testing outcomes remain severely understudied among Blacks. Past research on disclosure of genetic testing results to family members has disproportionately focused on White, educated, high socioeconomic status women. This study addresses this gap in knowledge by assessing (a) to whom Black women disclose genetic test results and (b) if patterns of disclosure vary based on test result (e.g., BRCA1/2 positive, negative, variant of uncertain significance [VUS]). Black women (N = 149) with invasive breast cancer diagnosed age ≤50 years from 2009 to 2012 received free genetic testing through a prospective, population-based study. At 12 months post-testing, women reported with whom they shared their genetic test results. The exact test by binomial distribution was used to examine whether disclosure to female relatives was significantly greater than disclosure to male relatives, and logistic regression analyses tested for differences in disclosure to any female relative, any male relative, parents, siblings, children, and spouses by genetic test result. Most (77%) women disclosed their results to at least one family member. Disclosure to female relatives was significantly greater than disclosure to males (p < .001). Compared to those who tested negative or had a VUS, BRCA1/2-positive women were significantly less likely to disclose results to their daughters (OR_{BRCA positive}  = 0.25, 95% CI = 0.07-0.94, p = .041) by 12 months post-genetic testing. Genetic test result did not predict any other type of disclosure (all ps > 0.12). Results suggest that in Black families, one benefit of genetic testing-to inform patients and their family about cancer risk information-is not being realized. To increase breast cancer preventive care among high-risk Black women, the oncology care team should prepare Black BRCA1/2-positive women to share genetic test results with family members and, in particular, their daughters.

Impact of Genetic Testing on Risk-Management Behavior of Black Breast Cancer Survivors: A Longitudinal, Observational Study

BACKGROUND

Black women are overrepresented among premenopausal breast cancer (BC) survivors. These patients warrant genetic testing (GT) followed by risk-reducing behaviors. This study documented patterns and predictors of cancer risk-management behaviors among young black BC survivors after GT.

METHODS

Black women (n = 143) with a diagnosis of BC at the age of 50 years or younger received GT. At 1 year after GT, participants reported receipt of risk-reducing mastectomy, risk-reducing salpingo-oophorectomy, mammogram, breast magnetic resonance imaging (MRI), CA125 test, and transvaginal/pelvic ultrasound. Logistic regression was used to examine predictors of BC risk management (risk-reducing mastectomy or breast MRI) and ovarian cancer risk management (risk-reducing salpingo-oophorectomy, CA125 test, or transvaginal/pelvic ultrasound).

RESULTS

Of the study participants, 16 (11%) were BRCA1/2-positive, 43 (30%) had a variant of uncertain significance, and 84 (59%) were negative. During the 12 months after GT, no women received risk-reducing mastectomy. The majority (93%) received a mammogram, and a smaller proportion received breast MRI (33%), risk-reducing salpingo-oophorectomy (10%), CA125 test (11%), or transvaginal/pelvic ultrasound (34%). Longer time since the BC diagnosis predicted lower likelihood of BC risk management (odds ratio [OR] 0.54). BRCA1/2 carrier status (OR 4.57), greater perceived risk of recurrence (OR 8.03), and more hereditary breast and ovarian cancer knowledge (OR 1.37) predicted greater likelihood of ovarian cancer risk management.

CONCLUSIONS

Young black BC survivors appropriately received mammograms and ovarian cancer risk management based on their BRCA1/2 test result. However, the low usage of MRI among BRCA1/2 carriers contrasts with national guidelines. Future research should examine barriers to MRI among black BC survivors. Finally, modifiable variables predicting risk management after GT were identified, providing implications for future interventions.

The effects of message framing and healthcare provider recommendation on adult hepatitis B vaccination: A randomized controlled trial

Many adults in the U.S. do not receive recommended vaccines, and the research literature remains inconclusive on the best communication strategies for increasing this behavior. This study examined the association of message framing (gained-framed vs. loss-framed vs. control), and healthcare provider (HCP) recommendation (offered vs. recommended) on uptake of adult hepatitis B virus (HBV) vaccination in a high risk population using a 3 × 2 block design randomized controlled trial. Fear of shots, fear of vaccines, and perceived message framing were examined in secondary analyses. Of the 1747 participants, 47.7% (n = 833) received 0 doses of HBV vaccine, 27.8% (n = 485) received 1 dose, 10.4% received 2 doses, and 14.1% received all 3 recommended doses. There was not a significant interaction between message framing and HCP recommendation (p = .59). Mean number of doses received by the gain-framed group (m = 0.96) was not significantly different from the loss-framed group (m = 0.97, RR = 0.99, 95% CI = 0.88-1.12). However, those receiving any framing message received significantly more doses (m = 0.96) than those in the control condition (m = 0.81, RR = 1.17, 95%CI = 1.06-1.31). Participants who received a HCP recommendation received significantly more vaccine doses (m = 0.95) than those in the vaccine-offered condition (mean = 0.82, RR = 1.16, 95%CI = 1.05-1.28). These results suggest there is no difference in vaccine uptake between gain-frame and loss-frame messages, but both are better than a control message. These results also support advising HCP to provide a strong recommendation for vaccinations beyond merely offering it to patients. This study has implications for vaccine uptake beyond HBV, and can inform future research on effective vaccine communication research. Clinicaltrials.gov Identifier: NCT00739752. Registration date: August 20, 2008.

Electronic medical record-verified hepatitis C virus screening in a large health system

BACKGROUND

Baby boomers are at increased risk for hepatitis C virus (HCV) infection and related cancer; therefore, one-time HCV screening is recommended.

METHODS

To assess prevalence of, and factors associated with providers ordering HCV screening, we examined a retrospective cohort of electronic medical records for patient visits from 01 August 2015 until 31 July 2017 in a large health system. HCV screening ordered was examined by patient age, gender, race/ethnicity, provider specialty, and number of clinical visits, stratified by birth cohort: born ≤1945, 1945-1965 (baby boomers), 1966-1985, and ≥1985. Multivariable regression identified factors independently associated with HCV screening ordered among average risk baby boomers.

RESULTS

A total of 65 114 patients ages ≥18 years were evaluated. Among baby boomers HCV screening test order increased threefold between the two study years (4.0%-12.9%). Odds of screening test ordered were significantly higher for non-Hispanic Blacks (multivariable adjusted odds ratio [aOR]=1.36; 95% CI = 1.19-1.55), males (aOR = 1.44; 95% CI = 1.33-1.57), and having a clinic visit with a primary care provider alone or with specialty care (aOR = 3.25-4.16). Medicare (aOR = 0.89; 95% CI = 0.80-0.99), Medicaid (aOR 0.89; 95% CI 0.80-0.99), and an unknown provider type (aOR = 0.16; 95% CI = 0.08-0.33), were associated with lower odds of screening tests ordered.

CONCLUSIONS

While the proportion of baby boomers with an HCV screening test ordered increased during the study, the rate of screening remains far below national goals. Data from this study indicate that providers are not ordering HCV screening universally for all of their baby boomer patients. Continued efforts to increase HCV screening are needed to reduce the incidence of HCV-related morbidity and mortality.

Provider perspectives on multilevel barriers to HPV vaccination

Understanding physician recommendation practices for HPV vaccination is a crucial step to developing interventions that can increase high quality recommendations and improve vaccination acceptance. Florida physicians (n = 340) completed a survey assessing recommendation strategies, specifically strength, consistency, and presentation. Physicians were also asked to provide suggestions for improving HPV vaccination in Florida. Responses were dichotomized for each outcome: strength (i.e., strongly recommend vs. other), consistently recommend (i.e., always recommend vs. other), and recommendation presentation (i.e., presented in the same manner as mandatory vaccines for adolescents vs. other). Bivariate logistic regression was conducted to determine the association between physician/practice characteristics and each outcome. Variables significant (p < .05) in bivariate analyses were included in multivariable logistic regression analyses. Vaccines for Children (VFC) provider status (OR = 2.62, 95% CI = 1.23-5.59 [strong]; OR = 2.84, 95% CI = 1.26-6.39 [consistent]) and not limiting the number of vaccines during a visit (OR = .283, 95% = CI .111-.722 [strong]; OR = .210, 95% = CI .066-.673 [consistent]) were significantly associated with strong and consistent recommendation. Reminders from the healthcare team were associated with consistency (OR = 2.26, 95% CI = 1.23-4.16) and EMR-based reminders were associated with presentation (OR = 2.00, 95% CI = 1.11-3.61). Multinomial logistic regression analysis examined factors associated with level of engagement in recommendation strategies. Multinomial regression indicated VFC providers (OR = 12.61, 95% CI = 1.89-82.20), and those receiving EMR-based reminders (OR = 4.02, 95% = CI 1.28-12.63), among others, were more likely to engage in all 3 types of recommendation practices. Physician suggestions for improving HPV vaccination rates included improving parent/patient/provider education and reducing vaccine costs. Future interventions should emphasize key components of delivering effective HPV vaccine recommendations, include information about insurance coverage, and improve provider awareness of VFC benefits.

A randomized controlled intervention to promote readiness to genetic counseling for breast cancer survivors

OBJECTIVE

Breast cancer (BC) survivors with a genetic mutation are at higher risk for subsequent cancer; knowing genetic risk status could help survivors make decisions about follow-up screening. Uptake of genetic counseling and testing (GC/GT) to determine BRCA status is low among high risk BC survivors. This study assessed feasibility, acceptability, and preliminary efficacy of a newly developed psychoeducational intervention (PEI) for GC/GT.

METHODS

High risk BC survivors (N = 119) completed a baseline questionnaire and were randomized to the intervention (PEI video/booklet) or control (factsheet) group. Follow-up questionnaires were completed 2 weeks after baseline (T2), and 4 months after T2 (T3). We analyzed recruitment, retention (feasibility), whether the participant viewed study materials (acceptability), intent to get GC/GT (efficacy), and psychosocial outcomes (eg, perceived risk, Impact of Events Scale [IES]). t tests or chi-square tests identified differences between intervention groups at baseline. Mixed models examined main effects of group, time, and group-by-time interactions.

RESULTS

Groups were similar on demographic characteristics (P ≥ .05). Of participants who completed the baseline questionnaire, 91% followed through to study completion and 92% viewed study materials. A higher percentage of participants in the intervention group moved toward GC/GT (28% vs 8%; P = .027). Mixed models demonstrated significant group-by-time interactions for perceived risk (P = .029), IES (P = .027), and IES avoidance subscale (P = .012).

CONCLUSIONS

The PEI was feasible, acceptable, and efficacious. Women in the intervention group reported greater intentions to pursue GC, greater perceived risk, and decreased avoidance. Future studies should seek to first identify system-level barriers and facilitators before aiming to address individual-level barriers.

Hepatitis C virus screening trends: A 2016 update of the National Health Interview Survey

BACKGROUND

50% of liver cancer is caused by hepatitis C virus (HCV). Baby boomers are at increased risk and are recommended for one-time HCV screening. However, <13% of baby boomers were screened in 2015.

MATERIALS AND METHODS

We are updating a previous study using 2013-2015 NHIS data to examine HCV screening prevalence by birth cohort, with 2016 data. We used logistic regression to evaluate whether HCV screening prevalence changed over time, stratified by birth cohort.

RESULTS AND DISCUSSION

The sample consisted of 132,742 participants from 2013-2016. Screening increased in baby boomers from 11.9 to 14.1%. Odds of HCV screening for baby boomers was significantly associated with age, gender, race/ethnicity, and other variables and increased significantly with each subsequent year (aOR = 1.21, aOR = 1.33, aOR = 1.42, consecutively). While HCV screening is increasing over time, there is still room for improvement and future interventions should focus on increasing HCV screening among groups demonstrating significantly lower screening prevalence.

Health beliefs associated with readiness for genetic counseling among high risk breast cancer survivors

We used the Health Belief Model (HBM) to explore factors associated with readiness for genetic counseling among breast cancer survivors. Breast cancer survivors meeting NCCN genetic counseling referral criteria completed questionnaires capturing demographic and clinical information and factors guided by the HBM, including health beliefs, psychosocial variables, and cues to action. Using logistic regression, we examined whether the above variables differed based on readiness group (pre-contemplators, who did not plan to make a genetic counseling appointment, and contemplators, who planned to make a genetic counseling appointment in the next 1-6 months). Of 111 participants, 57% were pre-contemplators and 43% were contemplators. Higher cancer worry was associated with increased odds of being a contemplator (OR = 2.99; 95% CI = 1.37-6.54) and higher perceived barriers to genetic counseling were associated with decreased odds of being a contemplator (OR = 0.31; 95% CI = 0.11-0.85). Those who reported a family member encouraged them to get tested were more likely to be contemplators (OR = 3.57; 95% CI = 1.19-10.70). Our results suggest key factors for predicting genetic counseling readiness include cancer worry, perceived barriers, and family influence. There is need for increased genetic counseling awareness. Better understanding of factors related to survivors' decisions about counseling can inform tailored interventions to improve uptake and ultimately reduce cancer recurrence risk.

Florida physicians' reported use of AFIX-based strategies for human papillomavirus vaccination

HPV vaccination rates in Florida are low. To increase rates, the CDC recommends clinics adhere to components of their evidence-based quality improvement program, AFIX (Assessment, Feedback, Incentives, and eXchange of information). We explored factors associated with engaging in HPV-specific AFIX-related activities. In 2016, we conducted a cross-sectional survey of a representative sample of 770 pediatric and family medicine physicians in Florida and assessed vaccination practices, clinic characteristics, and HPV-related knowledge. Data were analyzed in 2017. The primary outcome was whether physicians' clinics engaged in ≥1 AFIX activity. We stratified by physician specialty and developed multivariable models using a backward selection approach. Of the participants in the analytic sample (n = 340), 52% were male, 60% were White of any ethnicity, and 55% were non-Hispanic. Pediatricians and family medicine physicians differed on: years practicing medicine (p < 0.001), HPV-related knowledge (p < 0.001), and VFC provider status (p < 0.001), among others. Only 39% of physicians reported engaging in ≥1 AFIX activity. In the stratified multivariable model for pediatricians, AFIX activity was significantly associated with HPV-related knowledge (aOR = 1.33;95%CI = 1.08-1.63) and provider use of vaccine reminder prompts (aOR = 3.61;95%CI = 1.02-12.77). For family medicine physicians, HPV-related knowledge was significant (aOR = 1.57;95%CI = 1.20-2.05) as was majority race of patient population (non-Hispanic White vs. Other: aOR = 3.02;95%CI = 1.08-8.43), daily patient load (<20 vs. 20-24: aOR = 9.05;95%CI = 2.72-30.10), and vaccine administration to male patients (aOR = 2.98;95%CI = 1.11-8.02). Fewer than half of Florida pediatric and family medicine physicians engaged in any AFIX activities. Future interventions to increase AFIX engagement should focus on implementing and evaluating AFIX activities in groups identified as having low engagement in AFIX activities.

Psychosocial impact of BRCA testing in young Black breast cancer survivors

OBJECTIVE

Prior studies demonstrating minimal psychological consequences for women receiving genetic counseling/genetic testing (GC/GT) for hereditary breast and ovarian cancer rely on predominantly Caucasian women. We conducted a prospective follow-up of a subset of participants from a population-based study of Black breast cancer (BC) survivors receiving GC/GT for BRCA1 and BRCA2 mutations.

METHODS

Black women with invasive BC at age ≤ 50 years diagnosed between 2009 and 2012 were recruited through the Florida Cancer Registry. Participants (n = 215, age M = 44.7, SD = 6.2) were offered telephone pre- and post-test GC, a subset completed questionnaires assessing sociodemographic, clinical, and psychosocial variables.

RESULTS

There were no baseline differences in cancer-related distress, psychological distress, or quality of life between test result groups. Social well-being improved in women receiving negative results (P = .01), but no other outcomes demonstrated significant changes over time between groups.

CONCLUSIONS

Our study is among the first to demonstrate minimal negative psychosocial outcomes following GC/GT among young Black BC survivors, irrespective of test results.

An environmental scan to examine stakeholder perspectives on human papillomavirus vaccination: A mixed methods study

PURPOSE

Human papillomavirus (HPV) vaccine series completion rates among females and males remain low in Florida (46.4% and 34.5%, respectively). Multiple stakeholders influence vaccination uptake, including health care providers (HCPs), public health professionals (PHPs), and members of professional organizations. We examined stakeholder efforts related to increasing vaccine uptake and education among parents/adolescents and HCPs.

METHODS

We conducted an environmental scan of stakeholder efforts and identified stakeholders using our professional networks and a snowball sampling approach. Stakeholders (n = 46) completed a survey about involvement in and barriers to vaccination promotion efforts. A subset (n = 12) of stakeholders participated in follow-up interviews further exploring vaccination efforts and barriers. Survey data were analyzed using descriptive statistics. Interview data were analyzed using deductive analysis and coded using constructs from the PRECEDE-PROCEED model.

RESULTS

The majority of our survey sample was PHPs (50.0%) and HCPs (32.6%). Stakeholder efforts were focused on adolescent/parent/HCP education including providing: educational materials for HCPs (55.8%) and adolescents/parents (59.6%), one-on-one consultations for adolescents/parents (55.3%), and HCP education (54.7%). Lack of knowledge/understanding and education/information were barriers reported across almost all groups/areas. Office staff/HCP education and distribution of patient education materials were efforts described as important during qualitative interviews. Stakeholders also noted HCP discomfort when recommending HPV vaccine, parental perceptions that the vaccine is unnecessary, and a lack of education/understanding among parents and HCPs.

CONCLUSIONS

Results suggest the need for parent/adolescent education, specifically targeting key areas we identified: importance and benefits of HPV vaccine, and education and skill building in vaccine communication for HCPs.

Hepatitis C Virus Screening Trends: Serial Cross-Sectional Analysis of the National Health Interview Survey Population, 2013-2015

Background: Rates of hepatitis C virus (HCV) infection are markedly higher for baby boomers compared with other birth cohorts, and they are now recommended for universal one-time screening. This study examines HCV screening rates and predictors for four birth cohorts [born <1945, born 1945-1965 (baby boomers), born 1966-1985, and born >1985] of a nationally representative sample over time.Methods: We used data from the 2013-2015 National Health Interview Surveys, an annual weighted survey of the U.S. civilian noninstitutionalized population. We assessed HCV screening prevalence stratified birth cohort with bivariate and multivariable logistic regression analyses.Results: There were 15,100 participants born <1945, 28,725 baby boomers, 28,089 born 1966-1985, and 13,296 born >1985 in the final analytic sample. Screening was 11.5%-12.8% for baby boomers. The second youngest birth cohort was similar to baby boomers (13.7%-14.9%), whereas the older birth cohort was screened less. After excluding participants who typically have higher rates of HCV screening than the general population, we developed a multivariable model of the general population. In the final model for baby boomers the odds of HCV screening increased significantly with each subsequent year (OR=1.20; 95% CI=1.05-1.38 and OR=1.31; 95% CI=1.13-1.52). HCV screening was also significantly associated with age, gender, and race/ethnicity in baby boomers.Conclusions: While HCV screening is increasing over time, these increases are minimal and there is substantial room for improvement.Impact: Future research should develop interventions to increase HCV screening with special focus on groups demonstrating significantly lower screening rates, such as Hispanics and females. Cancer Epidemiol Biomarkers Prev; 27(4); 503-13. ©2018 AACR.

Human Papillomavirus Vaccination Training Experience Among Family Medicine Residents and Faculty

BACKGROUND AND OBJECTIVES

Residency training is a pivotal time to establish skills for career-long practices, particularly for challenging skills such as human papillomavirus (HPV) vaccine recommendation. Training experience and preferences related to delivering HPV vaccine recommendations were examined for family medicine (FM) residents and faculty.

METHODS

Residents (n=28) and faculty (n=19) were identified through a national FM residency directory and recruited from training programs in Florida. Participants completed a phone interview assessing key aspects of HPV vaccine recommendation training. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. A brief follow-up survey assessing training, practices, and demographics was emailed after the interview.

RESULTS

Residents' training experience with HPV vaccine recommendation varied from none to extensive, and was often self-directed. Variation in training was seen between and within programs. Faculty often noted HPV vaccination training was not standardized and residents lacked instruction about effective communication. Most programs relied on preceptors for training residents but training from preceptors varied widely and was often not standardized within the program.

CONCLUSIONS

This study identified a lack of consistent and standardized training for delivering HPV vaccine recommendations. A training curriculum that uses multiple modalities and reflects resident and faculty preferences is needed.

Health care providers' perceptions of use and influence of clinical decision support reminders: qualitative study following a randomized trial to improve HPV vaccination rates

BACKGROUND

Human Papillomavirus (HPV) leads to serious health issues and remains the most common sexually transmitted infection. Despite availability of effective vaccines, HPV vaccination rates are suboptimal. Furthermore, providers recommend the HPV vaccine less than half the time for eligible patients. Prior informatics research has demonstrated the effectiveness of computer-based clinical decision support (CDS) in changing provider behavior, especially in the area of preventative services.

METHODS

Following a randomized clinical trial to test the effect of a CDS intervention on HPV vaccination rates, we conducted semi-structured interviews with health care providers to understand whether they noticed the CDS reminders and why providers did or did not respond to the prompts. Eighteen providers, a mix of medical doctors and nurse practitioners, were interviewed from five publicly-funded, urban health clinics. Interview data were qualitatively analyzed by two independent researchers using inductive content analysis.

RESULTS

While most providers recalled seeing the CDS reminders, few of them perceived the intervention as effective in changing their behavior. Providers stated many reasons for why they did not perceive a change in their behavior, yet the results of the trial showed HPV vaccination rates increased as a result of the intervention.

CONCLUSIONS

CDS reminders may be effective at changing provider behavior even if providers perceive them to be of little use.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02551887 Registered on September 15, 2015.

Physicians' current use and preferences for male HPV vaccine-related patient education materials

Understanding physician preferences for educational materials to support male HPV vaccination is critical to improving vaccine uptake. Pediatric (Peds) and Family Medicine (FM) physicians in Florida completed a survey from May-August 2014 assessing current use of male-specific HPV vaccination patient education materials, and preferences for materials to increase HPV vaccination uptake. Peds and FM responses were compared with chi-squared or nonparametric tests. Most participants were FM (53.2%), White (66.6%), non-Hispanic (74.1%), and provided male patients/parents with HPV educational materials (59.1%). More than half (55.5%) provided a CDC factsheet for parents. Peds were more likely to indicate they provide educational materials (p<0.0001) than FM. The preferred source was the CDC (77.8%). Peds preferred using a factsheet as the medium of information more often than FM (85.6% vs. 68.0%; p<0.0001). When asked about preferences for targeted materials, 74.8% of providers indicated they would prefer materials targeted towards patients, 63.2% preferred information targeted towards parents, and 20.7% indicated they prefer non-targeted materials. Future research should focus on the development and testing of new HPV vaccine-specific materials and communication strategies for Peds and FM physicians.

Health-related quality of life in Black breast cancer survivors with and without triple-negative breast cancer (TNBC)

PURPOSE

Black women are more likely to develop early-onset (≤50 years) breast cancer (BC) and have the lowest five-year, cause-specific survival rate of any United States (U.S.) racial or ethnic group. These disparities can be attributed partially to the higher rate of triple-negative BC (TNBC) in Blacks. Yet, little is known about health-related quality of life (HRQOL) among Black women with TNBC.

METHODS

Black women with invasive BC ≤ 50 years were recruited via the Florida Cancer Data System as part of a population-based case-only study of etiology and outcomes of early-onset invasive BC. Of 460 consented participants, a subset of 355 self-reported sociodemographic, clinical, and psychosocial variables. Descriptive analyses included participants with known TNBC (n = 85) or non-TNBC (n = 245) disease. Univariable and multivariable analyses were conducted to examine differences in factors associated with HRQOL.

RESULTS

In unadjusted analyses, TNBC participants had significantly lower FACT-B total scores (90.1 ± 27.9) compared to non-TNBC (98.5 ± 27.6) participants (p < 0.05). For the TNBC group, multivariable analyses indicated five individual-level, and three systemic-level factors explain 80% of the response variation in HRQOL. For the non-TNBC group, seven individual-level factors and three systemic-level factors account for 76% of the variation in HRQOL scores.

CONCLUSIONS

Compared to Black women with non-TNBC, TNBC women have worse HRQOL. There are key individual and systemic-level factors that are unique to both groups. Findings can inform future HRQOL interventions to support young Black BC survivors.

Tempest in a teapot: A systematic review of HPV vaccination and risk compensation research

There has been some concern among parents and in the media that vaccinating children against human papillomavirus could be seen as giving children permission to engage in risky sexual behaviors (also known as sexual disinhibition). Several studies have found this concern to be unfounded but there have been no attempts to synthesize the relevant studies in order to assess if there is evidence of sexual disinhibition. The aim of this study was to synthesize recent literature examining sexual behaviors and biological outcomes (e.g., sexually transmitted infections) post-HPV vaccination. We reviewed literature from January 1, 2008-June 30, 2015 using PubMed, CINAHL, and Embase with the following search terms: [(sex behavior OR sex behavior OR sexual) AND (human papillomavirus OR HPV) AND (vaccines OR vaccine OR vaccination)] followed by a cited reference search. We included studies that examined biological outcomes and reported behaviors post-vaccination in both males and females. Studies were reviewed by title and abstract and relevant studies were examined as full-text articles. We identified 2,503 articles and 20 were eventually included in the review. None of the studies of sexual behaviors and/or biological outcomes found evidence of riskier behaviors or higher rates of STIs after HPV vaccination. Instead, the studies found that vaccinated compared to unvaccinated individuals were less likely to report vaginal intercourse without a condom (OR = 0.5; 95%CI = 0.4-0.6) and non-use of contraception (OR = 0.27; 95%CI = 0.15-0.48) and unvaccinated participants had higher rates of Chlamydia (OR = 2.3; 95%CI = 1.06-5.00). These results should be reassuring to parents and health care providers.

A qualitative study of healthcare provider awareness and informational needs regarding the nine-valent HPV vaccine

The 9-valent Human Papillomavirus (HPV) vaccine, 9vHPV, was licensed in the U.S. in December, 2014. We assessed healthcare provider (HCP) awareness of the newly approved vaccine and identified questions HCPs have about the vaccine. As part of a larger study, we used semi-structured interviews to ask 22 pediatric HCPs about their awareness of 9vHPV, questions they have about the vaccine, and questions they anticipate from patients and parents. Interviews were audio-recorded and transcribed then analyzed using inductive content analysis. Over half were aware of the vaccine but few HCPs claimed to be familiar with it. HCPs indicated several questions with common themes pertaining to efficacy, side effects, and cost. Only half of HCPs believed patients or parents would have questions. The results suggest strategies and areas for health systems and public health organizations to target in order to resolve unmet educational needs among HCPs regarding 9vHPV.

The effects of HIV testing advocacy messages on test acceptance: a randomized clinical trial

BACKGROUND

Nearly 1 in 5 people living with HIV in the United States are unaware they are infected. Therefore, it is important to develop and evaluate health communication messages that clinicians can use to encourage HIV testing.

METHODS

The objective was to evaluate health communication messages designed to increase HIV testing rates among women and evaluate possible moderators of message effect. We used a randomized four-arm clinical trial conducted at urban community outpatient health clinics involving 1,919 female patients, 18 to 64 years old. The four health message intervention groups were: i) information-only control; ii) one-sided message describing the advantages of HIV testing; iii) two-sided message acknowledging a superficial objection to testing (i.e., a 20 minute wait for results) followed by a description of the advantages of testing; and iv) two-sided message acknowledging a serious objection (i.e., fear of testing positive for HIV) followed by a description of the advantages of testing. The main outcome was acceptance of an oral rapid HIV test.

RESULTS

Participants were randomized to receive the control message (n = 483), one-sided message (n = 480), two-sided message with a superficial objection (n = 481), or two-sided message with a serious objection (n = 475). The overall rate of HIV test acceptance was 83%. The two-sided message groups were not significantly different from the controls. The one-sided message group, however, had a lower rate of testing (80%) than the controls (86%) (OR, 0.66; 95% CI, 0.47-0.93; P = 0.018). "Perceived obstacles to HIV testing" moderated this effect, indicating that the decrease in HIV test acceptance for the one-sided message group was only statistically significant for those who had reported high levels of obstacles to HIV testing (OR, 0.36; 95% CI, 0.19-0.67; P = 0.001).

CONCLUSIONS

None of the messages increased test acceptance. The one-sided message decreased acceptance and this effect was particularly true for women with greater perceived obstacles to testing, the very group one would most want to persuade. This finding suggests that efforts to persuade those who are reluctant to get tested, in some circumstances, may have unanticipated negative effects. Other approaches to messaging around HIV testing should be investigated, particularly with diverse, behaviorally high-risk populations.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00771537. Registration date: October 10. 2008.