Effect of an HPV Vaccination Multi-Level, Multi-Component Program on HPV Vaccination Initiation and Completion in a Pediatric Clinic Network.

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study's purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP's effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11-17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.

Racial/ethnic disparities in the association between patient care experiences and receipt of initial surgical breast cancer care: findings from SEER-CAHPS.

PURPOSE: We determined whether racial/ethnic differences in patient experiences with care influence timeliness and type of initial surgical breast cancer treatment for a sample of female Medicare cancer patients. METHODS: We conducted a retrospective cohort study using the linked Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset. The outcomes were: (1) time-to-initial surgical treatment, and (2) type of treatment [breast conserving surgery (BCS) vs. mastectomy]. The indicators were reports of four types of patient experiences with care including doctor communication, getting care quickly, getting needed care, and getting needed Rx. Interaction terms in each multivariable logistic model examined if the associations varied by race/ethnicity. RESULTS: Of the 2069 patients, 84.6% were White, 7.6% Black and 7.8% Hispanic. After adjusting for potential confounders, non-Hispanic Black patients who provided excellent reports of their ability to get needed prescriptions had lower odds of receiving surgery within 2-months of diagnosis, compared to NH-Whites who provided less than excellent reports (aOR: 0.29, 95% CI 0.09-0.98). There were no differences based on 1-month or 3-month thresholds. We found no other statistically significant effect of race/ethnicity. As to type of surgery, among NH Blacks, excellent reports of getting care quickly were associated with higher odds of receiving BCS versus mastectomy (aOR: 2.82, 95% CI 1.16-6.85) compared to NH Whites with less than excellent reports. We found no other statistically significant differences by race/ethnicity. CONCLUSION: Experiences with care are measurable and modifiable factors that can be used to assess and improve aspects of patient-centered care. Improvements in patient care experiences of older adults with cancer, particularly among minorities, may help to eliminate racial/ethnic disparities in timeliness and type of surgical treatment.

Adaptation and Formative Evaluation of Online Decision Support to Implement Evidence-Based Strategies to Increase HPV Vaccination Rates in Pediatric Clinics.

Human papilloma virus (HPV) vaccination rates remain below national goals in the United States despite the availability of evidence-based strategies to increase rates. The Adolescent Vaccination Program (AVP) is a multi-component intervention demonstrated to increase HPV vaccination rates in pediatric clinics through the implementation of six evidence-based strategies. The purpose of this study, conducted in Houston, Texas, from 2019-2021, was to adapt the AVP into an online decision support implementation tool for standalone use and to evaluate its feasibility for use in community clinics. Phase 1 (Adaptation) comprised clinic interviews (n = 23), literature review, Adolescent Vaccination Program Implementation Tool (AVP-IT) design documentation, and AVP-IT development. Phase 2 (Evaluation) comprised usability testing with healthcare providers (HCPs) (n = 5) and feasibility testing in community-based clinics (n = 2). AVP-IT decision support provides an Action Plan with tailored guidance on implementing six evidence-based strategies (immunization champions, assessment and feedback, continuing education, provider prompts, parent reminders, and parent education). HCPs rated the AVP-IT as acceptable, credible, easy, helpful, impactful, and appealing (≥80% agreement). They rated AVP-IT supported implementation as easier and more effective compared to usual practice (p ≤ 0.05). The clinic-based AVP-IT uses facilitated strategy implementation by 3-month follow-up. The AVP-IT promises accessible, utilitarian, and scalable decision support on strategies to increase HPV vaccination rates in pediatric clinic settings. Further feasibility and efficacy testing is indicated.

Perceived barriers to cervical cancer screening and motivators for at-home human papillomavirus self-sampling during the COVID-19 pandemic: Results from a telephone survey.

Background: Home-based self-sampling for human papillomavirus (HPV) testing may be an alternative for women not attending clinic-based cervical cancer screening. Methods: We assessed barriers to care and motivators to use at-home HPV self-sampling kits during the COVID-19 pandemic as part of a randomized controlled trial evaluating kit effectiveness. Participants were women aged 30-65 and under-screened for cervical cancer in a safety-net healthcare system. We conducted telephone surveys in English/Spanish among a subgroup of trial participants, assessed differences between groups, and determined statistical significance at p<0.05. Results: Over half of 233 survey participants reported that clinic-based screening (Pap) is uncomfortable (67.8%), embarrassing (52.4%), and discomfort seeing male providers (63.1%). The last two factors were significantly more prevalent among Spanish vs English speakers (66.4% vs 30% (p=0.000) and 69.9 vs 52.2% (p=0.006), respectively). Most women who completed the kit found Pap more embarrassing (69.3%), stressful (55.6%), and less convenient (55.6%) than the kit. The first factor was more prevalent among Spanish vs English speakers (79.6% vs 53.38%, p=0.001) and among patients with elementary education or below. Conclusions: The COVID-19 pandemic influenced most (59.5%) to participate in the trial due to fear of COVID, difficulty making appointments, and ease of using kits. HPV self-sampling kits may reduce barriers among under-screened women in a safety-net system. Funding: This study is supported by a grant from the National Institute for Minority Health and Health Disparitie s (NIMHD, R01MD013715, PI: JR Montealegre). Clinical trial number: NCT03898167.

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools.

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

Parents' stigmatizing beliefs about the HPV vaccine and their association with information seeking behavior and vaccination communication behaviors.

Parents' stigmatizing beliefs about the HPV vaccine, such as beliefs that it promotes adolescent sexual activity, constitute a notable barrier to vaccine uptake. The purpose of this study is to describe the associations between parents' stigmatizing beliefs about the HPV vaccine, psychosocial antecedents to vaccination, and parents' intentions to vaccinate their children. Parents of vaccine-eligible children (n = 512) were surveyed in a large urban clinical network. Results indicate that two stigmatizing beliefs were significantly associated with self-efficacy in talking with a doctor about the HPV vaccine. Believing that the vaccine would make a child more likely to have sex was associated with citing social media as a source of information about the vaccine. Other stigmatizing beliefs were either associated with citing healthcare professionals as sources of information about the vaccine, or they were not significantly associated with any information source. This finding suggests that stigmatizing beliefs might discourage parents from seeking out information about the vaccine. This study is significant because it further highlights the importance of doctor recommendations to all patients at recommended ages; doctor visits may represent one of the few opportunities to normalize HPV vaccination and address parents' stigmatizing beliefs about the HPV vaccine.

Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews.

INTRODUCTION: Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening. METHODS: Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community. RESULTS: The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status. DISCUSSION: Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.

Do breast cancer survivors with a recent history of clinical depression report worse experiences with care? A retrospective cohort study using SEER-CAHPS data.

PURPOSE: We examined whether breast cancer survivors' experiences with care differed by a recent history of clinical depression, and whether associations differed by race/ethnicity. METHODS: Using the Epidemiology and End Results-Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) dataset, we analyzed records of breast cancer survivors who completed a survey at least 12 months after their cancer diagnosis. We assessed clinical depression 12 months prior to survey completion using Medicare claims. We used separate multivariable logistic regressions to examine the associations between depression and excellent (vs. less than excellent) ratings of experiences with care (i.e., doctor communication, getting needed care, getting care quickly, getting prescription drugs, specialist and overall care). We also assessed interactions of depression by race/ethnicity. All models were adjusted for demographics and cancer prognostic and treatment factors. RESULTS: Of the 2271 survivors, 7.6% were clinically depressed. After adjusting for covariates, survivors with clinical depression had lower odds of reporting excellent ratings of their ability to get needed care, care by their specialist, and overall care, compared to those without depression (AOR = 0.58, 95% CI: 0.40-0.84; AOR = 0.40, CI: 0.31-0.76; and AOR = 0.61, CI: 0.42-0.89, respectively). Among Hispanics, having depression was associated with higher odds of excellent ratings of one's ability to get needed care (AOR: 5.42, 95% CI: 1.02-28.81). No other statistically significant associations by race/ethnicity were found. CONCLUSIONS: Breast cancer survivors with depression report poorer patient experiences with care. Further research is needed to understand complexities of ratings of experiences with care among survivors of diverse backgrounds. IMPLICATIONS: Survivors with a recent history of clinical depression may benefit from additional supportive care services.

Perceived barriers to cervical cancer screening and motivators for at-home human papillomavirus self-sampling during the COVID-19 pandemic: Results from a telephone survey.

Home-based self-sample human papillomavirus (HPV) testing may be an alternative for women who do not attend clinic-based cervical cancer screening. We assessed barriers to care and motivators to use at-home HPV self-sampling kits during the COVID-19 pandemic as part of a randomized controlled trial evaluating kit effectiveness. Participants were women, aged 30-65 years and underscreened for cervical cancer in a safety-net healthcare system. We conducted telephone surveys in English/Spanish among a subgroup of trial participants, assessed differences between groups and determined statistical significance at p<0.05. Over half of 233 survey participants reported clinic-based screening (Pap) is uncomfortable (67.8%), embarrassing (52.4%), and discomfort seeing male providers (63.1%). The latter two factors were significantly more prevalent among Spanish versus English speakers (66.4% vs 30% and 69.9 vs 52.2%, respectively, p<0.01). Most women who completed the kit found Pap more embarrassing (69.3%), stressful (55.6%) and less convenient (55.6%) than the kit. The first factor was more prevalent among Spanish versus English speakers (79.6% vs 53.38%, p<0.05). The COVID-19 pandemic influenced most (59.5%) to participate in the trial due to fear of COVID, difficulty making appointments and ease of using kits. HPV self-sampling kits may reduce barriers among underscreened women in a safety-net system.

AVPCancerFree: Impact of a digital behavior change intervention on parental HPV vaccine -related perceptions and behaviors.

Parent hesitancy contributes to reduced HPV vaccination rates. The HPVcancerfree app (HPVCF) was designed to assist parents in making evidence-based decisions regarding HPV vaccination. This study examined if parents of vaccine-eligible youth (11-12 yrs.) who use HPVCF in addition to usual care demonstrate significantly more positive intentions and attitudes toward HPV vaccination and greater HPV vaccination rates compared to those not using HPVCF. Clinics (n = 51) within a large urban pediatric network were randomly assigned to treatment (HPVCF + usual care) or comparison (usual care only) conditions in a RCT conducted between September 2017 and February 2019. Parents completed baseline and 5-month follow-up surveys. Participant-level analysis determined 1) change in HPV vaccination initiation behavior and related psychosocial determinants and 2) predictors of HPV vaccine initiation. Parents (n = 375) who completed baseline and 5-month follow-up surveys were female (95.2%), 40.8 (±5.8) yrs. married (83.7%), employed (68.3%), college educated (61.9%), and privately insured (76.5%). Between-group analysis of HPVCF efficacy demonstrated that parents assigned to receive HPVCF significantly increased knowledge about HPV and HPV vaccination (p < .05). Parents who accessed content within HPVCF significantly increased knowledge about HPV & HPV vaccine (p < .01) and perceived effectiveness of HPV vaccine (p < .05). Change in HPV vaccine initiation was not significant. A multivariate model to describe predictors of HPV vaccine initiation demonstrated an association with Tdap and MCV vaccination adoption, positive change in perceived effectiveness of the HPV vaccine, and reduction in perceived barriers against HPV vaccination. HPVCF appears to be a feasible adjunct to the education received in usual care visits and reinforces the value of apps to support the important persuasive voice of the health-care provider in overcoming parent HPV vaccine hesitancy.

Parent Engagement with a Self-Tailored Cancer Prevention Digital Behavior Change Intervention: Exploratory Application of Affiliation Network Analysis.

Evaluating digital behavior change intervention engagement is complex and requires multidimensional and novel approaches that are emerging. The relationship and interdependence between engagement with the technology and engagement with the psychosocial or behavior change process often presents conceptual and evaluative challenges. Large objective data sets detailing technology use are plentiful but meaningful interpretation can be challenging at granular levels. Affiliation network analysis which describes two-mode network data may provide a novel approach to evaluate engagement of digital behavior change interventions. The purpose of this paper is to use affiliation network analysis as an exploratory method to describe, assess and visualize content-specific patterns underlying psychosocial characteristics related to HPV vaccine safety concerns of parents using the HPVcancerFree intervention. Results indicate that affiliation network analysis shows promise in supplementing existing methods to assess engagement of digital interventions.

Evaluation of a 2-1-1 Telephone Navigation Program to Increase Cancer Control Behaviors: Results From a Randomized Controlled Trial.

PURPOSE: To evaluate the effectiveness of a telephone navigation intervention for increasing use of cancer control services among underserved 2-1-1 callers. DESIGN: Randomized controlled trial. SETTING: 2-1-1 call centers in Houston and Weslaco, Texas (located in the Rio Grande Valley near the Mexican border). PARTICIPANTS: 2-1-1 callers in need of Pap test, mammography, colorectal cancer screening, smoking cessation counseling, and/or HPV vaccination for a daughter (n = 1,554). A majority were low-income and described themselves as Black or Hispanic. INTERVENTION: Participants were randomly assigned to receive either a cancer control referral for the needed service(s) with telephone navigation from a trained cancer control navigator (n = 995) or a referral only (n = 559). MEASURES: Uptake of each individual service and any needed service. ANALYSIS: Assessed uptake in both groups using bivariate chi-square analyses and multivariable logistic regression analyses, adjusted for sociodemographic covariates. Both per-protocol and intent-to-treat approaches were used. RESULTS: Both interventions increased cancer control behaviors. Referral with navigation intervention resulted in significantly greater completion of any needed service (OR = 1.38; p = .042), Pap test (OR = 1.56; p = .023), and smoking cessation counseling (OR = 2.66; p = .044), than referral-only condition. Other outcomes showed the same trend although the difference was not statistically significant: mammography (OR = 1.53; p = .106); colorectal cancer screening (OR = 1.80; p = .095); and HPV vaccination of a daughter (OR = 1.61; p = .331). CONCLUSION: Adding cancer control referrals and navigation to an informational service like the 2-1-1 program can increase overall participation in cancer control services.

Medical ethics principles underscore advocating for human papillomavirus vaccine.

Studies have consistently shown that vaccination rates against human papillomavirus (HPV) lag far behind other adolescent vaccinations recommended at the same age, resulting in exposing adolescents to unnecessary future risk of infection, and genital and head and neck cancers. Studies also have demonstrated that a major barrier to vaccination is lack of a strong provider recommendation. Factors that providers offer for failing to give a strong recommendation range from perception that the child is not at risk or the need to explain that the vaccine is not mandated (lack of equity and justice) or respect for parental autonomy. We look at the issue through a different lens, and reframe the above viewpoint by describing how failing to make a strong recommendation means the provider is not meeting the four principles of medical ethics (justice, beneficence, non-maleficence and autonomy).

Parents' Experience With a Mobile Health Intervention to Influence Human Papillomavirus Vaccination Decision Making: Mixed Methods Study.

BACKGROUND: Human papillomavirus (HPV)-attributed cancers are preventable, yet HPV vaccination rates severely lag behind other adolescent vaccinations. HPVcancerFree (HPVCF) is a mobile health (mHealth) intervention developed to influence parental HPV vaccination decision making by raising awareness of HPV, reducing HPV vaccination barriers, and enabling HPV vaccination scheduling and reminders through a smartphone app. Evaluating the user experience of mHealth interventions is a vital component in assessing their quality and success but tends to be underreported in mHealth intervention evaluation. OBJECTIVE: We aimed to evaluate the user experience of HPVCF, an HPV cancer prevention app designed for a pediatric clinic network, using mixed methods data collected from log files, survey measures, and qualitative feedback. METHODS: Study data were evaluated from parents in a large US pediatric clinic network using HPVCF in the treatment study condition of a group randomized controlled trial. Log data captured HPVCF retention and use. Postintervention rating scales and items assessed HPVCF utility, usefulness, understandability, appeal, credibility, and perceived impact. Overall quality was evaluated using the user version of the Mobile Application Rating Scale (uMars). Open-ended responses assessed parent recommendations for HPVCF enhancement. RESULTS: The 98 parents were mainly female (n=94, 96%), 41 (5.67) years of age, college educated (n=55, 56%), and White and non-Hispanic (n=55, 56%) and had private health insurance for their children (n=75, 77%). Parents used HPVCF 197 times, with the average visit duration approximating 3.5 minutes. The uMARS app quality score was positively skewed (4.2/5.0). Mean ratings were highest for information (4.46 [SD 0.53]) and lowest for engagement (3.74 [SD 0.69]). In addition, of 95 parents, 45 (47%) rated HPVCF as helpful in HPV vaccination decision making and 16 (17%) attributed HPV vaccine initiation to HPVCF. Parents reported that HPVCF increased their awareness (84/95, 88%), knowledge (84/95, 88%), and HPV vaccination intentions (64/95, 67%). Most of the 98 parents rated the 4 HPVCF components as useful (72-92 [73%-94%]). Parents also agreed that HPVCF is clear (86/95, 91%), accurate (86/95, 91%), and more helpful than other HPV vaccine information they had received (89/95, 94%) and that they would recommend it to others (81/95, 85%). In addition, parents suggested ways to increase awareness and engagement with the app, along with opportunities to enhance the content and functionality. CONCLUSIONS: HPVCF was well received by parents and performed well on indicators of quality, usefulness, utility, credibility, and perceived impact. This study contributes a multimethod and multimeasure evaluation to the growing body of literature focused on assessing the user experience of patient-focused technology-mediated applications for HPV education.

A Centralized Program with Stepped Support Increases Adherence to Colorectal Cancer Screening Over 9 Years: a Randomized Trial.

BACKGROUND: Screening over many years is required to optimize colorectal cancer (CRC) outcomes. OBJECTIVE: To evaluate the effect of a CRC screening intervention on adherence to CRC screening over 9 years. DESIGN: Randomized trial. SETTING: Integrated health care system in Washington state. PARTICIPANTS: Between August 2008 and November 2009, 4653 adults in a Washington state integrated health care system aged 50-74 due for CRC screening were randomized to usual care (UC; N =1163) or UC plus study interventions (interventions: N = 3490). INTERVENTIONS: Years 1 and 2: (arm 1) UC or this plus study interventions; (arm 2) mailed fecal tests or information on scheduling colonoscopy; (arm 3) mailings plus brief telephone assistance; or (arm 4) mailings and assistance plus nurse navigation. In year 3, stepped-intensity participants (arms 2, 3, and 4 combined) still eligible for screening were randomized to either stopped or continued interventions in years 3 and 5-9. MAIN MEASURES: Time in adherence to CRC testing over 9 years (covered time, primary outcome), and percent with no CRC testing in participants assigned to any intervention compared to UC only. Poisson regression models estimated incidence rate ratios for covered time, adjusting for patient characteristics and accounting for variable follow-up time. KEY RESULTS: Compared to UC, intervention participants had 21% more covered time over 9 years (57.5% vs. 69.1%; adjusted incidence rate ratio 1.21, 95% confidence interval 1.16-1.25, P<0.001). Fecal testing accounted for almost all additional covered time among intervention patients. Compared to UC, intervention participants were also more likely to have completed at least one CRC screening test over 9 years or until censorship (88.6% vs. 80.6%, P<0.001). CONCLUSIONS: An outreach program that included mailed fecal tests and phone follow-up led to increased adherence to CRC testing and fewer age-eligible individuals without any CRC testing over 9 years. TRIAL REGISTRATION: Systems of Support (SOS) to Increase Colon Cancer Screening and Follow-up (SOS), NCT00697047, clinicaltrials.gov/ct2/show/NCT00697047.

Racial/ethnic disparities in use of surveillance mammogram among breast cancer survivors: a systematic review.

BACKGROUND: Increasing number of breast cancer survivors in the USA have led to greater focus on the long-term health outcomes and surveillance care among these women. However limited evidence exists of use of surveillance mammography among breast cancer survivors and how it varies across racial/ethnic groups. METHODS: We conducted a systematic review of the literature to explore disparities in use of surveillance mammogram among women breast cancer survivors by searching for relevant studies published between 2000 and 2020 from Medline (Ovid), PubMed (National Library of Medicine), and PsycINFO (Ovid) bibliographic databases. Two authors independently screened titles, abstracts, and full texts of all articles that reported surveillance mammography use across racial/ethnic groups. Data on study design, screening eligibility, sample size, operational definition, and/or measure of the use of a surveillance mammogram among breast cancer survivors and the association between race/ethnicity and use of a surveillance mammogram were summarized in the evidence tables. RESULTS: We identified 1544 records from the three databases, and 30 studies examined the use of surveillance mammograms among breast cancer survivors across race/ethnic groups. Of these, 21 provided adjusted estimates of racial/ethnic disparities in use of surveillance mammograms, and 15 of these reported statistically significant disparities. In summary, most studies reported that non-white women (mainly Blacks and Hispanics) were less likely to receive a timely surveillance mammogram compared to White. CONCLUSION: This study extends the evidence of racial/ethnic disparities beyond completion of initial treatment by finding similar disparities in receipt of surveillance mammograms among breast cancer survivors. IMPLICATION FOR CANCER SURVIVORS: Our findings identify a need to improve efforts to increase post-treatment use of surveillance mammography among racial/ethnic minority women to reduce these gaps and improve overall clinical and quality of life outcomes.

Informing Content and Feature Design of a Parent-Focused Human Papillomavirus Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Group Study.

BACKGROUND: Human papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making. OBJECTIVE: This study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI. METHODS: We conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network. RESULTS: The 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience. CONCLUSIONS: Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child's pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents.

Using increased trust in medical researchers to increase minority recruitment: The RECRUIT cluster randomized clinical trial.

While extensive literature exists on barriers and strategies to increase minority participation in clinical trials, progress is limited. Few strategies were evaluated in randomized trials. We studied the impact of RECRUIT, a trust-based, cluster randomized minority recruitment trial layered on top of four traditional NIH-funded parent trials (BMT CTN, CABANA, PACES, STEADY-PD III; fifty specialty sites). RECRUIT was conducted from July 2013 through April 2017. Intervention sites implemented trust-based approaches customized to individual sites, promoting relationships between physician-investigators and minority-serving physicians and their minority patients. Control sites implemented only parent trials' recruitment procedures. Adjusting for within-site clustering, we detected no overall intervention effect, odds ratio 1.3 (95% confidence limits 0.7,2.4). Heterogeneity among parent trials may have obscured the effect. Of the four parent trials, three enrolled more minorities in intervention versus control sites. CABANA odds ratio = 4.2 (adjusted 95%CL 1.5,11.3). PACES intervention sites enrolled 63% (10/16) minorities; control sites enrolled one participant in total, a minority, yielding an incalculable odds ratio. STEADY-PD III odds ratio = 2.2 (adjusted 95%CL 0.6,8.5). BMT CTN odds ratio < 1, 0.8 (adjusted 95%CL 0.4,1.8). In conclusion, RECRUIT findings suggest the unique trust-based intervention increased minority recruitment to intervention trials in ¾ of studied trials. Physician-investigators' participation was critical to recruitment success. Lack of commitment to minority recruitment remained a barrier for some physician-investigators, especially in control sites. We recommend prospective physician investigators commit to minority recruitment activities prior to selection as site investigators and trial funding include some compensation for minority recruitment efforts. TRIAL REGISTRATION ClinicalTrials.govNCT01911208.

Trends in health-related quality of life of female breast cancer survivors using the Medical Expenditure Panel Survey (MEPS), 2008-2016.

PURPOSE: In recent years, breast cancer detection and treatment have advanced. As a result, increased attention to breast cancer survivorship should have improved their health-related quality of life (HRQoL). Our aim was to examine the trends in the HRQoL of female breast cancer survivors between 2008 and 2016, to determine whether or not the increased focus on survivorship has translated into improved HRQoL. Furthermore, stratified analyses were conducted by race/ethnicity and age group and these were compared to a similar group of women without a breast cancer history. METHODS: Repeated cross-sectional analyses using the Medical Expenditure Panel Survey between 2008 and 2016 were conducted. Pooled ordinary least squares (OLS) regression was used to examine the trends in physical component scores (PCS-12) and mental component scores (MCS-12) among breast cancer survivors and a similar population of women without a breast cancer history. Analyses stratified by race/ethnicity and age group were also conducted. RESULTS: Among breast cancer survivors, after adjusting for confounders, there was no change in PCS-12 scores over time, but the MCS-12 scores increased by 0.27 points (95% CI 0.09-0.45). Those without a history of breast cancer had mean PCS-12 scores that were 0.13 points greater each year (95% CI 0.02-0.24) while their mean MCS-12 scores were 0.10 (95% CI 0.00-0.21) points greater each year. After stratifying by race/ethnicity, Hispanic breast cancer survivors had a small increase in PCS-12 (ß: 0.65; 95% CI 0.01-1.29), and MCS-12 scores (ß: 0.70; 95% CI 0.06-1.33) over time. Similar small effects were found when stratified by age group, both among breast cancer survivors and those without a history of breast cancer. The younger age group (< 50 years) reported poorer MCS-12 than the older population (age 50 years and above). CONCLUSION: Our study generated findings showing the trends in the HRQoL of breast cancer survivors and compared these to a similar population of women without a history of breast cancer. This paper highlights the importance of focusing on the mental health of young breast cancer survivors to improve their prospects at a good quality of life post-breast cancer diagnosis and treatment.

A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans.

BACKGROUND: Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality. OBJECTIVES: To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1. METHODS: Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step. RESULTS: After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%). CONCLUSIONS: In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.