A Consolidated Framework for Implementation Research-based process to develop theoretically-informed human papillomavirus vaccination educational materials for young adults

OBJECTIVE

To develop theory-informed human papillomavirus (HPV) vaccine education materials that appeal to 18-26-year-olds.

METHODS

First, draft materials informed by Theory of Planned Behavior (TPB) and Health Belief Model (HBM) were developed. Next, an initial set of Consolidated Framework for Implementation Research (CFIR)-guided interviews were conducted with 18-26-year-old participants to receive feedback about content, format, appeal, implementation facilitators and barriers, and potential delivery modalities. Then, interviews were transcribed, coded, and analyzed using thematic analysis. Next, materials were modified based upon feedback. Finally, another set of interviews was conducted.

RESULTS

Most participants (n = 15) were female (93%), White (60%), and non-Hispanic (93%). All (100%) had heard of HPV and the HPV vaccine, and 80% reported having received the vaccine. Participant feedback on materials included emphasizing vaccine benefits and efficacy, rewording to enhance comprehension, and adding images represent diversity beyond race/ethnicity and sexual orientation. Suggested delivery methods included social media, print materials, and posters.

CONCLUSION

Qualitative interviews with young adults suggest that HPV education materials targeted to 18-26-year-olds should include health behavior theory-aligned messaging, inclusive imagery, and be disseminated through multiple modalities.

PRACTICE IMPLICATIONS

Providers should consider utilizing theory-based education materials that are relevant and appealing to young adults.

HPV Multilevel Intervention Strategies Targeting Immunization in Community Settings (HPV MISTICS): Study protocol for a hybrid 1 stepped-wedge cluster randomized trial

BACKGROUND

This protocol paper describes the overall design for HPV MISTICS, a multilevel intervention to increase human papillomavirus (HPV) vaccination initiation and completion rates among adolescents aged 11-17.

METHODS

We will conduct a hybrid type 1 implementation-effectiveness trial using a stepped-wedge cluster randomized trial in eight federally qualified health centers (FQHCs) in Florida. Intervention components target three levels: system, providers, and parents. Outcomes will be assessed using quantitative (e.g., vaccination data, survey data) and qualitative methods (e.g., staff and parent interviews). We expect to quantify changes in HPV vaccine series initiation and completion rates for adolescents ages 11-17 in the eight FQHCs. We have hypothesized a 20-percentage point increase in HPV vaccine series initiation and a 10-percentage point increase in series completion. We also anticipate being able to explore factors at the system, provider, and patient levels as potential covariates. Implementation outcomes, barriers, and facilitators identified in the study will help characterize the implementation process and inform potential future intervention scale-up.

RESULTS

The project is ongoing; effectiveness and implementation outcomes will be determined following project completion.

CONCLUSIONS

Findings will provide evidence of an equity-informed research design and implementation procedures that could help improve HPV vaccination rates in similar health systems.

CLINICAL TRIALS IDENTIFIER

NCT05677360 (date registered: 2022-12-22); https://clinicaltrials.gov/study/NCT05677360?lead=Moffitt%20Cancer%20Center%20&aggFilters=status:rec&page=2&rank=17.

Longitudinal adherence to annual colorectal cancer screening among Black persons living in the United States enrolled in a community-based randomized trial

BACKGROUND

This study examined repeat colorectal cancer screening rates at 12 and 24 months as part of a randomized intervention trial among Black persons living in the United States and factors associated with screening adherence.

METHODS

Participants completed a survey assessing demographics and Preventive Health Model (PHM) factors (e.g., self efficacy, susceptibility) and received either a culturally targeted photonovella plus free fecal immunochemical test (FIT) kits (intervention group) or a standard educational brochure plus free FIT kits (comparison group). FIT return was assessed at 6, 12, and 24 months. Descriptive statistics summarized patterns of repeat screening. Logistic regression models assessed FIT uptake overtime, and demographic and PHM factors associated with screening adherence.

RESULTS

Participants (N = 330) were U.S.-born (93%), non-Hispanic (97%), and male (52%). Initial FIT uptake within 6 months of enrollment was 86.6%, and subsequently dropped to 54.5% at 12 months and 36.6% at 24 months. Higher FIT return rates were observed for the brochure group at 24 months (51.5% vs 33.3% photonovella, p = .023). Multiple patterns of FIT kit return were observed: 37% completed FIT at all three time points (full adherence), 22% completed two of three (partial adherence), 29% completed one of three (partial adherence), and 12% did not return any FIT kits (complete nonadherence). Predictors of full adherence were higher levels of education and self-efficacy.

CONCLUSIONS

Full adherence to repeat screening was suboptimal. Most participants had partial adherence (one or two of three) to annual FIT screening. Future studies should focus on strategies to support repeat FIT screening.

Factors associated with prior completion of colorectal cancer and hepatitis C virus screenings among community health center patients: a cross-sectional study to inform a multi-behavioral educational intervention

BACKGROUND

Colorectal cancer (CRC) and liver cancer are two of the leading causes of cancer death in the United States and persistent disparities in CRC and liver cancer incidence and outcomes exist. Chronic hepatitis C virus (HCV) infection is one of the main contributors to liver cancer. Effective screening for both CRC and HCV exist and are recommended for individuals based upon age, regardless of gender or sex assigned at birth. Recommendations for both screening behaviors have been recently updated. However, screening rates for both CRC and HCV are suboptimal. Targeting adoption of multiple screening behaviors has the potential to reduce cancer mortality and disparities.

OBJECTIVE

To examine psychosocial factors associated with completion of CRC and HCV screenings in order to inform a multi-behavioral educational intervention that pairs CRC and HCV screening information.

METHODS

A cross-sectional survey was conducted with participants (N = 50) recruited at two community health centers in Florida (United States). Kruskal-Wallis and Fisher's exact tests were used to examine associations between completion of both CRC and HCV screening, CRC and HCV knowledge, Preventive Health Model constructs (e.g., salience and coherence, response efficacy, social influence), and sociodemographic variables.

RESULTS

Most participants were White (84%), female (56%), insured (80%), and reported a household income of $25,000 or less (53%). 30% reported ever previously completing both CRC and HCV screenings. Prior completion of both screening behaviors was associated with higher educational attainment (p = .014), having health insurance (p = .022), being U.S.-born (p = .043), and higher salience and coherence scores for CRC (p = .040) and HCV (p = .004).

CONCLUSIONS

Findings demonstrate limited uptake of both CRC and HCV screenings among adults born between 1945 and 1965. Uptake was associated with multiple sociodemographic factors and health beliefs related to salience and coherence. Salience and coherence are modifiable factors associated with completion of both screening tests, suggesting the importance of incorporating these health beliefs in a multi-behavioral cancer education intervention. Additionally, health providers could simultaneously recommend and order CRC and HCV screening to improve uptake among this age cohort.

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.

Changes in Cancer Screening Knowledge Among a Prospective Cohort of Spanish-Speaking Hispanic Community Outreach Event Participants in Florida and Puerto Rico

The current study examined cancer prevention and early detection awareness (pre-workshop) and changes in knowledge (from pre- to post-workshop) among Hispanic/Latino (H/L) community members who participated in Spanish-language educational outreach events in Puerto Rico (PR) and Florida (FL). Spanish-language educational outreach events were comprised of an educational session lasting approximately 45-60 min and were delivered to groups in rural and urban community settings by a single trained community health educator (CHE). The research team assessed sociodemographic characteristics, personal and familial cancer health history, as well as awareness and knowledge (pre-test) of a range of cancer prevention and screening topics. Following the presentation, participants completed a post-test knowledge survey which also measured likelihood of engaging in cancer screening, cancer preventive behaviors, and cancer research as a result of information presented during the session. Change in the average knowledge score was evaluated using a paired samples t-test. Post-session likelihood of completing cancer screening and preventive behaviors and engaging in cancer research were examined using descriptive statistics and group/site comparisons. The percentage reporting awareness of screening procedures ranged from 33% (PSA test) to 79% (mammogram). H/L in PR reported higher percentage of stool blood test awareness when compared to H/L in FL (χ2(1)= 19.20, p<.001). The average knowledge score increased from 5.97 at pre-test to 7.09 at post-test (Cohen's d=0.69). The increase was significant across all participants (t(315)= 12.4, p<.001), as well as within the FL site (t(124)= 6.66, p<.001, d=0.59) and the PR site (t(190)=10.66, p<.001, d=0.77). Results from this study suggest that educational outreach events delivered to H/L community members by a CHE are valuable strategies to address challenges regarding cancer screening knowledge and engagement in multiple behaviors.

Transcreation matters: A learner centric participatory approach for adapting cancer prevention messages for Latinos

BACKGROUND

Advancing health equity requires innovative patient education approaches for adapting English-language evidence-based interventions (EBIs) to resonate with multicultural, multilingual audiences.

OBJECTIVE

Examine the benefit, functionality, and practical considerations of transcreation (translation + cultural adaptation) as a critical and salient learner-centric process for developing a Spanish-language intervention (photonovella + video): Un examen sencillo para un colon saludable (A simple test for a healthy colon).

PATIENT/COMMUNITY INVOLVEMENT

We involved patients/community members in a participatory reflective process, from problem identification to intervention design, development, delivery, and impact measurement.

METHODS

A community-based participatory research (CBPR) approach involving formative research plus systematic iterative pretesting and learner verification checks augmented by a community advisory board guided the transcreation processes.

RESULTS

Data collected using a learner-centric approach effectively produced a new Spanish-language EBI and substantiated the value of co-learner/co-design methods. Learner-centric methods identified cultural nuances that were treated as knowledge and integrated into the intervention materials and study design. Pilot testing of the intervention among Latinos receiving care at community clinics demonstrated improved initial colorectal cancer screening uptake, awareness, and perceived susceptibility.

DISCUSSION

Inherent in the transcreation process was learner involvement that informed essential modification and adaptation of the materials. The transcreation methods led to the development of a culturally salient intervention that maintained theoretical integrity and message intent as well as behavioral activation. Findings have broad implications for the creation and transfer of EBIs to new audiences for greater adoption, engagement, and 'reach' of interventions.

PRACTICAL VALUE

Transcreation aligns with a growing paradigm shift in health communication science that brings to light the beneficial effect that construction and application of cultural knowledge has on patient education toward health equity.

Equity and behavioral digital health interventions: Strategies to improve benefit and reach

BACKGROUND

Behavioral digital health interventions (e.g., mobile apps, websites, wearables) have been applied widely to improve health outcomes. However, many groups (e.g., people with low income levels, people who are geographically isolated, older adults) may face obstacles to technology access and use. In addition, research has found that biases and stereotypes can be embedded within digital health interventions. As such, behavioral digital health interventions that intend to improve overall population health may unintentionally widen health-related inequities.

PURPOSE

This commentary offers guidance and strategies to mitigate these risks when using technology as a means for delivering a behavioral health intervention.

METHODS

A collaborative working group from Society of Behavioral Medicine's Health Equity Special Interest Group developed a framework to center equity in the development, testing and dissemination of behavioral digital health interventions.

RESULTS

We introduce Partner, Identify, Demonstrate, Access, Report (PIDAR), a 5-point framework to avoid the creation, perpetuation, and/or widening of health inequities in behavioral digital health work.

CONCLUSIONS

It is critically important to prioritize equity when conducting digital health research. The PIDAR framework can serve as a guide for behavioral scientists, clinicians and developers.

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.

Cancer screening educational interventions in rural and farmworker communities: a systematic literature review

OBJECTIVES

Men and women living in rural communities of the United States (US) are less likely than those in urban or suburban communities to be up to date with cancer screenings. Delayed screening contributes to later stage at diagnosis and higher cancer mortality for individuals living in rural areas. These effects may be compounded in some rural subpopulations (e.g. migrant and seasonal farmworkers). This systematic review examines educational interventions aimed at increasing colorectal, breast, prostate, oral, and/or cervical cancer screening in the rural US, with special consideration for the farmworker subpopulation.

DESIGN

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, our systematic literature review employed the following databases: Ovid MEDLINE, CINAHL Complete, Embase, and Web of Science. Search terms included, but were not limited to 'rural,' 'cancer screening,' 'farmworker,' and 'cancer prevention.' Eligible studies featured an educational intervention implemented in agricultural or rural US settings with a cancer screening behavioral outcome, male and/or female participants, and were published in English between 2002 and 2020. Article screening and data extraction were conducted by two independent reviewers.

RESULTS

Twenty-six articles were eligible. Of the six studies focused on the farmworker population (n=2,732), 61.75% of participants reported Hispanic ethnicity. Of the sixteen studies on unspecified rural communities reporting participant race/ethnicity (n=10,442), 39.29% reported Black/African American race. Efficacious interventions included culturally-targeted educational materials, lay health advisors (LHAs), and components that addressed practical barriers (e.g. financial or logistical).

CONCLUSION

Results demonstrate the value of LHAs and targeted education to increase screening for multiple cancer types in rural communities. Prospective research should incorporate and facilitate access to screening and provider-level and/or organizational-level interventions to increase overall impact.

ABBREVIATIONS

HPV: human papillomavirus; LHA: lay health advisors; MeSH: Medical Subject Headings; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; US: United States.

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.

County-Level Factors Associated With HPV Vaccine Coverage Among 11-Year-Olds to 12-Year-Olds Living in Florida in 2019

BACKGROUND

In the United States, human papillomavirus (HPV) vaccine initiation and up-to-date (UTD) status are associated with multiple factors at the individual level such as racial/cultural (e.g., race, immigration status), socioeconomic status (e.g., living below poverty level, education), and healthcare access (e.g., insurance status/type). HPV vaccination rates differ dramatically by US geographic areas and within states. To tailor interventions to local areas, it is important to understand county-level characteristics associated with HPV vaccination rates.

METHODS

Using linear regression, we assessed the association between county-level HPV vaccination initiation and UTD rates for 11-year-olds to 12-year-olds in Florida (collected from the Florida SHOTS immunization registry) and county-level variables. Factors found significant in bivariate analysis and with a variance influence factors <4 were included in multivariable models.

RESULTS

In 2019, county-level HPV vaccine coverage among Florida 11-year-olds to 12-year-olds ranged from 31% to 92% initiation and 3%-36% UTD. Counties with the lowest HPV vaccine coverage were concentrated in Florida's North-Central and Panhandle regions. In multivariable models, counties with primarily rural populations had lower vaccination initiation and UTD coverage. Above and beyond the association with rurality, UTD coverage was associated with family physicians per 100,000 residents and uninsured or Medicaid-enrolled populations.

DISCUSSION

While Florida county-level HPV vaccine initiation rates among 11-year-olds to 12-year-olds varied by county in 2019, UTD rates remained universally low despite recommendations. Tailoring interventions toward healthcare access in rural communities may increase HPV vaccine coverage.

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.

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.

Cancer disparities in the context of rurality: risk factors and screening across various U.S. rural classification codes

PURPOSE

Prior cancer research is limited by inconsistencies in defining rurality. The purpose of this study was to describe the prevalence of cancer risk factors and cancer screening behaviors across various county-based rural classification codes, including measures reflecting a continuum, to inform our understanding of cancer disparities according to the extent of rurality.

METHODS

Using an ecological cross-sectional design, we examined differences in cancer risk factors and cancer screening behaviors from the Behavioral Risk Factor Surveillance System and National Health Interview Survey (2008-2013) across rural counties and between rural and urban counties using four rural-urban classification codes for counties and county-equivalents in 2013: U.S. Office of Management and Budget, National Center for Health Statistics, USDA Economic Research Service's rural-urban continuum codes, and Urban Influence Codes.

RESULTS

Although a rural-to-urban gradient was not consistently evident across all classification codes, the prevalence of smoking, obesity, physical inactivity, and binge alcohol use increased (all p_trend < 0.03), while colorectal, cervical and breast cancer screening decreased (all p_trend < 0.001) with increasing rurality. Differences in the prevalence of risk factors and screening behaviors across rural areas were greater than differences between rural and urban counties for obesity (2.4% vs. 1.5%), physical activity (2.9% vs. 2.5%), binge alcohol use (3.4% vs. 0.4%), cervical cancer screening (6.8% vs. 4.0%), and colorectal cancer screening (4.4% vs. 3.8%).

CONCLUSIONS

Rural cancer disparities persist across multiple rural-urban classification codes, with marked variation in cancer risk factors and screening evident within rural regions. Focusing only on a rural-urban dichotomy may not sufficiently capture subpopulations of rural residents at greater risk for cancer and cancer-related mortality.

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.

Strategies and Lessons Learned During Cleaning of Data From Research Panel Participants: Cross-sectional Web-Based Health Behavior Survey Study

Background

The use of web-based methods to collect population-based health behavior data has burgeoned over the past two decades. Researchers have used web-based platforms and research panels to study a myriad of topics. Data cleaning prior to statistical analysis of web-based survey data is an important step for data integrity. However, the data cleaning processes used by research teams are often not reported.

Objective

The objectives of this manuscript are to describe the use of a systematic approach to clean the data collected via a web-based platform from panelists and to share lessons learned with other research teams to promote high-quality data cleaning process improvements.

Methods

Data for this web-based survey study were collected from a research panel that is available for scientific and marketing research. Participants (N=4000) were panelists recruited either directly or through verified partners of the research panel, were aged 18 to 45 years, were living in the United States, had proficiency in the English language, and had access to the internet. Eligible participants completed a health behavior survey via Qualtrics. Informed by recommendations from the literature, our interdisciplinary research team developed and implemented a systematic and sequential plan to inform data cleaning processes. This included the following: (1) reviewing survey completion speed, (2) identifying consecutive responses, (3) identifying cases with contradictory responses, and (4) assessing the quality of open-ended responses. Implementation of these strategies is described in detail, and the Checklist for E-Survey Data Integrity is offered as a tool for other investigators.

Results

Data cleaning procedures resulted in the removal of 1278 out of 4000 (31.95%) response records, which failed one or more data quality checks. First, approximately one-sixth of records (n=648, 16.20%) were removed because respondents completed the survey unrealistically quickly (ie, <10 minutes). Next, 7.30% (n=292) of records were removed because they contained evidence of consecutive responses. A total of 4.68% (n=187) of records were subsequently removed due to instances of conflicting responses. Finally, a total of 3.78% (n=151) of records were removed due to poor-quality open-ended responses. Thus, after these data cleaning steps, the final sample contained 2722 responses, representing 68.05% of the original sample.

Conclusions

Examining data integrity and promoting transparency of data cleaning reporting is imperative for web-based survey research. Ensuring a high quality of data both prior to and following data collection is important. Our systematic approach helped eliminate records flagged as being of questionable quality. Data cleaning and management procedures should be reported more frequently, and systematic approaches should be adopted as standards of good practice in this type of research.

Cancer Screening Among Rural and Urban Clinics During COVID-19: A Multistate Qualitative Study

PURPOSE

The effects of COVID-19 have been understudied in rural areas. This study sought to (1) identify cancer screening barriers and facilitators during the pandemic in rural and urban primary care practices, (2) describe implementation strategies to support cancer screening, and (3) provide recommendations.

METHODS

A qualitative study was conducted (N = 42) with primary care staff across 20 sites. Individual interviews were conducted through videoconference from August 2020 to April 2021 and recorded, transcribed, and analyzed using deductive and inductive coding (hybrid approach) in NVivo 12 Plus. Practices included federally qualified health centers, tribal health centers, rural health clinics, hospital/health system-owned clinics, and academic medical centers across 10 states including urban (55%) and rural (45%) sites. Staff included individuals serving in the dual role of health care provider and administrator (21.4%), health care administrator (23.8%), physician (19.0%), advanced practice provider (11.9%), or resident (23.8%). The interviews assessed perceptions about cancer screening barriers and facilitators, implementation strategies, and future recommendations.

RESULTS

Participants reported multilevel barriers to cancer screening including policy-level (eg, elective procedure delays), organizational (eg, backlogs), and individual (eg, patient cancellation). Several facilitators to screening were noted, such as home-based testing, using telehealth, and strong partnerships with referral sites. Practices used strategies to encourage screening, such as incentivizing patients and providers and expanding outreach. Rural clinics reported challenges with backlogs, staffing, telehealth implementation, and patient outreach.

CONCLUSION

Primary care staff used innovative strategies during the pandemic to promote cancer screening. Unresolved challenges (eg, backlogs and inability to implement telehealth) disproportionately affected 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.

Change in Neurocognitive Performance Among Patients with Non-Hodgkin Lymphoma in the First Year after Chimeric Antigen Receptor T Cell Therapy

The success of chimeric antigen receptor (CAR) T cell therapy in treating patients with relapsed/refractory hematologic malignancies is leading to a growing number of survivors treated with this regimen. To our knowledge, no previous studies have examined neurocognitive performance in adult CAR T cell therapy recipients, despite high rates of neurotoxicity and cytokine release syndrome (CRS) in the acute treatment period. This study examined changes in neurocognitive performance in the first year after CAR T cell therapy for non-Hodgkin lymphoma (NHL). Putative risk factors for worsening neurocognitive performance (eg, neurotoxicity, CRS) were explored as well. Neurocognition was assessed before initiation of CAR T cell therapy and at 30, 90, and 360 days post-treatment. Clinical variables were abstracted from medical records. Mixed models were used to examine change in total neurocognitive performance (TNP) and cognitive domains (ie, attention, executive function, verbal ability, immediate and delayed memory, and visuospatial abilities). Among 117 participants (mean age, 61 years; 62% male), TNP and executive function declined slightly on average from baseline to day 90 and then improved from day 90 to day 360 (P < .04). Small but significant linear declines in visuospatial ability on average were also observed over time (P = .03). Patients who had 4 or more lines of previous therapy and those with worse neurotoxicity (but not CRS) demonstrated worse TNP. CAR T cell therapy recipients reported transient or persistent deterioration in several cognitive domains, although changes were slight. These findings may be useful when educating future patients on what to expect when receiving CAR T cell therapy.

Using the Electronic Health Record to Characterize the Hepatitis C Virus Care Cascade

OBJECTIVES

Chronic hepatitis C virus (HCV) infection is one of the main causes of hepatocellular carcinoma. Before initiating a multilevel HCV screening intervention, we sought to (1) describe concordance between the electronic health record (EHR) data warehouse and manual medical record review in recording aspects of HCV testing and treatment and (2) estimate the percentage of patients with chronic HCV infection who initiated and completed HCV treatment using manual medical record review.

METHODS

We examined the medical records for 177 patients (100 randomly selected patients born during 1945-1965 without evidence of HCV testing and 77 adult patients of any birth cohort who had completed HCV testing) with a primary care or relevant specialist visit at an academic health care system in Tampa, Florida, from 2015 through 2018. We used the Cohen κ coefficient to examine the degree of concordance between the searchable data warehouse and the medical record review abstractions. Descriptive statistics characterized referral to and receipt of treatment among patients with chronic HCV infection from medical record review.

RESULTS

We found generally good concordance between the data warehouse abstraction and medical record review for HCV testing data (κ ranged from 0.66 to 0.87). However, the data warehouse failed to capture data on HCV treatment variables. According to medical record review, 28 patients had chronic HCV infection; 16 patients were prescribed treatment, 14 initiated treatment, and 9 achieved and had a reported posttreatment undetected HCV viral load.

CONCLUSIONS

Using data warehouse data provides generally reliable HCV testing information. However, without the use of natural language processing and purposeful EHR design, manual medical record reviews will likely be required to characterize treatment initiation and completion.

A multilevel, low literacy dual language intervention to promote colorectal cancer screening in community clinics in Florida: A randomized controlled trial

One of the largest disparities in cancer mortality in the United States occurs with colorectal cancer (CRC). The objectives of this multilevel two-arm intervention trial were to compare the efficacy of two interventions to promote CRC screening (CRCS) with fecal immunochemical test (FIT) and examine sociodemographic and psychosocial predictors of FIT screening. Individuals ages 50-75 (n = 326) who were not up-to-date with CRCS, could understand English or Spanish, and were at average CRC risk were recruited from two federally qualified health centers (FQHCs) in Florida. Prior to intervention, CRCS rates in the FQHCs were 27.1% and 32.9%, respectively. Study enrollment occurred April 2018-November 2019. System-level intervention components included leveraging electronic medical record (EMR) systems and delivering patient reminders. Participants were randomized to C-CARES (education+FIT) or C-CARES Plus (C-CARES+personalized coaching [for those not completing FIT within 90 days]). Primary outcome was completed FIT returned <1 year. Primary outcome analyses were performed using logistic regression. 225 participants completed FIT (69.0% [95% CI: 64.0-74.0%]), with no significant difference in FIT uptake by intervention arm (67.3% C-CARES Plus vs. 70.8% C-CARES; p = .49). FIT uptake was significantly higher among patients who received intervention materials in Spanish (77.2%) compared to those who received materials in English (63.2%, p < .01). The personalized coaching in the C-CARES Plus arm did not appear to provide added benefit beyond the C-CARES intervention. Multilevel approaches that include EMR prompts, reminders, FIT access, and provision of low-literacy, language-concordant education can support efforts to improved community clinics' CRCS rates. Future efforts should focus on repeat FIT screening. Trial registration: The trial was registered at ClinicalTrials.gov (NCT03906110).

Feasibility, acceptability, and effectiveness of a decision aid versus an informational website to promote clinical trial decision-making among cancer patients: A pilot randomized controlled trial

OBJECTIVE

To assess intervention feasibility and acceptability, and compare the effectiveness of the CHOICES Decision Aid (DA) versus the National Cancer Institute (NCI) Cancer Clinical Trials (CCT) website to improve knowledge about CCTs and preparedness to make an informed decision.

METHODS

Oncology patients (n = 101) with a scheduled clinic visit were enrolled and randomized. Decision-making variables were collected at two timepoints. Post-intervention scores were examined via paired t-tests and multivariate regression analyses. Predictors of the magnitudes of the change in scores were examined in multivariable regression analyses.

RESULTS

The interventions were feasible to implement and acceptable to participants. Both interventions increased objective and subjective knowledge, improved clarity of opinions, and reduced decisional conflict (p-values < 0.01). Improvements in the belief that one could find out about CCTs were observed in the CHOICES DA arm (p < 0.001). Multivariable analyses controlling for educational attainment showed no significant differences in the magnitude of change in outcome variables between intervention arms, but did find that improvements in some variables in the NCI arm - but not CHOICES DA arm - were associated with previous educational attainment.

CONCLUSIONS

Interventions were feasible to implement and acceptable. Improvements in knowledge and decision-making outcomes were observed in both arms, supporting the view that interventions to improve CCT decision making are effective and feasible. Our results suggest that the CHOICES DA may be more effective than an informational website in improving decision-making outcomes regardless of participants' educational attainment.

PRACTICE IMPLICATIONS

CCT resources should support informed decision-making among all cancer survivors, regardless of educational attainment.

Online health information seeking and eHealth literacy among Spanish language- dominant Latinos receiving care in a community clinic (Preprint)

Background

eHealth literacy is the ability to seek, obtain, and decipher online health information (OHI) for health and disease management. Rapid developments in eHealth (eg, health care services and online information) place increased demands on patients to have high eHealth literacy levels. Yet, greater emphasis on eHealth may disproportionately affect groups with limited eHealth literacy. Cultural background, language, and eHealth literacy are influential considerations affecting health care and information access, health care use, and successful eHealth resource use, and they may influence OHI seeking for behavioral change toward cancer prevention.

Objective

This study aimed to characterize the extent of OHI seeking and eHealth literacy among Spanish-dominant (SD) Latino adults aged 50 to 75 years. Further, we aimed to examine potential associations between sociodemographic characteristics, Preventive Health Model (PHM) constructs, OHI-seeking behaviors, and eHealth literacy, separately.

Methods

Participants (N=76) self-identified as Latino, were enrolled in a colorectal cancer (CRC) screening intervention, were aged 50 to 75 years, were at average risk for CRC, were not up to date with CRC screening, and preferred receiving health information in Spanish. We describe participants’ sociodemographic characteristics, PHM constructs, OHI-seeking behaviors, and eHealth literacy—among those seeking OHI—assessed at enrollment. Descriptive analyses were first performed for all variables. Next, primary univariate logistic analyses explored possible associations with OHI seeking. Finally, using data from those seeking OHI, exploratory univariate analyses sought possible associations with eHealth literacy.

Results

A majority (51/76, 67%) of the participants were female, 62% (47/76) reported not having graduated high school, and 41% (31/76) reported being unemployed or having an annual income of less than US $10,000. Additionally, 75% (57/76) of the participants reported not having health insurance. In total, 71% (54/76) of the participants reported not having sought OHI for themselves or others. Univariate logistic regression suggested that higher educational attainment was significantly associated with an increased likelihood of having sought OHI (odds ratio 17.4, 95% CI 2.0-150.7; P=.009). Among those seeking OHI (22/76, 29%), 27% (6/22) were at risk of having low eHealth literacy based on an eHealth Literacy Scale score of less than 26. Among OHI seekers (22/76, 29%), an examination of associations found that higher eHealth literacy was associated with greater self-efficacy for screening with the fecal immunochemical test (β=1.20, 95% CI 0.14-2.26; P=.02).

Conclusions

Most SD Latino participants had not sought OHI for themselves or others (eg, family or friends), thus potentially limiting access to beneficial online resources. Preliminary findings convey that higher eHealth literacy occurs among those with higher self-efficacy for CRC screening. Findings inform areas of focus for future larger-scale investigations, including further exploration of reasons for not seeking OHI among SD Latino adults and an in-depth look at eHealth literacy and cancer screening behaviors.

Trial Registration

ClinicalTrials.gov NCT03078361; https://clinicaltrials.gov/ct2/show/NCT03078361

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.

Meta-Analysis of Quality of Life in Cancer Patients Treated with Immune Checkpoint Inhibitors

BACKGROUND

Trials of immune checkpoint inhibitors (ICIs) have published patient-reported quality of life (QOL), but the size and heterogeneity of this literature can make patient education difficult. This meta-analysis aimed to describe change in QOL and symptomatology in patients receiving ICIs for cancer.

METHODS

Following PRISMA guidelines, databases were searched through November 2019 for articles or abstracts of prospective, original studies reporting longitudinal QOL in adult cancer patients treated with ICIs. The prespecified primary outcomes were change in global QOL among patients treated with ICIs and difference in change since baseline in global QOL between patients treated with ICI vs. non-ICI active treatment. Secondary outcomes included physical functioning and symptomatology. All statistical tests were 2-sided.

RESULTS

Twenty-six of 20,323 publications met inclusion criteria. Global QOL did not change over time in patients treated with ICIs (k = 26, n = 6,974, P = .19). Larger improvements in global QOL was observed in patients receiving ICI vs. non-ICI regimens (k = 16, ICI n = 3,588, non-ICI n = 2,948, P < .001). Physical functioning did not change in patients treated with ICIs (k = 14, n = 3,169, P=.47); there were no differences in mean change between ICI vs. non-ICI regimens (k = 11, n = 4,630, P=.94. Regarding symptoms, appetite loss, insomnia, and pain severity decreased but dyspnea severity increased in patients treated with ICIs (k = 14, n = 3,243-3,499) (Ps < 0.001). Insomnia severity was higher in patients treated with ICIs than non-ICI regimens (k = 11, n = 4,791) (P < .001).

CONCLUSIONS

This study is among the first to quantitatively summarize QOL in patients treated with ICIs. Findings suggest ICI recipients report no change in global QOL and higher QOL than patients treated with non-ICI regimens.

Considering religion and spirituality in precision medicine

The emerging era of precision medicine (PM) holds great promise for patient care by considering individual, environmental, and lifestyle factors to optimize treatment. Context is centrally important to PM, yet, to date, little attention has been given to the unique context of religion and spirituality (R/S) and their applicability to PM. R/S can support and reinforce health beliefs and behaviors that affect health outcomes. The purpose of this article is to discuss how R/S can be considered in PM at multiple levels of context and recommend strategies for integrating R/S in PM. We conducted a descriptive, integrative literature review of R/S at the individual, institutional, and societal levels, with the aim of focusing on R/S factors with a high level of salience to PM. We discuss the utility of considering R/S in the suitability and uptake of PM prevention and treatment strategies by providing specific examples of how R/S influences health beliefs and practices at each level. We also propose future directions in research and practice to foster greater understanding and integration of R/S to enhance the acceptability and patient responsiveness of PM research approaches and clinical practices. Elucidating the context of R/S and its value to PM can advance efforts toward a more whole-person and patient-centered approach to improve individual and population health.

Computer-tailored intervention increases colorectal cancer screening among low-income African Americans in primary care: Results of a randomized trial

INTRODUCTION

Although African Americans have the highest colorectal cancer (CRC) incidence and mortality rates of any racial group, their screening rates remain low.

STUDY DESIGN/PURPOSE

This randomized controlled trial compared efficacy of two clinic-based interventions for increasing CRC screening among African American primary care patients.

METHODS

African American patients from 11 clinics who were not current with CRC screening were randomized to receive a computer-tailored intervention (n = 335) or a non-tailored brochure (n = 358) designed to promote adherence to CRC screening. Interventions were delivered in clinic immediately prior to a provider visit. Univariate and multivariable logistic regression models analyzed predictors of screening test completion. Moderators and mediators were determined using multivariable linear and logistic regression analyses.

RESULTS

Significant effects of the computer-tailored intervention were observed for completion of a stool blood test (SBT) and completion of any CRC screening test (SBT or colonoscopy). The colonoscopy screening rate was higher among those receiving the computer-tailored intervention group compared to the nontailored brochure but the difference was not significant. Predictors of SBT completion were: receipt of the computer-tailored intervention; being seen at a Veterans Affairs Medical Center clinic; baseline stage of adoption; and reason for visit. Mediators of intervention effects were changes in perceived SBT barriers, changes in perceived colonoscopy benefits, changes in CRC knowledge, and patient-provider discussion. Moderators of intervention effects were age, employment, and family/friend recommendation of screening.

CONCLUSION

This one-time computer-tailored intervention significantly improved CRC screening rates among low-income African American patients. This finding was largely driven by increasing SBT but the impact of the intervention on colonoscopy screening was strong. Implementation of a CRC screening quality improvement program in the VA site that included provision of stool blood test kits and follow-up likely contributed to the strong intervention effect observed at that site. The trial is registered at ClinicalTrials.gov as NCT00672828.

Cervical cancer screening in the United States: Challenges and potential solutions for underscreened groups

Cervical cancer screening rates in the United States are generally high, yet certain groups demonstrate disparities in screening and surveillance. Individuals at greatest risk for cervical cancer are often from marginalized or underserved groups who do not participate in regular screening for a variety of reasons. Using the Population-based Research to Optimize the Screening Process (PROSPR) Trans-Organ Conceptual Model, including concepts of individual-, provider-, facility-, system-, or policy-level factors, we provide a commentary to highlight reasons for low screening participation among subgroups in the U.S. These include racial and ethnic minorities, rural residents, sexual and gender minorities, those with limited English proficiency, those with particular religious beliefs, and various health conditions. We describe barriers and offer potential solutions for each group. In addition, we discuss cross-cutting barriers to screening including difficulty interacting with the healthcare system (limited knowledge and health literacy, lack of provider recommendation/contact), financial (cost, lack of insurance), and logistical barriers (e.g., lack of usual source of care, competing demands, scheduling issues). Solutions to address these barriers are needed to improve screening rates across all underscreened groups. Changes at state and national policy levels are needed to address health insurance coverage. Mobile screening, ensuring that interpreters are available for all visits, and targeted in reach at non-gynecological visits can further overcome barriers. Employing community outreach workers can increase community demand for screening, and patient navigators can improve adherence to both screening and follow-up diagnostic evaluation. HPV self-sampling can address multiple barriers to cervical cancer screening.

Learner Verification: A Methodology to Create Suitable Education Materials

Background:

Learner verification and revision (LV&R) is a research methodological approach to inform educational message design with the aim of producing suitable, actionable, and literacy appropriate messages to aid in awareness, adoption of healthy behaviors, and decision-making. It consists of a series of participatory steps that engage users throughout materials development, revision, and refinement. This approach is congruent with Healthy People 2030 communication objectives to improve access to information among diverse, multicultural, multilingual populations, and enhance health care quality toward health equity.

Brief description of activity:

To illustrate LV&R, we describe its use in three cancer education projects that produced targeted information about (1) inherited breast cancer among African Americans (brochure); (2) colorectal cancer screening among Latinos (photo novella and DVD); and (3) smoking-relapse prevention among patients receiving cancer treatment (video). We discuss rationale for its application in the three exemplars and extrapolate lessons learned from our experiences when using this approach.

Implementation:

A qualitative approach entailing individual or group-based discussions helped to examine the elements of learner verification (i.e., attraction, comprehension, self-efficacy, cultural acceptability, persuasion). The following steps are reported: (1) preparation of materials, interview guide, and recruitment; (2) interviewing of participants; and (3) evaluation of responses. Data were analyzed by use of a coding system that placed participant responses from each of the elements into data summary matrices. Findings informed revisions and refinement of materials.

Results:

LV&R was effectively applied across the three cancer education projects to enhance the suitability of the materials. As a result, the materials were improved by using clearer, more salient language to enhance comprehension and cultural acceptability, by integrating design elements such as prompts, headers, and stylistic edits to reduce text density, incorporating preferred colors and graphics to improve aesthetic appeal, and including actionable terms and words to bolster motivation and self-efficacy.

Lessons learned:

Results suggest that LV&R methodology can improve suitability of education materials through systematic, iterative steps that engage diverse, multicultural, multilingual populations. This approach is a critical participa-tory strategy toward health equity, and is appropriate in a variety of education, research, and clinical practice settings to improve health communications. [HLRP: Health Literacy Research and Practice. 2021;5(1):e49–e59.]

Plain Language Summary:

This article describes the use of a systematic approach called “learner verification” used for developing educational materials. This approach involves obtaining feedback from audience members to ensure that the information is understandable, attractive in design, motivating, and culturally relevant.

Abstract PO-258: Cancer risk factors and screening across various U.S. rural classification codes: Cancer disparities in the context of rurality

Incidence and mortality of many preventable cancers are higher in rural compared to urban U.S. regions. However, prior research is limited by methodological inconsistencies in defining rurality, and has largely focused on a rural-urban dichotomy which ignores potential variability of cancer risk factors and outcomes within rural and urban settings. These limitations hamper data interpretation and may lead to inequitable distribution of resources to address disparities. In this study, we describe cancer risk factors and screening across various U.S. rural-urban classification codes to inform our understanding of cancer disparities across the rural to urban continuum. We examined the prevalence and trends in cancer risk factors and screening across the following rural-urban classification codes for counties and county-equivalents in 2013; U.S. Office of Management and Budget (OMB), National Center for Health Statistics (NCHS), U.S. Department of Agriculture, Economic Research Service’s rural-urban continuum codes (RUCC), and Urban Influence Codes (UIC). County-level data on demographics (age, race, education, income, poverty level, insurance status), and cancer risk factors (obesity, physical inactivity, alcohol consumption), including cancer screening (colorectal, cervical and breast) were obtained from the U.S. Census Bureau, Behavioral Risk Factor Surveillance System, and National Health Interview Survey from 2008-2013. Overall, rural counties’ populations were more likely to be older, white, and uninsured with lower educational attainment and household income than urban counties (all ptrend&lt;0.001). Across all classification codes, the prevalence of smoking, obesity, physical inactivity, and binge alcohol use increased (all ptrend&lt;0.03), while colorectal, cervical and breast cancer screening decreased (all ptrend&lt;0.001) with increasing rurality. Variation in the prevalence of cancer risk factors and screening was also evident within rural regions. For example, cervical cancer screening ranged from 67.6% to 74.7%, breast cancer screening from 65.4% to 68.2%, and colorectal cancer screening from 52.8% to 57.2% across rural counties. Our findings suggest that rural cancer disparities persist across multiple rural-urban classification codes, with marked variation in cancer risk factors and screening apparent within rural regions. Thus, focusing on a rural-urban dichotomy may fail to identify subpopulations of rural residents at greater risk for cancer and cancer-related mortality. As such, the variation in cancer disparities within rural regions, including persistent racial/ethnic and socioeconomic differences, should be considered in future cancer control research to inform the development of targeted policies and strategies to address rural cancer disparities.

Citation Format: Kelly A. Hirko, Huiwen Xu, Laura Q. Rogers, Michelle Y. Martin, Siddhartha Roy, Kimberly M. Kelly, Shannon M. Christy, Kimlin T. Ashing, Jean C. Yi, Marquita W. Lewis-Thames, Cathy D. Meade, Qian Lu, Clement K. Gwede, Julianna Nemeth, Rachel M. Ceballos, Usha Menon, Katie Cueva, Karen Yeary, Lisa Klesges, Monica L. Baskin, Kassandra I. Alcaraz, Sabrina Ford. Cancer risk factors and screening across various U.S. rural classification codes: Cancer disparities in the context of rurality [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-258.

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.

An RCT to Increase Breast and Colorectal Cancer Screening

INTRODUCTION

Adherence to breast and colorectal cancer screenings reduce mortality from these cancers, yet screening rates remain suboptimal. This 2 × 2 RCT compared 3 theory-based interventions to usual care to simultaneously increase breast and colon cancer screening in women who were nonadherent to both screenings at study entry.

DESIGN

RCT.

SETTING/PARTICIPANTS

Women (n=692) who were nonadherent to both breast and colon cancer screenings and aged 51-75 years were recruited. Enrollment, intervention delivery, and data collection were completed between 2013 and 2017, and data analyzed in 2018.

INTERVENTION

The randomized intervention included the following 4 groups: 3 intervention arms (personally tailored messages using a web-based intervention, phone delivery by a trained navigator, or both) compared with usual care. Women at an average risk for colon cancer were allowed to select either colonoscopy or stool test as their preferred colon cancer screening. Mammography was promoted for breast cancer screening.

MAIN OUTCOME MEASURES

Outcome data at 6 months included self-report and medical records for screening activity.

RESULTS

All intervention arms significantly increased receipt of either a mammogram or stool test compared with control (web: p<0.0249, phone: p<0.0001, web + phone: p<0.0001). When considering receipt of both mammogram and stool test, all intervention arms were significantly different from usual care (web: p<0.0249, phone: p<0.0003, web + phone: p<0.0001). In addition, women who were adherent to mammography had a 4.5 times greater odds of becoming adherent to colonoscopy.

CONCLUSIONS

The tailored intervention simultaneously supporting both breast and colon cancer screenings significantly improved rates of obtaining one of the screenings and increased receipt of both tests.

TRIAL REGISTRATION

This study is registered with the clinical trials identifier NCT03279198 at www.clinicaltrials.gov.

Demographic and psychosocial factors associated with limited health literacy in a community-based sample of older Black Americans

OBJECTIVES

Individuals with limited health literacy often experience suboptimal health outcomes. This study examined the frequency of limited health literacy and demographic and psychosocial factors associated with limited health literacy in a sample of older Black Americans.

METHODS

Participants (n = 330) enrolled in a community-based intervention to promote colorectal cancer (CRC) screening completed baseline surveys assessing health literacy with the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) test, CRC awareness, cancer fatalism, Preventive Health Model (PHM) constructs, and demographics.

RESULTS

Approximately 52% of participants had limited health literacy, the REALM-R score was 5.4 (SD = 2.7). Univariable correlates of limited health literacy were gender, employment, income, prior screening, cancer fatalism, CRC awareness, and PHM constructs (religious beliefs, salience/coherence, perceived susceptibility). Multivariable correlates of limited health literacy were male gender (OR = 2.3, CI = 1.4-3.8), unable to work (OR = 2.8, CI = 1.3-6.1), lower household income (OR = 3.0, CI = 1.6, 5.5), and higher PHM religious beliefs (OR = 1.1, CI = 1.0-1.2).

CONCLUSION

Limited health literacy was associated with multiple complex factors. Interventions should incorporate patient health literacy and low-literacy materials that can be delivered through multiple channels.

PRACTICE IMPLICATIONS

Future studies are needed to understand the role of health literacy in an individual's health behavior and the provision of effective healthcare.

Economic Evaluation of Tailored Web versus Tailored Telephone-Based Interventions to Increase Colorectal Cancer Screening among Women

Screening for colorectal cancer is cost-effective, but many U.S. women are nonadherent, and the cost-effectiveness of web-based tailored screening interventions is unknown. A randomized controlled trial, COBRA (Increasing Colorectal and Breast Cancer Screening), was the source of information for the economic evaluation. COBRA compared screening among a Usual Care group to: (i) tailored Phone Counseling intervention; (ii) tailored Web intervention; and (iii) tailored Web + Phone intervention groups. A sample of 1,196 women aged 50 to 75 who were nonadherent to colorectal cancer screening were recruited from Indiana primary care clinics during 2013 to 2015. Screening status was obtained through medical records at recruitment with verbal confirmation at consent, and at 6-month follow-up via medical record audit and participant self-report. A "best sample" analysis and microcosting from the patient and provider perspectives were applied to estimate the costs and effects of the interventions. Statistical uncertainty was analyzed with nonparametric bootstrapping and net benefit regression analysis. The per participant cost of implementing the Phone Counseling, Web-based, and Web + Phone Counseling interventions was $277, $314, and $336, respectively. The incremental cost per person screened for the Phone Counseling compared with no intervention was $995, while the additional cost of Web and the Web + Phone compared with Phone Counseling did not yield additonal persons screened. Tailored Phone Counseling significantly increased colorectal cancer screening rates compared with Usual Care. Tailored Web interventions did not improve the screening rate compared with the lower cost Phone Counseling intervention.

Impact of Tailored Interventions on Receipt of a Preference-Concordant Colorectal Cancer Screening Test

Background. Individuals at average risk for colorectal cancer (CRC) have multiple test options. Preference for a specific test modality may affect decision making about CRC screening. The current study examined 1) the sociodemographic and health belief characteristics of average-risk participants with a test preference for stool blood test (SBT) versus those with a preference of colonoscopy, and following receipt of a tailored CRC screening intervention, 2) the percentage of participants who completed a preference-concordant CRC screening test, and 3) the sociodemographic, health care experience, and health belief characteristics and intervention group(s) associated with completion of a preference-concordant screening test. Methods. Participants (N = 603) were female, aged 50 to 75 years, at average CRC risk, not currently up-to-date with CRC screening recommendations, had Internet access, and were randomized to receive 1 of 3 tailored CRC screening promotion interventions. Multivariable logistic regression analyses were conducted. Results. Most women (64%) preferred SBT, whereas 36% preferred colonoscopy. There were significant differences in test preference by age, stage of change for the specific tests, perceived benefits of CRC screening, perceived barriers to both tests, and self-efficacy for colonoscopy. Two hundred thirty participants completed CRC screening at 6 months post-intervention. Of those, most (84%) completed a test concordant with their preference. Multivariable analyses revealed that compared with participants completing a preference-discordant test, those completing a preference-concordant test were older (P = 0.01), had health insurance (P < 0.05), and were in the phone counseling-only group (P < 0.01). Conclusions. High levels of completion of preference-concordant CRC screening can be achieved by educating average-risk patients about the multiple screening test options, soliciting their preferences, and offering testing that is concordant with their preference.

A culturally and linguistically salient pilot intervention to promote colorectal cancer screening among Latinos receiving care in a Federally Qualified Health Center

Despite established benefits, colorectal cancer (CRC) screening is underutilized among Latinos/Hispanics. We conducted a pilot 2-arm randomized controlled trial evaluating efficacy of two intervention conditions on CRC screening uptake among Latinos receiving care in community clinics. Participants (N = 76) were aged 50-75, most were foreign-born, preferred to receive their health information in Spanish, and not up-to-date with CRC screening. Participants were randomized to either a culturally linguistically targeted Spanish-language fotonovela booklet and DVD intervention plus fecal immunochemical test [FIT] (the LCARES, Latinos Colorectal Cancer Awareness, Research, Education and Screening intervention group); or a non-targeted intervention that included a standard Spanish-language booklet plus FIT (comparison group). Measures assessed socio-demographic variables, health literacy, CRC screening behavior, awareness and beliefs. Overall, FIT uptake was 87%, exceeding the National Colorectal Cancer Roundtable's goal of 80% by 2018. The LCARES intervention group had higher FIT uptake than did the comparison group (90% versus 83%), albeit not statistically significant (P = 0.379). The LCARES intervention group was associated with greater increases in CRC awareness (P = 0.046) and susceptibility (P = 0.013). In contrast, cancer worry increased more in the comparison group (P = 0.045). Providing educational materials and a FIT kit to Spanish-language preferring Latinos receiving care in community clinics is a promising strategy to bolster CRC screening uptake to meet national targets.

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.

Examining the Durability of Colorectal Cancer Screening Awareness and Health Beliefs Among Medically Underserved Patients: Baseline to 12 months Post-Intervention

The current study examines changes in awareness and health beliefs from baseline to 12 months post-intervention following receipt of one of two colorectal cancer (CRC) educational interventions that aimed to promote CRC screening among a racially and ethnically diverse and medically underserved population. Participants (N = 270) were enrolled in a randomized controlled trial to increase CRC screening and completed both baseline and 12-month follow-up assessments. Participants were aged 50-75, at average CRC risk, not up-to-date with CRC screening guidelines, and receiving care at one of three community-based clinics. Participants were randomized to receive either a targeted, low-literacy intervention informed by the Preventive Health Model [PHM] (photonovella and DVD plus fecal immunochemical test [FIT]) or a non-targeted intervention (standard educational brochure plus FIT). Changes in CRC awareness and health beliefs from baseline to 12 months were examined both within and between intervention groups using Student's t tests. Participants in both intervention conditions demonstrated an increase in CRC awareness, PHM social influence, and trust in the healthcare system (all p's < .0001), with no significant between-group differences. Among those receiving the targeted intervention, there also was an increase in PHM salience (p < .05). Among individuals receiving the non-targeted intervention, there was an increase in PHM response efficacy (p < .01) and PHM self-efficacy (p < .0001). Both CRC screening interventions promoted positive changes in awareness and several health beliefs from baseline to 12 months, suggesting important benefits of CRC education. Regardless of whether education was targeted or non-targeted, providing CRC screening education successfully promoted durable changes in awareness and health beliefs.

Application of the ConNECT Framework to Precision Health and Health Disparities

BACKGROUND

An emphasis on precision health (PH) has stimulated precision medicine studies to focus on the interplay of biological, behavioral, and environmental factors with disease risks, treatments, prognoses, and outcomes affecting health disparities. It is imperative, as well, that improving health equity among underserved populations remains central to the efforts and aims of PH.

OBJECTIVES

The aim if this study was to apply the transdisciplinary ConNECT Framework: A Model for Advancing Behavioral Medicine Science and Practice to Foster Health Equity to PH by integrating a population health agenda for reducing health disparities.

METHODS

There are five ConNECT principles: (a) integrating context; (b) fostering a norm of inclusion; (c) ensuring equitable diffusion of innovations; (d) harnessing communication technology; and (e) prioritizing specialized training as an organizing framework to PH, including examples of how to integrate behavioral and socioecological determinants to better understand the contexts of individuals, systems, and place to design targeted treatments and interventions.

RESULTS

We describe proactive, actionable strategies for the systematic application of ConNECT Framework principles to address health equity via the PH initiative. Context and implications for nursing research and practice are also described.

DISCUSSION

The ConNECT Framework emphasizes that diversity inclusion is imperative for true population health benefit from PH, broadly in public health, behavioral medicine, medicine, and nursing, to equip health researchers and practitioners to account for contextual socioecologic data that can be aligned with biologic data for more population responsive and individually tailored interventions to prevent, diagnose, and treat diseases.

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.

A Randomized Trial to Compare a Tailored Web-Based Intervention and Tailored Phone Counseling to Usual Care for Increasing Colorectal Cancer Screening

BACKGROUND

Colorectal cancer mortality could be decreased with risk-appropriate cancer screening. We examined the efficacy of three tailored interventions compared with usual care for increasing screening adherence.

METHODS

Women (n = 1,196) ages 51 to 74, from primary care networks and nonadherent to colorectal cancer guidelines, were randomized to (1) usual care, (2) tailored Web intervention, (3) tailored phone intervention, or (4) tailored Web + phone intervention. Average-risk women could select either stool test or colonoscopy, whereas women considered at higher than average risk received an intervention that supported colonoscopy. Outcome data were collected at 6 months by self-report, followed by medical record confirmation (attrition of 23%). Stage of change for colorectal cancer screening (precontemplation or contemplation) was assessed at baseline and 6 months.

RESULTS

The phone (41.7%, P < 0.0001) and combined Web + phone (35.8%, P < 0.001) interventions significantly increased colorectal cancer screening by stool test compared with usual care (11.1%), with ORs ranging from 5.4 to 6.8 in models adjusted for covariates. Colonoscopy completion did not differ between groups except that phone significantly increased colonoscopy completion compared with usual care for participants in the highest tertile of self-reported fear of cancer.

CONCLUSIONS

A tailored phone with or without a Web component significantly increased colorectal cancer screening compared with usual care, primarily through stool testing, and phone significantly increased colonoscopy compared with usual care but only among those with the highest levels of baseline fear.

IMPACT

This study supports tailored phone counseling with or without a Web program for increasing colorectal cancer screening in average-risk women.

Educating Hispanic Women about Cervical Cancer Prevention: Feasibility of a Promotora-Led Charla Intervention in a Farmworker Community

Hispanic women suffer disproportionately from cervical cancer incidence and mortality compared with non-Hispanic Whites in the United States. Peer-led health education and coaching via charlas (talking circles) may improve cervical cancer screening and early detection rates among specific sub-groups such as farmworker communities. This pilot study sought to collect preliminary evaluation data about the feasibility of implementing a promotora-led cervical cancer education intervention among women from a farmworker community. The study took place between April 2014 and November 2014. Created based on an established network (Tampa Bay Community Cancer Network, TBCCN), in partnership with a local farmworker organization (Farmworkers Self-Help, Inc.), the project entailed refinement of a curriculum guide including Spanish-language educational resources (teaching cards). Social Cognitive Theory and the Health Belief Model provided the conceptual framework for the study. Six women from the farmworker community helped to refine the intervention and were trained as promotoras. They successfully delivered the program via charlas to a total of 60 participants who completed baseline and post-intervention measures on knowledge (cervical cancer/HPV), beliefs, self-efficacy, and intentions. Findings demonstrated gains in knowledge and self-efficacy among charla participants (P<.0001), and support the promise of a community-driven intervention that is delivered by promotoras who use their cultural knowledge and trustworthiness to educate women about cancer screening practices. Results also add to the literature on the use of a charla approach for cancer prevention education within a farmworker community to prompt discussions about health. Future research should evaluate peer-led programs on a larger scale and among other at-risk groups in other community settings.

Does Self-Efficacy Mediate the Relationships Between Social-Cognitive Factors and Intentions to Receive HPV Vaccination Among Young Women?

Drawing upon health behavior change theories, the current study examined whether self-efficacy mediated relationships between social-cognitive factors (i.e., perceived risk, perceived benefits, perceived barriers, perceived severity, and cue to action) and human papillomavirus (HPV) vaccination intentions among college women. Unvaccinated women (N = 115) aged 18 to 25 years attending a Midwestern university completed an anonymous web-based survey assessing study variables. Correlational analyses and mediation analyses were conducted. Self-efficacy mediated relationships between two social-cognitive factors (i.e., perceived barriers to HPV vaccination-indirect effect = -.16, SE = .06, 95% confidence interval [CI] = [-.31, -.06]-and perceived risk of HPV-related conditions-indirect effect = .16, SE = .09, 95% CI = [.01, .37]) and HPV vaccination intentions but was unrelated to the other three social-cognitive factors. Based on these findings, future research should test whether increasing self-efficacy through education on risk of HPV-related conditions and reducing barriers to HPV vaccination improves vaccine uptake in college women.

Health Literacy among Medically Underserved: The Role of Demographic Factors, Social Influence, and Religious Beliefs

The current study examined the sociodemographic and psychosocial variables that predicted being at risk for low health literacy among a population of racially and ethnically diverse patients accessing primary care services at community-based clinics. Participants (N = 416) were aged 50-75 years, currently not up-to-date with colorectal cancer (CRC) screening, at average CRC risk, and enrolled in a randomized controlled trial (RCT) aimed at promoting CRC screening. Participants completed a baseline interview that assessed health literacy as measured by Rapid Estimate of Adult Literacy in Medicine-Revised, sociodemographic factors, and psychosocial variables (e.g., health beliefs) prior to randomization and receipt of an intervention. Thirty-six percent of the participants were found to be at risk for low health literacy. Sociodemographic and psychosocial variables were assessed as predictors of being at risk for low health literacy using logistic regression. In the final model, predictors were male gender, being from a racial/ethnic minority group, being unable to work, having higher social influence scores, and having higher religious belief scores. These findings suggest several patient characteristics that may be associated with low health literacy, and highlight the importance of supporting all patients through simplified and clear communications and information to improve understanding of CRC screening information.

Abstract A63: Changes in health beliefs among medically-underserved patients enrolled in a community-based randomized controlled trial to promote colorectal cancer screening

Marked health disparities exist in colorectal cancer (CRC) screening, incidence, and mortality among medically-underserved communities. Literature suggests certain health beliefs (e.g., perceived risk) may be related to screening behavior. This study examined changes in CRC health beliefs following receipt of one of two educational interventions aimed at promoting CRC screening uptake among a medically-underserved population. We compared changes in CRC health beliefs at baseline and 12 months later both within and between the two intervention groups.

Enrolled participants were aged 50-75, at average CRC risk, not up-to-date with CRC screening guidelines, enrolled in a randomized controlled trial to increase CRC screening that was conducted at community clinics in the Tampa Bay area, and completed both the baseline and 12 month follow-up assessments. Participants were randomized to receive either a culturally-targeted photonovella and DVD plus fecal immunochemical test (FIT) intervention (titled Colorectal Cancer Awareness, Research, Education and Screening, or CARES, intervention group condition) or a Centers for Disease Control and Prevention (CDC) standard educational brochure plus FIT intervention (comparison group condition). At both time points, participants completed a questionnaire that included multiple health-related beliefs including Preventive Health Model (PHM) constructs (i.e., perceived susceptibility, perceived salience, self-efficacy, response efficacy, cancer worry, social influence, and religious beliefs), CRC awareness, decisional conflict regarding CRC screening, cancer fatalism, trust in the healthcare system, and perceived discrimination. Changes in health belief scores and group differences in change were examined using Student's t-tests.

The majority of participants (n=270) were: female (58%); white (67%) or black (26%); insured (59%) including county health insurance; had a household income &lt;$10,000 (65%); and had a high school education (35%) or more than high school education (41%). In both intervention conditions, there was an increase in CRC awareness, PHM social influence, and trust in the healthcare system (all p's&lt;.0001). In the CARES intervention group, there also was an increase in PHM salience (p&lt;.05). Among individuals in the comparison group, there was an increase in PHM response efficacy (p&lt;.01) and PHM self-efficacy (p&lt;.0001). There were no significant between-group differences on any of the health belief change scores.

Both CRC screening interventions promoted positive changes in multiple health beliefs from baseline to 12 months which suggests clear benefits of educational interventions. The interventions had common positive effects (i.e., CRC awareness, PHM social influence, and trust in the healthcare system), but also unique effects on PHM salience (CARES condition) and PHM self-efficacy and PHM response efficacy (comparison condition). However, between-group intervention comparisons were not significant suggesting that both educational interventions are beneficial. Given that individuals in both intervention groups were provided with access to CRC screening via FIT kit, future analyses will examine whether changes in health beliefs were associated with higher CRC screening uptake.

Citation Format: Shannon M. Christy, Steven K. Sutton, Enmanuel Chavarria, Stacy N. Davis, Rania Abdulla, Gwendolyn P. Quinn, Susan T. Vadaparampil, Chitra Ravindra, Ida Schultz, Richard Roetzheim, David Shibata, Cathy D. Meade, Clement K. Gwede. Changes in health beliefs among medically-underserved patients enrolled in a community-based randomized controlled trial to promote colorectal cancer screening. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A63.

A randomized controlled trial of a multicomponent, targeted, low-literacy educational intervention compared with a nontargeted intervention to boost colorectal cancer screening with fecal immunochemical testing in community clinics

BACKGROUND

The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention.

METHODS

Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention.

RESULTS

Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P =  .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P =  .04]).

CONCLUSIONS

The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2017;123:1390-1400. © 2016 American Cancer Society.

A community-based trial of educational interventions with fecal immunochemical tests for colorectal cancer screening uptake among blacks in community settings

BACKGROUND

Intervention studies among individuals in diverse community settings are needed to reduce health disparities in colorectal cancer (CRC) screening and mortality rates. The current study compared the efficacy of 2 intervention conditions promoting CRC screening among black individuals.

METHODS

Black individuals ages 50 to 75 years (N = 330) were recruited in community settings in 4 Tampa Bay counties. After obtaining consent and conducting a baseline interview to assess sociodemographic and health-related variables, participants received either a culturally targeted CRC photonovella booklet plus a fecal immunochemical test (FIT) kit or a standard CRC screening brochure plus an FIT kit. The primary outcome was FIT kit screening uptake.

RESULTS

FIT screening uptake at 6 months was 86.7% overall (90.3% in the brochure group and 81.9% in the photonovella group). Controlling for baseline between-group differences, there was no influence of intervention on FIT kit uptake (P = .756). Significant predictors of not returning an FIT kit included being unable to work (P = .010), having higher religious belief scores (P = .015), and living farther from the cancer center (P = .015).

CONCLUSIONS

Providing FIT kits and educational print materials to black individuals in community settings resulted in high rates of CRC screening. The study also identified subgroups of participants who were less likely to return an FIT kit and provides insight for future interventions. Cancer 2016;122:3288-3296. © 2016 American Cancer Society.

Masculinity Beliefs and Colorectal Cancer Screening in Male Veterans

As the third most common cause of cancer death among United States men, colorectal cancer (CRC) represents a significant threat to men's health. Although adherence to CRC screening has the potential to reduce CRC mortality by approximately half, men's current rates of adherence fall below national screening objectives. In qualitative studies, men have reported forgoing screenings involving the rectum (e.g., colonoscopy) due to concern about breaching masculinity norms. However, the extent to which masculinity beliefs predict men's CRC screening adherence has yet to be examined. The current study tested the hypothesis that greater endorsement of masculinity beliefs (i.e., self-reliance, risk-taking, heterosexual self-presentation, and primacy of work) would be associated with a lower likelihood of adherence to CRC screening with any test and with colonoscopy specifically. Participants were 327 men aged 51-75 at average risk for CRC who were accessing primary care services at a Midwestern Veterans Affairs Medical Center. Contrary to hypotheses, masculinity beliefs did not predict CRC screening outcomes in hierarchical regression analyses that controlled for demographic predictors of screening. Although results are largely inconsistent with masculinity theory and prior qualitative findings, further research is needed to determine the degree to which findings generalize to other populations and settings.