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

BACKGROUND: In the United States, the most common sexually transmitted infection, human papillomavirus (HPV), causes genital warts and is associated with an estimated 33,700 newly diagnosed cancer cases annually. HPV vaccination, especially for preteens aged 11 to 12 years, is effective in preventing the acquisition of HPV and HPV-associated cancers. However, as of 2018, completion of the 2- or 3-dose HPV vaccination series increased only from 48.6% to 51.1% in teens aged 13 to 17 years, and this increase was observed only in boys. By comparison, 88.7% of teens had more than one dose of the recommended vaccine against tetanus, diphtheria, and acellular pertussis (Tdap), and 85.1% of teens had more than one dose of meningococcal vaccine. Immunizations for Tdap, meningococcal disease, and HPV can occur at the same clinical visit but often do not. OBJECTIVE: Vaccination against HPV is recommended for routine use in those aged 11 to 12 years in the United States, yet it is underutilized. We aimed to develop an educational video game to engage preteens in the decision to vaccinate. METHODS: Land of Secret Gardens is a metaphor for protecting seedlings (body) with a potion (vaccine). We screened 131 dyads of parents and preteens from 18 primary practices in North Carolina who had not initiated HPV vaccination. We measured vaccination intentions, story immersion, and game play and documented HPV vaccination rates. A total of 55 dyads were enrolled, and we randomly assigned 28 (21 completed) to play the game and 27 (26 completed) to the comparison group. RESULTS: In total, 18 preteens reported playing the game. The vaccination self-efficacy score was higher in the comparison group than the intervention group (1.65 vs 1.45; P=.05). The overall mean decisional balance score trended toward greater support of vaccination, although differences between the groups were not significant.. Vaccine initiation and completion rates were higher in the intervention group (22% vs 15%; P=.31) than in the comparison group (9% vs 2%; P=.10), although the difference was not significant. CONCLUSIONS: Video games help preteens in the decision to pursue HPV vaccination. A serious video game on HPV vaccination is acceptable to parents and preteens and can be played as intended. Gamification is effective in increasing preteen interest in HPV vaccination, as game features support decision making for HPV vaccination. TRIAL REGISTRATION: ClinicalTrials.gov NCT04627298; https://www.clinicaltrials.gov/ct2/show/NCT04627298.

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

OBJECTIVE: Health care provider recommendation is a key determinant of human papillomavirus (HPV) vaccination. We developed an online training program for providers that addressed vaccine guidelines, hesitancy to strongly recommend the vaccine, and reluctance to discuss HPV infection as a sexually transmitted infection. DESIGN: Single-group evaluation with 3 waves. Providers completed a 29-item electronic survey with closed and open-ended response options after course completion. SETTING: Pediatric and family medicine practices in North Carolina. PARTICIPANTS: Prescribing clinicians (MD, DO, family nurse practitioner, physician assistant) who serve preteens aged 11 to 12 years. In wave 3, we expanded our communities to include nursing and medical staff. INTERVENTION: An asynchronous online course to promote preteen HPV vaccination. Topics included HPV epidemiology, vaccine recommendations from the Advisory Committee on Immunization Practices (ACIP), preteen-provider-parent communication, topics about hesitancy to seek vaccination, subjects related to sexual health, and practice-level strategies to increase vaccination rates. The course, approved for 12 CME and CNE credits, was live for 4 weeks and available on-demand for 3 additional months. MAIN OUTCOME MEASURES: Provider-reported change in vaccine communication, perceptions of course content in improving practice, and satisfaction with materials. RESULTS: A total of 113 providers from 25 practices enrolled in the course and 69 (61%) completed an evaluation. Providers spent an average of 6.3 hours on the course and rated the CDC (Centers for Disease Control and Prevention)-ACIP Web site and multiple resources on hesitancy and communication about sexually transmitted infection vaccines most highly of all materials across the 3 waves. Almost all (96%) agreed the course will improve their practice. About half of all participants said they were either "much more likely" (28%) or "more likely" (19%) to recommend the vaccine after course participation. CONCLUSIONS: An online format offers a highly adaptable and acceptable educational tool that promotes interpersonal communication and practice-related changes known to improve providers' vaccine uptake by their patients.

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

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

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

INTRODUCTION: Vaccination against human papillomavirus (HPV) is routinely recommended for ages 11-12, yet in 2016 only 49.5% of women and 37.5% of men had completed the three-dose series in the United States. Offering information and cues to action through a serious videogame for preteens may foster HPV vaccination awareness, information seeking, and communication. MATERIALS AND METHODS: An iterative process was used to develop an interactive videogame, Land of Secret Gardens. Three focus groups were conducted with 16 boys and girls, ages 11-12, for input on game design, acceptability, and functioning. Two parallel focus groups explored parents' (n = 9) perspectives on the game concept. Three researchers identified key themes. RESULTS: Preteens wanted a game that is both entertaining and instructional. Some parents were skeptical that games could be motivational. A back-story about a secret garden was developed as a metaphor for a preteen's body and keeping it healthy. The goal is to plant a lush secret garden and protect the seedlings by treating them with a potion when they sprout to keep them healthy as they mature. Points to buy seeds and create the potion are earned by playing mini-games. Throughout play, players are exposed to messaging about HPV and the benefits of the vaccine. Both boys and girls liked the garden concept and getting facts about HPV. Parents were encouraged to discuss the game with their preteens. CONCLUSION: Within a larger communication strategy, serious games could be useful for engaging preteens in health decision making about HPV vaccination.

Immunization effects of a communication intervention to promote preteen HPV vaccination in primary care practices.

OBJECTIVES: HPV vaccination at the recommended ages of 11-12 is highly effective yet has stalled well below the goal of 80% of the population. We evaluated a statewide practice-based communication intervention (tools: brochures, posters, online training for providers and resources for parents, video game for preteens) to persuade parents, preteens and providers to vaccinate against HPV. The 9-month intervention started May 1, 2015. METHODS: We compared vaccine initiation and completion rates over three 9-month periods (baseline, intervention, post-intervention) between practices enrolled in the intervention and a comparable comparison group. All practices reported to the North Carolina Immunization Registry (NCIR) and had at least 100 11- and 12-year-olds who had not completed the HPV vaccine series. Of 175 eligible practices, the 14 intervention practices included 19,398 individuals and the 161 comparison practices included 127,896 individuals. An extended Cox model was used to test the intervention effect. RESULTS: The intervention had a significant effect on both initiation and completion during the intervention and post-intervention periods; the estimated hazard ratio (HR) for initiation was 1.17 (p = .004) during the intervention and 1.11 (p = .005) post-intervention. Likewise, completion during the intervention period was 17% higher in intervention practices, after controlling for baseline differences. This effect increased in the post-intervention period to 30% higher (p = .03). CONCLUSIONS: Individuals in the intervention practices were 17% more likely to initiate and complete HPV vaccination than in the comparison practices during the intervention period and the effect was sustained post-intervention. This intervention is promising for increasing rates of HPV vaccination at ages 11-12.

Changing Attitudes About Concurrency Among Young African Americans: Results of a Radio Campaign.

We created and evaluated an 8-month campaign of provocative radio ads to change attitudes about concurrent (overlapping) sexual partnerships among young African Americans. We created a concurrency attitude scale and compared its score distributions in independent samples of African Americans, ages 18-34 years, interviewed by telephone before (n = 678) and after (n = 479) the campaign. Pre- and post-campaign samples reflected similar response rates (pre: 32.6%; post: 31.8%) and distributions of personal characteristics. Reported exposure to concurrency messages was greater after the campaign (pre: 6.3%, post: 30.9%), and mean scores indicated less acceptance of concurrency (pre: 3.40 [95% CI 3.23, 3.57]; post: 2.62 [2.46, 2.78]). Score differences were not a function of differences in composition of the samples (adjusted means: pre: 3.37 [3.21, 3.53]; post: 2.62 [2.47, 2.76]). Findings demonstrate that a carefully targeted, intensive mass media campaign can change attitudes about concurrency, which should facilitate behavior change.

Communication technologies to improve HPV vaccination initiation and completion: A systematic review.

OBJECTIVES: This systematic review examines the effectiveness of communication technology interventions on HPV vaccination initiation and completion. METHODS: A comprehensive search strategy was used to identify existing randomized controlled trials testing the impact of computer-, mobile- or internet-based interventions on receipt of any dose of the HPV vaccine. Twelve relevant studies were identified with a total of 38,945 participants. RESULTS: The interventions were delivered using several different methods, including electronic health record (i.e. recall/reminder) prompts, text messaging, automated phone calls, interactive computer videos, and email. Vaccine initiation and completion was greater for technology-based studies relative to their control conditions. CONCLUSION: There is evidence that interventions utilizing communication technologies as their sole or primary mode for HPV vaccination intervention delivery may increase vaccination coverage. PRACTICE IMPLICATIONS: Communication technologies hold much promise for the future of HPV vaccination efforts, especially initiatives in practice-based settings.

Reducing Concurrent Sexual Partnerships Among Blacks in the Rural Southeastern United States: Development of Narrative Messages for a Radio Campaign.

In the United States, heterosexual transmission of HIV infection is dramatically higher among Blacks than among Whites. Overlapping (concurrent) sexual partnerships promote HIV transmission. The authors describe their process for developing a radio campaign (Escape the Web) to raise awareness among 18-34-year-old Black adults of the effect of concurrency on HIV transmission in the rural South. Radio is a powerful channel for the delivery of narrative-style health messages. Through six focus groups (n = 51) and 42 intercept interviews, the authors explored attitudes toward concurrency and solicited feedback on sample messages. Men were advised to (a) end concurrent partnerships and not to begin new ones; (b) use condoms consistently with all partners; and (c) tell others about the risks of concurrency and benefits of ending concurrent partnerships. The narrative portrayed risky behaviors that trigger initiation of casual partnerships. Women were advised to (a) end partnerships in which they are not their partner's only partner; (b) use condoms consistently with all partners; and (c) tell others about the risks of concurrency and benefits of ending concurrent partnerships. Messages for all advised better modeling for children.

Social marketing to promote HPV vaccination in pre-teenage children: talk about a sexually transmitted infection.

A significant barrier to the delivery of HPV vaccine is reluctance by both healthcare providers and parents to vaccinate at age 11 or 12, which may be considered a young age. This barrier has been called "vaccine hesitancy" in recent research. In this commentary, we suggest using social marketing strategies to promote HPV vaccination at the recommended preteen ages. We emphasize a critical public health message of a sexually transmitted infection (STI) as preventable and vaccination against HPV as a way to protect against its consequences. The message tackles the issue of vaccine hesitancy head on, by saying that most people are at risk for HPV and there is a way to prevent HPV's serious consequences of cancer. Our approach to this conversation in the clinical setting is also to engage the preteen in a dialog with the parent and provider. We expect our emphasis on the risk of STI infection will not only lead to increased HPV vaccination at preteen ages but also lay important groundwork for clinical adoption of other STI vaccines in development (HIV, HSV, Chlamydia, and Gonorrhea) as well as begin conversations to promote sexual health.

Partnering with middle school students to design text messages about HPV vaccination.

Human papillomavirus (HPV) vaccination is routinely recommended for U.S. adolescents ages 11 to 12 years, yet vaccine coverage remains low. Text message HPV immunization reminders to parents have been effective with increasing uptake, but text messages directly to adolescents in order to increase HPV vaccination uptake are unknown. The purpose of this study was to examine the acceptability of text messages about HPV vaccination and message preferences among adolescents. Middle school students (n = 43) assisted in designing text messages to promote HPV vaccine among their peers. Through seven focus groups and two in-class surveys, we assessed students' knowledge of HPV vaccine, use of texting, and preferences for text messages and sources. The average age of participants was 13 years, and all were White (17 males, 26 females) in this rural setting. More than 70% used text messaging with a cell phone. The text message with the best composite score (M = 2.33, SD = 0.72) for likeability, trustworthiness, and motivation to seek more information was a gain frame emphasizing reduction in HPV infection if vaccinated against HPV. Text messages with lower scores emphasized threats of disease if not vaccinated. Participants (68%) preferred doctors as their information source. Text messaging to adolescents may be a strategy to improve HPV knowledge and vaccination.

Intervention effects from a social marketing campaign to promote HPV vaccination in preteen boys.

OBJECTIVES: Adoption of human papillomavirus (HPV) vaccination in the US has been slow. In 2011, HPV vaccination of boys was recommended by CDC for routine use at ages 11-12. We conducted and evaluated a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys. METHODS: We targeted parents and providers of 9-13 year old boys in a 13 county NC region. The 3-month intervention included distribution of HPV vaccination posters and brochures to all county health departments plus 194 enrolled providers; two radio PSAs; and an online CME training. A Cox proportional hazards model was fit using NC immunization registry data to examine whether vaccination rates in 9-13 year old boys increased during the intervention period in targeted counties compared to control counties (n=15) with similar demographics. To compare with other adolescent vaccines, similar models were fit for HPV vaccination in girls and meningococcal and Tdap vaccination of boys in the same age range. Moderating effects of age, race, and Vaccines for Children (VFC) eligibility on the intervention were considered. RESULTS: The Cox model showed an intervention effect (ß=0.29, HR=1.34, p=.0024), indicating that during the intervention the probability of vaccination increased by 34% in the intervention counties relative to the control counties. Comparisons with HPV vaccination in girls and Tdap and meningococcal vaccination in boys suggest a unique boost for HPV vaccination in boys during the intervention. Model covariates of age, race and VFC eligibility were all significantly associated with vaccination rates (p<.0001 for all). HPV vaccination rates were highest in the 11-12 year old boys. Overall, three of every four clinic visits for Tdap and meningococcal vaccines for preteen boys were missed opportunities to administer HPV vaccination simultaneously. CONCLUSIONS: Social marketing techniques can encourage parents and health care providers to vaccinate preteen boys against HPV.

Designing messages to motivate parents to get their preteenage sons vaccinated against human papillomavirus.

CONTEXT: Human papillomavirus (HPV) vaccine, licensed for use in 9--26-year-olds, is most effective when given before sexual activity begins. HPV causes genital warts, is associated with several cancers and disproportionately affects racial and ethnic minorities. Parents are typically unaware of male HPV vaccine; messages that might motivate them to get their preteenage sons vaccinated are unexplored. METHODS: Messages promoting vaccination of preteenage boys were designed and tested in 2009 and 2010. Five focus groups were conducted with 29 black parents of 11-12-year-old boys, recruited through three churches and a middle school in North Carolina, and a racially diverse sample of 100 parents of 9-13-year-old boys in a university-based adolescent health clinic was interviewed. A constant comparison method was used to code transcripts and interpret themes. Chi-square and t tests or analyses of variance were used to assess differences in quantitative data. RESULTS: Focus group parents knew little about HPV in males. Although concerned about safety and cost, parents supported vaccination for their sons. They wanted to see racial diversity and both parents in motivational materials. In interviews, 89% of parents reported never having heard of male HPV vaccine. The largest proportion said that a message stressing the prevalence and possible consequences of HPV infection was the most motivating (32%); the design favored by the largest proportion (43%) showed two parents. CONCLUSIONS: Messages that may most motivate parents to get preteenage boys vaccinated against HPV focus on infection risk and include images of parents with their sons.

Evaluating a County-Sponsored Social Marketing Campaign to Increase Mothers' Initiation of HPV Vaccine for their Pre-teen Daughters in a Primarily Rural Area.

Routine vaccination against human papillomavirus (HPV), the main cause of cervical cancer, is recommended for 11-12 year old girls, yet vaccine uptake is low. This study evaluates a social marketing campaign initiated by 13 North Carolina counties to raise awareness among parents and reduce barriers to accessing the vaccine in a primarily rural area. The 3-month campaign targeted mothers of girls ages 11-12 and healthcare practices serving pre-teen girls in four counties. Principles of social marketing were: product (recommended vaccine against HPV), price (cost, perception of safety and efficacy, and access), promotion (posters, brochures, website, news releases, doctor's recommendation), and place (doctors' offices, retail outlets). We analyzed (1) website traffic, hotline calls, and media placement; (2) cross-sectional surveys of mothers and providers; and (3) HPV immunization rates in intervention versus non-intervention counties. Of respondent mothers (n=225), 82% heard or saw campaign messages or materials. Of respondent providers (n=35), 94% used campaign brochures regularly or occasionally in conversations with parents. HPV vaccination rates within six months of campaign launch were 2% higher for 9-13 year old girls in two of the four intervention counties compared to 96 non-intervention counties. This evaluation supports campaign use in other primarily rural and underserved areas.

Asking mom: formative research for an HPV vaccine campaign targeting mothers of adolescent girls.

Vaccination against the types of human papillomavirus (HPV) that cause about 70% of cervical cancers is approved for use in girls and women between 9 and 26 years of age and recommended routinely in 11-12-year-old girls. This article reports on the systematic theory-based formative research conducted to develop HPV vaccine messages for a campaign targeting racially diverse mothers of nonvaccinated 11-12-year-old girls in rural Southeastern United States. A consortium of 13 county health departments concerned about high rates of cervical cancer in their region relative to state and national averages initiated the campaign. The research examined behavioral determinants for vaccination decisions as well as mothers' reactions to message frames and emotional appeals. On the basis of focus groups and intercept interviews (n = 79), the authors demonstrated how preproduction message research and production message testing were used to develop messages that would motivate mothers of preteen girls. Core emotional truths that emerged were a mother's instinct to protect her daughter from harm and to embrace aspirations for her daughter's future. Mothers also reacted more positively to text about preventing cervical cancer than about preventing HPV, a sexually transmitted disease. Mothers preferred message concepts with photos of minorities and Caucasian mothers and daughters.

How parents hear about human papillomavirus vaccine: implications for uptake.

PURPOSE: To examine correlates of human papillomavirus (HPV) vaccine awareness and information sources in a state requiring schools to inform parents about HPV vaccine. METHODS: Telephone survey of a North Carolina population-based sample of 696 parents of females aged 10-17 years about HPV vaccine awareness and information sources (daughters' schools, healthcare provider, drug company advertisements, news stories) was conducted. RESULTS: Overall, 91% of parents had heard of HPV vaccine. Parents were more likely to be aware if they had household incomes of $50,000 or higher, were women, had non-Hispanic white daughters, or had daughters vaccinated against meningitis. Information sources included drug company advertisements (64%), healthcare providers (50%), news stories (50%), and schools (9%). Only parents who heard from their children's healthcare providers were more likely to initiate HPV vaccine for their daughters. CONCLUSIONS: Parents had rarely heard of the vaccine through schools. The only source associated with vaccine initiation was hearing from a healthcare provider.

Statewide HPV vaccine initiation among adolescent females in North Carolina.

BACKGROUND: Cervical cancer incidence in the United States may be greatly reduced through widespread human papillomavirus (HPV) vaccination. We estimated the statewide level of HPV vaccine initiation among adolescent girls in North Carolina and identified correlates of vaccine initiation. METHODS: We used data from 617 parents of adolescent females from North Carolina who completed the population-based 2008 Child Health Assessment and Monitoring Program survey. Analyses used weighted multivariate logistic regression. RESULTS: Overall, 31.3% of parents reported their daughters had received at least 1 dose of HPV vaccine. Vaccine initiation was higher among daughters aged 13 to 15 years (odds ratio [OR] = 2.03, 95% CI, 1.12-3.67) or 16 to 17 years (OR = 3.21, 95% CI, 1.76-5.86) compared with those 10 to 12 years old. Additional correlates of HPV vaccine initiation included the daughter having a preventive check-up in the last 12 months (OR = 5.09, 95% CI, 2.43-10.67), having received meningococcal vaccine (OR = 2.50, 95% CI, 1.55-4.01), or being from an urban area (OR = 1.81, 95% CI, 1.02-3.21). Among parents of unvaccinated daughters, intent to vaccinate in the next year was higher among those with daughters aged 13 to 17 years. Parents of unvaccinated non-Hispanic white daughters reported lower levels of intent to vaccinate within the next year compared with parents of unvaccinated daughters of other races. CONCLUSIONS: HPV vaccine initiation in North Carolina is comparable with other US areas. Potential strategies for increasing HPV vaccination levels include reducing missed opportunities for HPV vaccination at preventive check-ups and increasing concomitant administration of HPV vaccine with other adolescent vaccines.

Disparities in how parents are learning about the human papillomavirus vaccine.

BACKGROUND: Differential access to basic health information may contribute to persistent cervical cancer disparities. We examined whether human papillomavirus (HPV) vaccine awareness, HPV knowledge, and use of information sources about the vaccine differ by sociodemographic characteristics associated with cervical cancer. METHODS: Study participants (n = 889) were caregivers of adolescent girls ages 10 to 18 years living in southeastern North Carolina. Analyses simultaneously controlled for caregivers' gender, race, age, education, income, and rural residence. RESULTS: Although most caregivers were aware of HPV (83%) and the HPV vaccine (82%), awareness differed by gender, race, education, and income. The largest differences were for race, with 87% of Whites versus 68% of African Americans having heard of the vaccine (P < 0.001). Caregivers correctly answered an average of 69% of questions on HPV, with differences by race and education. Most respondents heard of the HPV vaccine through drug company advertisements (83%) or broadcast media coverage (69%). African Americans were less likely than Whites to have heard about the vaccine from advertisements but more likely from a broadcast source (P < 0.05). Health care providers (88%) and the internet (65%) were the most favored sources for future information about the vaccine. Vaccine uptake was associated with awareness, knowledge, and media use. DISCUSSION: Whereas drug company advertisements seem to play a central role in high HPV vaccine awareness, doctors and the internet are the preferred future "go to" sources for seeking out information. Communication-based interventions for caregivers from cervical cancer risk groups, especially African Americans, may need to use different communication channels and content.

Racial differences in HPV knowledge, HPV vaccine acceptability, and related beliefs among rural, southern women.

CONTEXT: Because cervical cancer mortality in the United States is twice as high among black women as white women and higher in rural areas, providing human papillomavirus (HPV) vaccine to rural black adolescents is a high priority. PURPOSE: To identify racial differences in knowledge and attitudes about HPV, cervical cancer, and the HPV vaccine that may influence uptake of the vaccine. METHODS: We interviewed women (91 black and 47 white) living in a rural area of the Southern United States in 2006. Analyses controlled for socioeconomic status, age, and recruitment location. FINDINGS: More white respondents had heard of HPV than had black respondents (57% vs 24%, P < .001), and whites had higher HPV knowledge (42% vs 29% correct responses, P < .05). Blacks were less likely than whites to think that cervical cancer would be a serious threat to their daughters' health (75% vs 96%, P < .001). More blacks than whites thought the ideal age to receive the vaccine was 17 years or older (63% vs 40%, P < .05). Blacks reported lower intentions to vaccinate their daughters than whites (M = 4.14 vs 4.55, P < .05 in unadjusted analyses, but not statistically significant in adjusted analyses). CONCLUSIONS: Black and white respondents had different awareness, knowledge, and beliefs related to the HPV vaccine. Communication-based interventions to maximize uptake of the HPV vaccine in the rural, Southern United States may need different messages for black parents of adolescent girls.