Making a Shared Decision on Meningococcal B Vaccine: Provider Feedback on an Educational Tool Developed for Use With Patients.

BACKGROUND: In 2015, the Advisory Committee on Immunization Practices recommended Meningococcal B vaccination for healthy 16- to 23-year-olds based on shared clinical decision-making between the patient and the provider. There has been some confusion regarding how to implement this recommendation. METHODS: Through discussions among the authors, a review of relevant literature, and consultation with vaccine experts, we developed educational materials for providers that included a patient handout to help initiate and guide conversations leading to shared clinical decision-making for the Meningococcal B vaccine. Materials were distributed to 88 health care providers who subsequently completed surveys to evaluate their impressions of the materials and the utility of the materials for clinical practice. RESULTS: The survey results from the 88 providers revealed that they valued the materials; 93% percent indicated they would share these materials with colleagues, and 95% agreed or strongly agreed that they would share these materials with patient families. Responses to an open-ended question indicate that some providers initiated discussions regarding the Meningococcal B vaccine in ways that truncated conversation rather than encouraging a shared decision-making process. CONCLUSIONS: Overall, the materials developed and implemented for this project support the initiation of, and help standardize provider conversations regarding, Meningococcal B vaccination for healthy adolescents.

A qualitative analysis of the vaccine intention-behaviour relationship: parents' descriptions of their intentions, decision-making behaviour and planning processes towards HPV vaccination.

OBJECTIVE: The objective of this study is to identify factors influencing the vaccine intention-behaviour relationship. DESIGN: A total of 445 parents who received a brief intervention to promote HPV vaccination were categorized based on their intentions post-intervention (yes/unsure/eventually/never) and subsequent adolescents' vaccine status (yes/no). Fifty-one of these parents participated in qualitative interviews. MAIN OUTCOME MEASURES: Parents described their intentions, decision-making and planning processes towards vaccination. Framework analysis was used to analyse the data. RESULTS: Parents in the 'Yes/Yes' category were knowledgeable about HPV/vaccine, described strong, stable intentions, considered themselves the primary decision-makers about vaccination and said they vaccinated immediately. 'Yes/No' parents described strong intentions and thought their adolescent was vaccinated OR described hesitant intentions, seeking advice/agreement from others and noting barriers to vaccination without solutions. 'Unsure/Yes' parents described their intentions as strengthening with information from credible sources and identified strategies for overcoming barriers. 'Unsure/No' and 'Eventually/No' parents had misinformation/negative beliefs regarding vaccination, described being ambivalent or non-supportive of vaccination and cited barriers to vaccination. 'Never/No' parents held negative beliefs about vaccination, described strong, stable intentions to NOT vaccinate, deferring the decision to others, and reported no planning towards vaccination. CONCLUSIONS: Intention characteristics and planning processes could moderate the vaccine intention-behaviour relationship, potentially serving as targets for future vaccine strategies.

Trust and a school-located immunization program.

PURPOSE: To determine variables associated with parental trust in a school-located immunization program (SLIP) and the effect of trust-building interventions on trust and participation in SLIPs. METHODS: Parents among eight schools randomized to a trust-building intervention or a control condition (four schools each) completed a five-item trust survey before SLIP implementation both in year 1 (fall 2012) and in year 2 (fall 2013). Mean trust scores were calculated. Associations between baseline demographic and experiential variables and mean trust scores were analyzed. Mean trust scores in intervention and control schools were compared before SLIP in years 1 and 2, and SLIP participation rates were noted. RESULTS: From year 1, 1,608 parent surveys were analyzed. Baseline mean trust score across schools was 3.59 of 5 (5 = highest trust). In a multiple linear regression model, annual household income, survey language version, participation in a previous SLIP, child's health insurance status, and perceived vaccine importance were significantly associated with parental trust in SLIPs (R(2)= .06, p < .001). There was no difference in mean trust scores between intervention and control schools (p = .8). In year 2, 844 surveys were analyzed, and a modest difference was observed between intervention and control schools (mean trust score = 3.66 and 3.57, respectively, p = .07). SLIP participation rates appeared higher in intervention (7.7%) versus control schools (4.3%) in year 1. CONCLUSIONS: Baseline trust in SLIPs among a low-income, largely Hispanic group of parents in Texas was moderately high. Factors associated with trust included demographic and experiential variables, and interventions aimed at increasing parents' perception of vaccine importance and participation in SLIPs may be effective in increasing parental trust in SLIPs.

School-based HPV immunization of young adolescents: effects of two brief health interventions.

Adolescent immunization rates for human papillomavirus (HPV) are low and interventions within school-based health centers (SBHCs) may increase HPV uptake and series completion. We examined the effect of a parent health message intervention on HPV vaccination intent, first dose uptake and series completion among adolescents who received care at SBHCs. Via computer-assisted telephone interviews (CATI), 445 parents of young adolescents were randomly assigned to 2 two-level interventions using a 2 × 2 design (rhetorical question (RQ) or no-RQ and one-sided or two-sided message). The RQ intervention involved asking the parent a question they were likely to endorse (e.g., "Do you want to protect your daughter from cervical cancer?") with the expectation that they would then behave in a manner consistent with their endorsement (i.e., agree to vaccinate). For the one-sided message, parents were given information that emphasized the safety and effectiveness of HPV vaccine, whereas the two-sided message acknowledged that some parents might have concerns about the vaccine, followed by reassurance regarding the safety and effectiveness. At CATI conclusion, parents indicated intentions to have their adolescents vaccinated. Parents who endorsed any intent were sent a consent form to return and all adolescents with signed returned consents were vaccinated at SBHCs. Medical records were reviewed for uptake/completion. Parents were 87% female; adolescents were 66% male and racially/ethnically diverse. 42.5% of parents indicated some intention to immunize, 51.4% were unsure, and 6.1% were not interested. 34% (n = 151) of adolescents received their first dose with series completion rates of 67% (n = 101). The RQ component of the intervention increased intention to vaccinate (RR = 1.45; 95%CI 1.16,1.81), but not first dose uptake or series completion. The 1-sided and 2-sided messages had no effect. This brief, RQ health intervention enhanced intent, but did not impact vaccination rates, likely due to the time delay between the intervention and consent form receipt.

Disasters and Depressive Symptoms in Children: A Review.

BACKGROUND: Disasters are destructive, potentially traumatic events that affect millions of youth each year. OBJECTIVE: The purpose of this paper was to review the literature on depressive symptoms among youth after disasters. Specifically, we examined the prevalence of depression, risk factors associated with depressive symptoms, and theories utilized in this research area. METHODS: We searched MEDLINE, PsycInfo, and PubMed electronic databases for English language articles published up to May 1, 2013. Reference lists from included studies were reviewed to capture additional studies. Only quantitative, peer reviewed studies, conducted with youth under the age of 18 years, that examined postdisaster depressive symptoms were included. Seventy-two studies met inclusion criteria. Prevalence of depressive symptoms, disaster type, correlates of depressive symptoms, and theories of depressive symptoms were reviewed. RESULTS: Only 27 studies (38%) reported on prevalence rates among youth in their sample. Prevalence rates of depression among youth postdisaster ranged from 2% to 69%. Potential risk factors were identified (e.g., female gender, exposure stressors, posttraumatic stress symptoms). Theories were examined in less than one-third of studies (k = 21). CONCLUSIONS: Given the variability in prevalence rates, difficulty identifying a single profile of youth at risk for developing depressive symptoms, and lack of a unifying theory emerging from the studies, recommendations for future research are discussed. Use of established batteries of assessments could enable comparisons across studies. Merging existing theories from children's postdisaster and depression literatures could aid in the identification of risk factors and causal pathways.

Dissonance-based prevention of eating disorder risk factors in middle school girls: results from two pilot trials.

OBJECTIVE: Although several eating disorder prevention programs reduce eating disorder risk factors and symptoms for female high school and college students, few efficacious prevention programs exist for female middle school students, despite the fact that body image and eating disturbances often emerge then. Two pilot trials evaluated a new dissonance-based eating disorder prevention program for middle school girls with body image concerns. METHOD: Female middle school students with body dissatisfaction from two sites [Study 1: N = 81, M age = 12.1, standard deviation (SD) = 0.9; Study 2: N = 52, M age = 12.5, SD = 0.8] were randomized to a dissonance intervention (MS Body Project) or educational brochure control; Study 2 included a 3-month follow-up. RESULTS: Intervention participants showed significant post-test reductions in only one of the six variables with both Studies 1 and 2 (i.e., pressure to be thin and negative affect, respectively), though post-test effect sizes suggested medium reductions in eating disorder risk factors and symptoms (Study 1: M d = .40; Study 2: M d = .65); reductions at 3-month follow-up in Study 2 were not evident (M d = .19). CONCLUSIONS: Results suggest that this new middle school version of the Body Project is producing medium magnitude reductions in eating disorder risk factors at post-test but that effects are showing limited persistence. Continued refinement and evaluation of this intervention appears warranted to develop more effective prevention programs for this age group.

School-based vaccination of young US males: impact of health beliefs on intent and first dose acceptance.

Little is known about adolescent males and their parents with respect to intent and first dose uptake of the human papillomavirus (HPV) vaccine outside of primay care settings. The purpose of this study was to evaluate potential predictors of parental intent to vaccinate (study was conducted in November 2010-December 2012) and of first dose uptake of HPV vaccine among a sample of young adolescent males, 11-15 years of age, who received care at a school-based health center (SBHC). We also examined intent as a potential mediator of the relationships between predictors (health beliefs and perceived spousal agreement) and vaccination. Slightly more than half (n=135 of 249) of parents reported an intention to vaccinate and 28% (n=69) of males received their first dose of the HPV vaccine. Two of three health beliefs were significantly associated with both intention and uptake as was perceived spousal agreement. We found intention to vaccinate was a partial mediatator between the perceived benefits of HPV vaccine and first dose acceptance. We also determined that intent was a strong mediator between both general immunization benefits and perceived spousal agreement and first dose uptake. While vaccine uptake was lower than expected, particularly considering that many barriers to vaccine initiation were eliminated because of the SBHC setting, this rate is higher than in traditional settings. After controlling for intent, only perceived benefits of the HPV vaccine remained a significant predictor of first dose acceptance.

Adolescents' and young women's use of a microbicide surrogate product when receiving oral sex.

STUDY OBJECTIVE: Genital herpes, which can be spread through oral sex, is an important target for microbicides. We examined episode-specific predictors of young women's receptive oral sex and of microbicide surrogate use. DESIGN: Longitudinal study. SETTING: Participants were recruited to participate in a microbicide acceptability study from adolescent clinics and local colleges and through snowballing. PARTICIPANTS: Young women (ages 14 to 21 y) who reported sexual contact on at least 1 weekly phone interview (n = 181) were included from the larger sample of 208 young women. MAIN OUTCOME MEASURES: On weekly diary phone interviews, participants reported whether or not their last sexual contact included receptive oral sex and whether or not their last sexual contact included use of a microbicide surrogate. RESULTS AND CONCLUSIONS: Participants reported a total of 1042 episodes of sexual contact of which 311 included receptive oral sex and 354 included microbicide surrogate use. Being older, having sex for the first time with a partner, and having given oral sex were associated with having received oral sex during a sexual episode. Being older, being African American, and having discussed the microbicide surrogate with their partner were associated with having used the microbicide surrogate use during a sexual episode. These results indicate that oral sex should be considered in the design of clinical trials. Future studies need to evaluate ways to promote consistent microbicide use in the context of receiving oral sex as well as those factors (eg, taste, pleasure) which may serve as a barrier.

Children's symptoms of posttraumatic stress and depression after a natural disaster: comorbidity and risk factors.

BACKGROUND: The current study examined rates of comorbidity among children's symptoms of posttraumatic stress (PTS) and depression after a natural disaster, Hurricane Ike. We also compared children with comorbid symptoms to children without comorbid symptoms, examining recovery, severity of symptoms, and risk factors. METHOD: Children (n=277; 52% girls; 38% Hispanic, 28% White, 19% Black; grades 2-4) were assessed at 8 and 15 months postdisaster. Children completed measures of PTS and depressive symptoms at both time points and measures of exposure and recovery stressors at 8 months postdisaster. RESULTS: At 8 months postdisaster, 13% of children reported elevated PTS-only, 11% depression-only, and 10% comorbid symptoms of PTS and depression. At 15 months postdisaster, 7% of children reported elevated PTS-only, 11% depression-only, and 7% comorbid symptoms of PTS and depression. Children with comorbid symptoms of PTS and depression had poorer recovery, more severe symptoms, and they reported greater exposure and recovery stressors. LIMITATIONS: We lacked information on children's predisaster functioning and diagnostic interview of psychological distress symptoms. CONCLUSIONS: Children with comorbid symptoms need to be identified early postdisaster. Levels of stressors should be monitored postdisaster, as highly stressed youth have difficulties recovering and may need help. Interventions should be tailored for children with comorbid symptoms of PTS and depression.

Adolescent intimate heterosexual relationships: measurement issues.

During adolescence, individuals develop increased ability to have emotionally and physically intimate relationships. The type of intimate relationship will make a difference as to whether the adolescent engages in protective behaviors or avoids risky behaviors. However, in reviewing the literature on the association of relationship type and sexual risk and protective behaviors, four methodological challenges were noted. These challenges limit our understanding of the impact of relationship type. These four challenges are: (a) inconsistent definitional frameworks; (b) lack of adolescent voices; (c) lack of consideration of gender; and (d) poor differentiation between individual and relationship risk. These issues direct the course of future work in this area and are necessary to advance the field of adolescent sexual health, particularly with regard to the development and testing of appropriate interventions designed to reduce untoward outcomes of adolescent sexuality.

The connection between young women's body esteem and sexual assertiveness.

STUDY OBJECTIVE: Healthy sexuality includes having positive feelings about one's body and developing positive romantic relationships. Previous research predicts that women dissatisfied with their bodies may be less likely to enforce their rights of sexual autonomy (i.e., sexual assertiveness). DESIGN: We assessed whether the body esteem of young women was related to their reports of sexual assertiveness. Young women from local colleges (N = 127) completed a questionnaire that included demographics, self reported weight and height, sexual history, along with body esteem and sexual assertiveness. RESULTS: Overall, body esteem was related to sexual assertiveness regarding condom use when controlling for other variables. Women with less body esteem were less likely to insist that their partner use a condom. Individual components of body esteem did not independently predict insistence of condom use. Body esteem was not related to initiation of sex or refusal of unwanted sex. DISCUSSION: The current study found relationships between body esteem and sexual assertiveness regarding STI prevention behaviors. Given these findings, implications for STI prevention programs are discussed.

Relationship context associated with microbicide-like product use.

STUDY OBJECTIVE: Topical microbicides are being developed to provide an alternative method of prevention of HIV and sexually transmitted infections. Although topical microbicides would be a female-controlled method of prevention, their use is likely to be disclosed to partners. Thus, the characteristics of the partner relationship may play a role in their use. We sought to examine whether qualities of the relationship and of the partner were associated with using a microbicide-like product. DESIGN: We studied 166 females (14 to 21 years of age) who were participating in a 6-month study of microbicide-like products (vaginal lubricants). They described partner relationships and characteristics of the partners. RESULTS: Of the 166 participants, 118 used the product. In bivariate analyses, those whose relationships were longer, monogamous, more mutual, and more satisfying were more likely to use the product. Further, when sex occurred in the young women's or couples' homes, use also was more likely. There was no relationship between product use and whether the partner had a job or was in school or between the partners' levels of substance use. In a multivariable logistic regression with backwards elimination, only relationship satisfaction remained significant in the model. CONCLUSION: Topical microbicides will be used within the context of a relationship, and characteristics of the relationship most likely will influence use. These findings suggest that special attention may have to be given to supporting use in high-risk relationships and that all interventions to enhance uptake should consider the relationship context.

Associations between parenting behaviors and adolescent romantic relationships.

We examined associations between parenting behaviors and romantic relationship qualities in 102 adolescent girls 14-21 years of age who lived with their parent/parental figure and had current boyfriends. Adolescent girls' perceptions that parents were accepting/involved and provided appropriate strictness and supervision were significantly related to adolescent girls' perceptions of mutuality (i.e., bidirectional movement of thoughts, feelings, and activities between persons) within their own romantic relationships, which in turn was related to their romantic relationship satisfaction. No parenting variables were related to nonexclusivity.

Racial/ethnic differences in patterns of sexual behavior and STI risk among sexually experienced adolescent girls.

STUDY OBJECTIVE: Racial/ethnic differences in prevalence and patterns of oral and anal sex were analyzed among girls participating in a microbicide acceptability study. DESIGN: Cross-sectional analysis SETTING: Recruitment to participate in a 6-month study examining microbicide acceptability was conducted at a school-based health clinic and local colleges in Galveston, Texas and through snowball sampling. PARTICIPANTS: Sexually experienced girls (n = 202) ages 14 to 21 years of age. MAIN OUTCOME MEASURES: Girls reported on their demographic and sexual history at the intake interview. RESULTS AND CONCLUSIONS: Their mean age was 18.2 years; 26% were white, 43% African-American, and 31% Hispanic. African-American girls were significantly less likely than whites and Hispanics to have had oral sex; no differences were found for anal sex. African-American girls were significantly older than whites and Hispanics when they initiated oral sex. African-American girls had a greater difference between ages of vaginal and oral sex initiation than whites and Hispanics. Oral sex history was associated with a 6-factor increase and anal sex history was associated with a 3-factor increase in the likelihood of a history of sexually transmitted infection. Future studies should explore these differences in greater depth in order to develop culturally specific STI prevention efforts.

Male partners of young women: assessing their attitudes toward topical microbicides.

Male partners' attitudes toward microbicide use are important to understand; however, there are challenges in conducting research with adolescent couples. We describe the experience of recruiting male partners of adolescent females enrolled in a microbicide acceptability study. Creative solutions to enrolling partners of young women in studies need to be explored.

Microbicides: information, beliefs, and preferences for insertion.

OBJECTIVES: Microbicides are products in development to prevent sexually transmitted infection and HIV acquisition; they are not yet available to the public. We evaluated (1) where women would expect to seek information about microbicides, (2) factors that women think might affect microbicide effectiveness, and (3) women's anticipated preferences for timing and place of insertion and partner involvement. METHODS: A cross-sectional face-to-face interview was administered to women aged 18-35 years (n=126) recruited from a gynecology clinic in Galveston, Texas. Women were shown a microbicide surrogate and asked to complete a series of closed-ended questions focusing on demographics, expected sources of information on microbicides, perceived factors related to effectiveness, and preferences for timing and place of insertion and level of partner involvement. Univariate descriptive analyses were used to calculate means, medians, and frequencies. RESULTS: Women's most cited anticipated sources of information for microbicides were physicians (89%), the package insert/box (86%), and pharmacists (70%). Approximately two thirds of the women believed that menstruation or taking other medicines and approximately one third believed that taking a bath/shower before intercourse or after intercourse or using birth control medication could limit effectiveness. Women anticipated preferring to insert the microbicide before intercourse (90%) and while in the bathroom (73%). Most (95%) anticipated telling their partners they planned to use a microbicide, and 38% anticipated having their partner insert the product for them. CONCLUSIONS: Women's beliefs about those factors that could limit effectiveness of microbicides should be addressed as part of anticipatory guidance or in the package inserts. Partners likely will be involved in the use of microbicides; thus, education/marketing efforts should also incorporate partner beliefs and preferences.

Perceptions of sexual assertiveness among adolescent girls: initiation, refusal, and use of protective behaviors.

STUDY OBJECTIVE: We describe adolescent girls' perceptions of sexual assertiveness and examine the relationship of these perceptions with developmental and interpersonal variables. DESIGN: Cross-sectional analysis. SETTING: Participants were recruited from a school-based health clinic and local colleges, and through snowballing to participate in a 6-month study examining microbicide acceptability. PARTICIPANTS: 106 sexually experienced girls (ages 14 through 21 years). METHODS: Girls described their demographics, sexual history, and romantic relationships and completed the Sexual Assertiveness Scale for Women (SAS-W), which assesses perceptions of sexual assertiveness: Initiation of Sex, Refusal of Unwanted Sex, and Pregnancy-STD Prevention. RESULTS: Girls perceived themselves as asserting themselves between 50% and 75% of the time with their current or most recent partner. The Initiation subscale was not related to the other two subscales. In final models, girls with a prior pregnancy perceived themselves as initiating sex more than girls without a prior pregnancy. Having a greater number of lifetime partners was related to perceptions of less refusal, whereas greater number of partners, being sexually experienced longer, and engaging in more unprotected sex were related to perceptions of less implementation of preventive methods. None of the relationship variables were related to scores on any subscale. CONCLUSIONS: Most of these girls perceived themselves as sexually assertive. Given that sexual experience, not relationship factors, were related to perceptions of sexual assertiveness, the design of counseling messages should incorporate sexual experience. These messages should find effective ways to help girls both to communicate their sexual desires and to enhance their ability to protect themselves.

Predictors of sexual satisfaction in an adolescent and college population.

STUDY OBJECTIVE: To assess the degree to which adolescents/young adults are satisfied in their current sexual relationships and to evaluate intrapersonal and interpersonal predictors of sexual satisfaction among that population. DESIGN: Cross-sectional analysis. SETTING: Participants were recruited from an adolescent medicine clinic and a college in Cincinnati, Ohio. PARTICIPANTS: A total of 313 sexually experienced adolescent/young adults ranging in age from 14 to 24 participated. Fifty percent were white and 60% female. METHODS: Participants completed a questionnaire about their demographics, romantic relationships, mental health, sexual history/behavior, and sexual satisfaction. Univariate logistic regression models were conducted to determine the relationship between each predictor and satisfaction with their current sexual relationship. To identify the most important predictors of sexual satisfaction, a final multiple logistic regression model was created using backward elimination. RESULTS: Approximately 85% of adolescents/young adults in the present study reported feeling satisfied in their current sexual relationships. Those who were in an overall positive relationship, who were less sensitive emotionally within interpersonal relationships, and who had more frequent sex, fewer lifetime sexual partners, and more condom-protected sex were more likely to be satisfied with the current sexual relationship. CONCLUSIONS: Sexuality develops within the context of both intrapersonal and interpersonal factors. Thus, researchers should incorporate a multi-factorial approach when designing studies on adolescent sexuality.

Measurement of microbicide acceptability among U.S. adolescent girls.

BACKGROUND AND OBJECTIVE: Topical microbicides will only be effective if they are acceptable to potential users. The purpose of this study is to develop a scale to evaluate characteristics and aspects of topical microbicides that are important to adolescent girls. STUDY DESIGN: Girls (n = 207) completed a questionnaire on perceptions of microbicide-like products. RESULTS: A principal components factor analysis with a varimax rotation produced a 6-factor solution. The mean factor scores suggested that girls saw the products positively. Age was positively correlated with "comparison to condoms" and "comfort while using" factor scores and inversely correlated with "negative impact on interpersonal relationships" factor score. Sexually transmitted infection (STI) history was related to higher scores on the "health benefits" and "pleasure" factors. Age, race/ethnicity, and STI history were not related to the other factor scores. CONCLUSION: The current scale shows promise in assessment of microbicide acceptability, and in general, girls expressed positive views about microbicides.