Economic analysis of foregoing Rh immunoglobulin for bleeding in pregnancy <12 weeks gestation.

OBJECTIVES: To perform cost analyses of foregoing RhD blood type testing and administration of Rh immunoglobulin (RhIg) for bleeding in pregnancy at <12 weeks gestation in the United States. STUDY DESIGN: We created a decision-analytic model comparing the current standard treatment pathway for patients who have threatened, spontaneous, or induced abortion in the United States, with a new pathway foregoing RhD testing and administration of RhIg for those who are RhD-negative at <12 weeks gestation, assuming that the risk of sensitization is 0%. We derived population and cost estimates from current literature and calculated the number needed to treat, and number needed to screen, to avoid one case of fatal hemolytic disease of the fetus and newborn. We performed sensitivity analyses assuming Rh-sensitization risks of 1.5% and 3% and varying the subsequent pregnancy rates from 44-100%. RESULTS: The annual savings to healthcare payers in the United States of foregoing RhD testing and RhIg administration to RhD-negative patients with bleeding events at <12 weeks is $5.5 million/100,000 total pregnancies, assuming that the risk of sensitization is 0%. In the sensitivity analyses with sensitization risk 1.5% and subsequent pregnancy rate 84.3%, foregoing Rh testing and RhIg administration <12 weeks would save $2.8 million/100,000 pregnancies, with a corresponding number needed to treat of 7,322 and number needed to screen of 48,816. At a 3% sensitization rate, the current standard treatment pathway is the most economical. CONCLUSIONS: There is an opportunity to save the United States healthcare payers as much as $5.5 million/100,000 pregnancies by withholding RhIg in specific situations and conserving it for use later in pregnancy. IMPLICATIONS: Cost analyses support foregoing RhD blood type screening and RhIg administration at <12 weeks gestation if the sensitization rate is <3%. By de-implementing this low value care, payers in the United States can save as much as $5.5 million/100,000 pregnancies and conserve RhIg for use later in pregnancy.

Treatment Interruptions and Mortality among Puerto Rican Women with Gynecologic Cancers in Puerto Rico after Hurricanes Irma and María: A Retrospective Cohort Study.

OBJECTIVE: Cancer patients are among the most vulnerable populations during and after a disaster. We evaluated the impact of treatment interruption on the survival of women with gynecologic cancer in Puerto Rico following hurricanes Irma and María. METHODS: Retrospective cohort study among a clinic-based sample of women diagnosed between January 2016-September 2017 (n=112). Women were followed up from their diagnosis until December 2019, to assess vital status. Kaplan-Meier survival curves and Cox proportional hazards models were performed. RESULTS: Mean age was 56 (±12.3) years; corpus uteri (58.9%) was the most common gynecologic cancer. Predominant treatments were surgery (91.1%) and chemotherapy (44.6%). Overall, 75.9% were receiving treatment before the hurricanes, 16.1% experienced treatment interruptions and 8.9% died during the follow-up period. Factors associated with treatment interruption in bivariate analysis included younger age (≤55 years), having regional/distant disease, and receiving >1 cancer treatment (p<0.05). Crude analysis revealed an increased risk of death among women with treatment interruption (HR: 3.88, 95% CI=1.09-13.77), persisting after adjusting for age and cancer stage (HR: 2.49, 95% CI= 0.69-9.01). CONCLUSIONS: Findings underscore the detrimental impact of treatment interruption on cancer survival in the aftermath of hurricanes, emphasizing the need for emergency response plans for this vulnerable population.

Identifying effective vaccine champions: Findings from a national survey of primary care professionals.

BACKGROUND: Vaccine champions are common in primary care, but little is known about which champions are effective. METHODS: In 2022, we surveyed 2,144 US primary care professionals (PCPs) who reported working with vaccine champions. Respondents rated the champion with whom they worked most closely on their effectiveness at improving vaccination rates. RESULTS: About half (49 %) of PCPs perceived their closest champion as highly effective. PCPs perceived advanced practice providers and nursing staff as highly effective somewhat more often than physicians (52 % and 58 % vs 43 %, p <.001). Other correlates of perceived effectiveness included being a formally appointed versus informal champion, working extremely versus less closely with PCPs, and using a high (4-5) versus low (0-1) number of implementation strategies to improve vaccination rates (all p <.001). CONCLUSIONS: Results suggest vaccine champions may benefit from having formal roles and opportunities to work closely with colleagues to improve vaccination rates using multiple strategies.

Stories to Prevent Cancer: A Pilot Study Using Cancer Survivor Narratives to Increase Human Papillomavirus Vaccine Intentions.

INTRODUCTION: Human papillomavirus (HPV) vaccination rates are lower than other recommended adolescent vaccines. Cancer survivor narratives are used to promote cancer prevention and control, but little is known about their impact on adolescent HPV vaccination. OBJECTIVE: This pilot study explored the feasibility and effects of a video education intervention using a cancer survivor narrative to improve parents' attitudes toward and intentions to get the HPV vaccine. METHODS: This study utilized a one-group design; participants completed a pre-intervention survey, watched the video before attending their sons' wellness visits, and completed a post-intervention survey within one week of their appointment. Using the narrative persuasion framework, we developed a 4-minute video of a local HPV-related cancer survivor to promote the HPV vaccine as cancer prevention. We recruited 37 participants between June and October 2020. Participants were parents of males ages 9-17 who had not yet initiated HPV vaccination. RESULTS: After the video, more parents agreed that HPV vaccination is safe (pre: 66% vs. post: 82%; P = .045) and that their child's chances of getting HPV-related cancer in the future are high (pre: 24% vs. post: 46%; P = .014). Overall, 91% of parents felt the cancer survivor story helped them understand the risks of HPV cancers, and 52% said the story influenced their decision to start HPV vaccination for their child. CONCLUSIONS: Our findings suggest that cancer survivor narratives influence parents' vaccine opinions and understanding of their child's risk of HPV infection, leading to increased parental intent to get the HPV vaccine for their adolescent males.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals.

BACKGROUND: Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care. METHODS: In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates." RESULTS: Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001). CONCLUSIONS: Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Understanding factors associated with COVID-19 vaccination among health care workers using the Diffusion of Innovation Theory.

BACKGROUND: The COVID-19 vaccine was initially offered to frontline health care workers (HCWs), due to the high risk of contracting COVID-19 through occupational exposure to patients. Low HCW vaccine uptake can impact overall community-level vaccine uptake. This study used the Diffusion of Innovation (DOI) Theory to understand factors related to COVID-19 vaccine uptake in HCWs. METHODS: We surveyed Pennsylvanian HCWs (excluding Philadelphia) from August 2022 to February 2023. Survey questions inquired about demographics, COVID-19 vaccination status, reasons for receiving/declining the COVID-19 vaccine, and sources of information about the vaccine. RESULTS: Participants (n = 3,490) were 85% female, 89% White, and 93% (n = 3,255) reported receiving at least one dose of a COVID-19 vaccine. HCWs were categorized into adopter categories of the DOI Theory: innovators (56%), early adopters (9%), early majority (11%), late majority (7%), and laggards (17%). The major reason that prompted participants to get the vaccine was to protect them against COVID-19 infection (78%), while the major reason for declining the vaccine was due to concern about possible side effects from the vaccine (78%). CONCLUSIONS: We applied the DOI Theory to characterize adopters and identify factors related to COVID-19 vaccine uptake in HCWs. As updated COVID-19 vaccines are approved for the United States market, our findings may be used to improve vaccine education and communication among HCWs to support vaccine uptake.

Prevalence of High-Risk Human Papillomavirus Genotypes among Young Women in Puerto Rico; a retrospective longitudinal study.

Background: Human Papillomavirus (HPV) is the most common sexually transmitted infection. High-risk HPV types are the main cause of cervical cancer. Annually, cervical cancer is among the top 10 cancers in Puerto Rican women, with 22% of these cases ending in death. The purpose of this study was to establish the prevalence of high-risk HPV genotypes in a large cohort of young women living in Puerto Rico. Methods: A retrospective longitudinal analysis was performed with a sample of 5,749 HPV results obtained from a clinical database of women ages 21 to 29 from 2014-2016. Results: Outcomes indicate that among those with a positive HPV result, about one-third (35.2%) had a high-risk HPV infection. Women between the ages of 21 to 23 showed the highest prevalence (40.6%) of high-risk HPV. Among genotypes HPV 16 and 18, genotype 16 was the most prevalent. Interestingly, 85.4% of results were positive for other high-risk HPV types other than 16 or 18. Of the 458 women who had at least two tests completed, 217 had an initial positive result for HPV and only 108 (49.7%) resolved the infection. Conclusions: This study confirms the high prevalence of several genotypes of high-risk HPV in young women in a large Puerto Rican sample.

Expanding opportunities for chronic disease prevention for Hispanics: the Better Together REACH program in Pennsylvania.

Background: Hispanics in Lebanon and Reading, Pennsylvania, experience high levels of socioeconomic and health disparities in risk factors for chronic disease. In 2018, our community-academic coalition "Better Together" received a Racial and Ethnic Approaches to Community Health (REACH) award to improve healthy lifestyles. This report describes our work-in-progress and lessons learned to date from our REACH-supported initiatives in Lebanon and Reading. Methods: For the past 4 years, our coalition has leveraged strong community collaborations to implement and evaluate culturally-tailored practice- and evidence-based activities aimed at increasing physical activity, healthy nutrition, and community-clinical linkages. This community case report summarizes the context where our overall program was implemented, including the priority population, target geographical area, socioeconomic and health disparities data, community-academic coalition, conceptual model, and details the progress of the Better Together initiative in the two communities impacted. Results: To improve physical activity, we are: (1) creating new and enhancing existing trails connecting everyday destinations through city redesigning and master planning, (2) promoting outdoor physical activity, (3) increasing awareness of community resources for chronic disease prevention, and (4) supporting access to bikes for youth and families. To improve nutrition, we are: (1) expanding access to locally-grown fresh fruit and vegetables in community and clinical settings, through the Farmers Market Nutrition Program to beneficiaries of the Women, Infants, and Children (WIC) program and the Veggie Rx to patients who are at risk for or have diabetes, and (2) providing bilingual breastfeeding education. To enhance community-clinical linkages, we are training bilingual community health workers to connect at-risk individuals with diabetes prevention programs. Conclusions: Intervening in areas facing high chronic disease health disparities leads us to develop a community-collaborative blueprint that can be replicated across Hispanic communities in Pennsylvania and the United States.

Increasing the adoption of evidence-based communication practices for HPV vaccination in primary care clinics: The HPV ECHO study protocol for a cluster randomized controlled trial.

BACKGROUND: The safe, highly-effective human papillomavirus (HPV) vaccine remains underused in the US. The Announcement Approach Training (AAT) has been shown to effectively increase HPV vaccine uptake by training providers to make strong vaccine recommendations and answer parents' common questions. Systems communications, like recall notices, can further improve HPV vaccination by reducing missed clinical opportunities for vaccination. Never tested in supporting HPV vaccination, the ECHO (Extension for Community Healthcare Outcomes) model is a proven implementation strategy to increase best practices among healthcare providers. This trial uses a hybrid effectiveness-implementation design (type II) to evaluate two ECHO-delivered interventions intended to increase HPV vaccination rates. METHODS: This 3-arm cluster randomized controlled trial will be conducted in 36 primary care clinics in Pennsylvania. Aim 1 evaluates the impact of HPV ECHO (AAT to providers) and HPV ECHO+ (AAT to providers plus recall notices to vaccine-declining parents) versus control on HPV vaccination (≥1 dose) among adolescents, ages 11-14, between baseline and 12-month follow-up (primary outcome). Using a convergent mixed-methods approach, Aim 2 evaluates the implementation of the HPV ECHO and HPV ECHO+ interventions. Aim 3 explores exposure to and impact of vaccine information from providers and other sources (e.g., social media) on secondary acceptance among 200 HPV vaccine-declining parents within 12 months. DISCUSSION: We expect to demonstrate the effectiveness and evaluate the implementation of two highly scalable interventions to increase HPV vaccination in primary care clinics. Our study seeks to address the communication needs of both providers and parents, increase HPV vaccination, and, eventually, prevent HPV-related cancers. TRIAL REGISTRATION: ClinicalTrials.govNCT04587167. Registered on October 14, 2020.

Accelerating guideline dissemination in nursing homes during the COVID-19 pandemic: A patient-centered randomized controlled trial.

BACKGROUND: Nursing homes were ill-equipped for the pandemic; though facilities are required to have infection control staff, only 3% have taken a basic infection control course. Little is known about the implementation of effective practices outside of the acute care setting. We proposed an intervention utilizing Project ECHO, to connect Penn State University experts with nursing home staff and administrators to explore how infection control guidelines can be implemented effectively. METHODS: A stratified cluster randomized design was used to assign nursing homes to either AHRQ-funded COVID-19 ECHO or AHRQ-funded COVID-19 ECHO+. RESULTS: 136 nursing homes participated. There were no significant differences in COVID-19 infection rate, hospitalization, deaths, or influenza, between ECHO or ECHO+. DISCUSSION: The ECHO model has significant strengths when compared to traditional training, as it allows for remote learning delivered by a multidisciplinary team of experts and utilizes case discussions that match the context of nursing homes.

The Healthy, Immunized Communities Study: A pilot intervention to increase parents' intentions to get vaccines for their middle school children.

Pennsylvania shortened the provisional period for student vaccine compliance in 2018. We pilot tested a school-based health education intervention, The Healthy, Immunized Communities Study, to improve parents' intentions to get school-required (tetanus, diphtheria, acellular pertussis [Tdap]; and meningococcal conjugate [MCV]) and recommended (human papillomavirus [HPV]) vaccines for their children. In Phase 1, we partnered with the School District of Lancaster (SDL) to conduct four focus groups with stakeholders (local clinicians, school staff, school nurses, and parents) to inform the development of the intervention. In Phase 2, we randomized four middle schools in SDL to either the intervention (six email communications and school-community educational event) or control group. Seventy-eight parents took part in the intervention and 70 joined the control group. Vaccine intentions were compared within and between groups from baseline to 6-month follow-up with generalized estimating equations (GEE) models. Compared to the control, the intervention did not increase parents' vaccine intentions for Tdap (RR = 1.18; 95 % CI:0.98-1.41), MCV (RR = 1.10; 95 % CI:0.89-1.35), or HPV (RR = 0.96; 95 % CI:0.86-1.07). Among intervention participants, only 37 % opened ≥ 3 email communications and 23 % attended the event. Intervention participants reported high satisfaction with email communications (e.g., informative = 71 %) and felt that the school-community event met their educational objectives on key topics (e.g., immune system = 89 %). In conclusion, although we observed no intervention effect, our data suggest that this could be a result of the low uptake of intervention components. Further research is needed to understand how school-based vaccination-focused interventions can be successfully implemented with high fidelity among parents.

Perceptions of preparedness, timing of cancer diagnosis, and objective emergency preparedness among gynecological cancer patients in Puerto Rico before and after Hurricane Maria.

OBJECTIVES: This study investigated the impact of cancer diagnosis status, individual feelings of preparedness, and other covariates on objective emergency preparedness among women diagnosed with gynecological cancers before or after the 2017 Hurricanes Irma and Maria in Puerto Rico. METHODS: This study included 240 women who were interviewed by telephone from 9/2019-11/2020. Objective emergency preparedness was assessed using a list of six items. Subjective emergency preparedness was assessed by asking the women how prepared they felt (well, somewhat, or not at all) to face an emergency. Crude and multivariable logistic regression analyses were conducted to assess the associations (odds ratios [ORs] and 95% confidence intervals [CIs]) between variables of interest and objective preparedness. RESULTS: Before and after the hurricanes, 60% and 66% of women, respectively, were objectively prepared. Before the hurricanes, women reporting feeling well-prepared (vs. not prepared) (OR=9.31, 95%CI:3.96-21.91) and those who were diagnosed before (vs. after) the hurricanes (OR=1.71, 95%CI:0.95-3.09) were more likely to be objectively prepared. After the hurricanes, self-perceived well-preparedness (OR=2.46, 95% CI: 1.10-5.51) was positively associated with emergency preparedness when compared to feeling unprepared. CONCLUSIONS: Perceptions of emergency preparedness and having a cancer diagnosis increased the likelihood of being objectively prepared for an emergency. POLICY SUMMARY: This study demonstrates the need for state, territorial, and federal governments to include emergency preparedness plans for cancer patients in the Comprehensive Cancer Control plans. The study also indicates a need for cancer specific emergency preparedness information to be readily available for patients.

Assessing the use of constructs from the consolidated framework for implementation research in U.S. rural cancer screening promotion programs: a systematic search and scoping review.

BACKGROUND: Cancer screening is suboptimal in rural areas, and interventions are needed to improve uptake. The Consolidated Framework for Implementation Research (CFIR) is a widely-used implementation science framework to optimize planning and delivery of evidence-based interventions, which may be particularly useful for screening promotion in rural areas. We examined the discussion of CFIR-defined domains and constructs in programs to improve cancer screening in rural areas. METHODS: We conducted a systematic search of research databases (e.g., Medline, CINAHL) to identify studies (published through November 2022) of cancer screening promotion programs delivered in rural areas in the United States. We identified 166 records, and 15 studies were included. Next, two reviewers used a standardized abstraction tool to conduct a critical scoping review of CFIR constructs in rural cancer screening promotion programs. RESULTS: Each study reported at least some CFIR domains and constructs, but studies varied in how they were reported. Broadly, constructs from the domains of Process, Intervention, and Outer setting were commonly reported, but constructs from the domains of Inner setting and Individuals were less commonly reported. The most common constructs were planning (100% of studies reporting), followed by adaptability, cosmopolitanism, and reflecting and evaluating (86.7% for each). No studies reported tension for change, self-efficacy, or opinion leader. CONCLUSIONS: Leveraging CFIR in the planning and delivery of cancer screening promotion programs in rural areas can improve program implementation. Additional studies are needed to evaluate the impact of underutilized CFIR domains, i.e., Inner setting and Individuals, on cancer screening programs.

Impact of Brief Quality Improvement Coaching on Adolescent HPV Vaccination Coverage: A Pragmatic Cluster Randomized Trial.

BACKGROUND: Health departments in the United States routinely conduct quality improvement (QI) coaching to help primary care providers optimize vaccine delivery. In a prior trial focusing on multiple adolescent vaccines, this light-touch intervention yielded only short-term improvements in HPV vaccination. We sought to evaluate the impact of an enhanced, HPV vaccine-specific QI coaching intervention when delivered in person or virtually. METHODS: We partnered with health departments in three states to conduct a pragmatic cluster randomized trial in 2015 to 2016. We randomized 224 primary care clinics to receive no intervention (control), in-person coaching, or virtual coaching. Health department staff delivered the brief (45-60 minute) coaching interventions, including HPV vaccine-specific training with assessment and feedback on clinics' vaccination coverage (i.e., proportion of patients vaccinated). States' immunization information systems provided data to assess coverage change for HPV vaccine initiation (≥1 doses) at 12-month follow-up, among patients ages 11 to 12 (primary outcome) and 13 to 17 (secondary outcome) at baseline. RESULTS: Clinics served 312,227 patients ages 11 to 17. For ages 11 to 12, coverage change for HPV vaccine initiation was higher in the in-person and virtual coaching arms than in the control arm at 12-month follow-up (1.2% and 0.7% point difference, both P < 0.05). For ages 13 to 17, coverage change was higher for virtual coaching than control (1.4% point difference, P < 0.001), but in-person coaching did not yield an intervention effect. CONCLUSIONS: Our brief QI coaching intervention produced small long-term improvements in HPV vaccination. IMPACT: Health departments may benefit from targeting QI coaching to specific vaccines, like HPV vaccine, that need them most.

Associations Between Human Papillomavirus Vaccine Decisions and Exposure to Vaccine Information in Social Media.

PURPOSE: Exposure to different types of vaccine information in social media can result in parents making disparate vaccine decisions, including not following national guidelines for human papillomavirus (HPV) vaccination. We sought to characterize parents' exposure to and engagement with information about HPV vaccination in social media, and the associations between exposure to such information and vaccine decisions for their adolescent children. METHODS: In 2019, we conducted a web-based survey with a national sample of 1073 parents of adolescents who use social media. The survey assessed whether parents have seen information in favor, against, or mixed about HPV vaccination. Multivariable logistic regressions assessed correlates of vaccine decisions, including HPV vaccine initiation, delay, and refusal. RESULTS: Sixty-one percent of parents reported that their children have initiated HPV vaccination. Over one-third of parents (37%) reported seeing HPV vaccine information on social media, which was either in favor (20%), against (5%), or a mix (12%). Parents exposed to information in favor were more likely than those who saw no information to have initiated HPV vaccination (OR = 1.74, 95% CI:1.24, 2.44). Parents exposed to information against vaccination were more likely to have delayed (OR = 3.29, 95% CI:1.66, 6.51) or refused (OR = 4.72, 95% CI:2.35, 9.50) HPV vaccination. Exposure to mixed information was also significantly associated with vaccine delay and refusal. DISCUSSION: Our findings suggest that the type of information seen on social media regarding HPV vaccination may influence the decisions parents make about vaccinating their children. Efforts should be sought to increase online information in favor of HPV vaccination and combat vaccine misinformation in social media.

Implementing Locally Tailored Strategies to Promote Redemption of Farmers' Market Nutrition Program Vouchers Among WIC Participants in Central Pennsylvania.

The Pennsylvania Farmers' Market Nutrition Program (FMNP) provides vouchers to participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to purchase locally grown fruits, vegetables (F&V), and herbs every year from June to November. Voucher redemption is suboptimal among WIC participants in Lebanon County, a community with high numbers of low-income and Hispanic families. Supported by a Racial and Ethnic Approaches to Community Health (REACH) award, our community-academic coalition partnered with the local WIC provider to implement locally tailored strategies to promote redemption of FMNP vouchers. In 2019, we surveyed FMNP participants (n = 100) to examine opportunities for improved voucher redemption. Increasing sites for voucher use (47%) and a larger variety of F&V (27%) were the most commonly selected improvements participants identified. Participants also supported improvements to increase awareness of available seasonal produce (14%), text/phone reminders to redeem vouchers (13%), and having recipes to cook meals with FMNP-approved F&V (12%). These findings led us to implement a weekly, Farm-to-WIC "grab bag" program in 2020/2021. We partnered with a local farmer to offer a variety of FMNP-approved produce in $3 and $6 grab bags at the local WIC provider. Each grab bag included healthy recipes using the included produce. In 2021, we launched a text/phone reminder intervention to encourage voucher redemption among FMNP participants (n = 57). Our work demonstrates the value of community-academic partnerships to identify and implement feasible strategies that are responsive to local needs as well as supporting existing programs providing greater access to affordable produce.

Comparing two advance care planning conversation activities to motivate advance directive completion in underserved communities across the USA: The Project Talk Trial study protocol for a cluster, randomized controlled trial.

BACKGROUND: Advance care planning (ACP) is a process involving conversations between patients, loved ones, and healthcare providers that consider patient preferences for the types of medical therapies received at the end of life. Underserved populations, including Black, Hispanic, rural, and low-income communities are less likely to engage in ACP than other communities, a health inequity that results in lower-quality care and reduced hospice utilization. The purpose of this trial is to compare efficacy of two interventions intended to motivate ACP (particularly advance directive completion) for those living in underserved communities. METHODS: This 3-armed cluster, randomized controlled mixed methods design is being conducted in 75 community venues in underserved communities across the USA. The goal of the trial is to compare the efficacy of two interventions at motivating ACP. Arm 1 uses an end-of-life conversation game (Hello); Arm 2 uses a nationally utilized workshop format for ACP conversations (The Conversation Project); and Arm 3 uses an attention control game (TableTopics). Events are held in partnership with 75 local community-based host organizations and will involve 1500 participants (n=20 per event). The primary outcome is completion of a visually verified advance directive at 6 months post-event. Primary analyses compare efficacy of each intervention to each other and the control arm. Secondary mixed methods outcomes include (a) other ACP behaviors and engagement; (b) communication quality; (c) impact of sociocultural environment on ACP (via qualitative interviews); and (d) implementation and sustainability. Subgroup analyses examine outcomes for Black, Hispanic, and rural groups in particular. DISCUSSION: This trial will add to the evidence base behind various conversational ACP interventions, examine potential mechanisms of action for such interventions, and provide qualitative data to better understand the sociocultural environment of how community-based ACP interventions are experienced by underserved populations. Results will also provide important data for future researchers to learn whether visual verification of advance directives is necessary or whether reliance on self-reported outcomes is of comparable value. Data from this study will inform ways to effectively motivate underserved communities to participate in advance care planning. TRIAL REGISTRATION: ClinicalTrials.gov NCT04612738. Registered on October 12, 2020. All information from the WHO Trial Registration Data Set can be found within the protocol.

Skeptical Health Mavens May Limit COVID-19 Vaccine Diffusion: Using the Innovation Diffusion Cycle to Interpret Results of a Cross-sectional Survey among People Who are Socially Vulnerable.

We sought to identify barriers to COVID-19 vaccine uptake among persons who are socially vulnerable in light of the natural cycle of innovation diffusion. Widespread adoption of a health innovation requires a cadre of opinion leaders to build on successes experienced by early adopters. One type of opinion leader in healthcare are health mavens: members of a community who maintain up-to-date health knowledge and share their knowledge others. We surveyed 139 persons who are socially vulnerable regarding their COVID-19 vaccination intention, and evaluated their responses based on psychological traits captured by two scales: innovativeness and health mavenism. Health mavenism was not strongly correlated with COVID-19 vaccine intention. Health mavens often relied on their own healthcare providers (n = 46) and health agency websites (n = 42) for vaccine information. Those who relied on their faith leaders (n = 4) reported a lower likelihood of getting vaccinated (31.5% vs. 76.0%, p < .05). The observed lack of support by health mavens represents a critical barrier to COVID-19 vaccine uptake; targeting campaigns to health mavens may increase COVID-19 vaccine uptake in socially vulnerable communities.

Support for HPV vaccine school-entry requirements in the United States: The role of exemption policies.

In the United States (U.S.), only five states or territories require human papillomavirus (HPV) vaccination for school attendance, even though almost all U.S. jurisdictions have debated adopting this type of policy. In this U.S. based study, we sought to estimate the level of support for HPV vaccine school-entry requirements with varying exemption policies and documentation procedures to obtain exemptions. Between July and August 2019, we conducted a web-based survey with a national sample of 1,109 U.S. parents of 11- to 17-year-olds. The survey assessed support for four school-entry vaccine requirement policies: without exemption or with exemption for medical, religious or philosophical reasons. Analyses used multivariable logistic regression to assess correlates of support for each policy. Overall, 38% of parents agreed with laws requiring HPV vaccination for school attendance without exemptions. When including exemption provisions, agreement increased to 45% for philosophical reasons, 50% for religious reasons, and 59% for medical reasons. Parents more often agreed on requirements without any exemptions if they were female (OR = 1.37, 95% CI:1.01-1.87), their child had initiated HPV vaccination (OR = 2.05, 95% CI:1.50-2.87), reported high levels of vaccine confidence (OR = 2.41, 95% CI:1.77-3.27), or reported having values similar to those of the people in their community (OR = 1.85, 95% CI:1.39-2.47). Parents more often agreed with requirements that included religious or philosophical exemptions if they reported having values similar to their community or high levels of psychological reactance (all p <.05). Many parents also supported requiring a written notice signed by a health care provider (40%) or religious leader (49%) to obtain a medical or religious exemption, respectively. In conclusion, exemption policies greatly increase parent support of school-entry requirements for HPV vaccination but may decrease their impact in practice. A large number of U.S. parents support strict documentation to obtain exemptions, signaling a promising area of policymaking to strengthen vaccine policies for school attendance.

Disruptions in Oncology Care Confronted by Patients with Gynecologic Cancer Following Hurricanes Irma and Maria in Puerto Rico.

BACKGROUND: In September 2017, hurricanes Irma and Maria affected Puerto Rico (PR) and the US Virgin Islands (USVI), causing major disruptions in basic services and health care. This study documented the stressors and experiences of patients with gynecologic cancer receiving oncology care in PR following these hurricanes. METHODS: We conducted 4 focus groups (December 2018-April 2019) among women aged ≥21 years from PR who were diagnosed with gynecological cancer between September 2016 and September 2018 (n = 24). Using the same eligibility criteria, we also interviewed patients from the USVI (n = 2) who were treated in PR. We also conducted key-informant interviews with oncology care providers and administrators (n = 23) serving gynecologic cancer patients in PR. Discussions were audio-recorded, transcribed verbatim, and coded to identify emergent themes using a constant comparison method. RESULTS: Analyses of focus group discussions and interviews allowed us to identify the following emergent themes: 1) disruptions in oncology care were common; 2) communication between oncology providers and patients was challenging before and after the hurricanes hit; 3) patient resilience was key to resume care; and 4) local communities provided much-needed social support and resources. CONCLUSIONS: This study provides firsthand information about the disruptions in oncology care experienced by and the resiliency of women with gynecologic cancer following hurricanes Irma and Maria. Our findings underscore the need to incorporate oncology care in the preparedness and response plans of communities, health systems, and government agencies to maintain adequate care for cancer patients during and after disasters such as hurricanes.