Prevalence of Healthcare Barriers Among US Adults With Chronic Liver Disease Compared to Other Chronic Diseases.

Background and Aims: The extent of healthcare barriers and its association with acute care use among adults with chronic liver disease (CLD) relative to other chronic conditions remains understudied. We compared the probability of barriers and recurrent acute care use among persons with CLD and persons with chronic obstructive pulmonary disease (COPD) and/or cardiovascular disease (CVD). Methods: We assembled a population-based, cross-sectional study using pooled self-reported National Health Interview Survey data (2011-2017) among community-dwelling persons. Probability of barriers by disease group (CLD vs COPD/CVD) was assessed using hurdle negative binomial regression. Results: The sample included 47,037 adults (5062 with CLD, 41,975 with COPD/CVD). The CLD group was younger (median age 55 vs 62 years) and included more Hispanics (17.5% vs 8.6%) and persons with poverty (20.1% vs 15.3%) than the COPD/CVD group. More respondents with CLD vs COPD/CVD reported barriers (44.7% vs 34.4%), including unaffordability (27.5% vs 18.8%), transportation-related (6.1% vs 4.1%), and organizational barriers at entry to (17.6% vs 13.0%) and within healthcare (19.5% vs 14.2%). While adults with CLD were more likely to experience at least 1 barrier (adjusted incident rate ratio, 1.12 [1.01-1.24], P = .03), they were not associated with more (1.05 [1.00-2.71], P = .06). Probability of recurrent acute care use was associated with more healthcare barriers. Conclusion: Findings from this nationally representative sample of over 43 million US adults reveal that persons with CLD have increased probability of healthcare barriers, likely related to their higher prevalence of socioeconomic vulnerabilities compared to persons with COPD/CVD. CLD warrants attention as a priority condition in public policies that direct resources towards high-risk populations.

Impact of management guidelines for abnormal cervical cytology on colposcopy procedure rates among young women.

OBJECTIVE: In 2012, updated ASCCP management guidelines for abnormal cervical cytology recommended observation rather than immediate referral to colposcopy for low-grade abnormalities in women ages 21-24. We evaluated the impact of these guidelines on changes in colposcopy procedure rates among young women. METHODS: We analyzed administrative and claims data from the largest statewide family planning program between July 2011 and June 2015. Using a difference-in-differences approach, we estimated changes in colposcopy procedure rates among women ages 21-24 years before and after the 2012 ASCCP management guidelines, relative to a comparison group of women ages 25-44. RESULTS: Our analysis included 333,977 women from 216 primary care provider sites. After publication of the 2012 ASCCP management guidelines, colposcopy rates significantly declined from 6.70% (95% CI 6.21-7.19) to 3.94% (95% CI 3.60-4.29) among women ages 21-24 and from 4.35% (95% CI 4.03-4.67) to 3.53% (3.25-3.80) among women over 24 years. These declines correspond to a 1.93 percentage point reduction (95% CI 1.62-2.25; p < 0.001) in colposcopy rate among women 21-24 vs. over 24 years, or a two-fold relative reduction. Among women ages 21-24, colposcopy receipt was associated with speaking primarily English vs. non-English (OR 1.46, 95% CI 1.35-1.57), having a cervical cytology test within the past year vs. not (OR 1.55, 95% CI 1.44-1.66), and receiving care from a public vs. private provider (OR 1.31, 95% CI 1.06-1.62). CONCLUSIONS: Colposcopy procedure rates among young women significantly declined following publication of the 2012 management guidelines, which has implications for reducing potential harms of overtreatment.

Barriers and proposed solutions to at-home colorectal cancer screening tests in medically underserved health centers across three US regions to inform a randomized trial.

INTRODUCTION: At-home colorectal cancer (CRC) screening is an effective way to reduce CRC mortality, but screening rates in medically underserved groups are low. To plan the implementation of a pragmatic randomized trial comparing two population-based outreach approaches, we conducted qualitative research on current processes and barriers to at-home CRC screening in 10 community health centers (CHCs) that serve medically underserved groups, four each in Massachusetts and California, and two tribal facilities in South Dakota. METHODS: We conducted 53 semi-structured interviews with clinical and administrative staff at the participating CHCs. Participants were asked about CRC screening processes, categorized into eight domains: patient identification, outreach, risk assessment, fecal immunochemical test (FIT) workflows, FIT-DNA (i.e., Cologuard) workflows, referral for a follow-up colonoscopy, patient navigation, and educational materials. Transcripts were analyzed using a Rapid Qualitative Analysis approach. A matrix was used to organize and summarize the data into four sub-themes: current process, barriers, facilitators, and solutions to adapt materials for the intervention. RESULTS: Each site's process for stool-based CRC screening varied slightly. Interviewees identified the importance of offering educational materials in English and Spanish, using text messages to remind patients to return kits, adapting materials to address health literacy needs so patients can access instructions in writing, pictures, or video, creating mailed workflows integrated with a tracking system, and offering patient navigation to colonoscopy for patients with an abnormal result. CONCLUSION: Proposed solutions across the three regions will inform a multilevel intervention in a pragmatic trial to increase CRC screening uptake in CHCs.

Trust in health workers and patient-centeredness of care were strongest factors associated with vaccination for Kenyan children born between 2017-2022.

Objective: Although vaccination confidence is declining globally, there is little detailed information from low- and middle-income countries about factors influencing routine vaccination behavior in these contexts. Methods: In mid-2022, we surveyed people who gave birth in Kenya between 2017-2022, and asked them about their children's vaccination history and about hypothesized correlates of vaccination per the Behavioural and Social Drivers of Vaccination model. Results: Of 873 children in this sample, 117 (13%) were under-vaccinated (i.e., delayed or missing vaccine dose(s)) - and under-vaccination was more common among births during the COVID-19 pandemic (2020-2022) versus pre-pandemic (2017-2019). In multi-level multivariable models, children of respondents who expressed concerns about serious side effects from vaccines had significantly higher odds of missed vaccine dose(s) (aOR 2.06, 95 % CI 1.14-3.72), and there was a strong association between having more safety concerns now versus before the COVID-19 pandemic (aOR missed dose(s) 4.44, 95 % CI 1.71-11.51; aOR under-vaccination 3.03, 95 % CI 1.28-7.19). People with greater trust in health workers had lower odds of having a child with missed vaccine dose(s) (aOR 0.85, 95 % CI 0.75-0.97). People who reported higher patient-centered quality of vaccination care had much lower odds of having children with delayed or missed vaccine dose(s) (aOR missed dose(s) 0.14, 95 % CI 0.04-0.58; aOR under-vaccination 0.27, 95 % CI 0.10-0.79). Conclusions: These findings highlight potential strategies to improve vaccine coverage: greater focus on patient-centered quality of care, training healthcare workers on how to address safety concerns about vaccines, and building trust in the health care system and in health workers.

Los Angeles County dentists' opinions on discussing human papilloma virus-related oral health issues and recommending vaccine to patients.

Dentists are well-positioned to discuss oral health issues related to Human Papillomavirus (HPV) and recommend the HPV vaccine to their patients, mainly because the HPV virus causes oropharyngeal cancers.. We assessed Los Angeles (LA) County dentists' opinions on discussing HPV-related oral health issues and recommending the HPV vaccine to their patients. We tested if opinions differed between dentists whose primary patient population was only adults versus children and adults. We mailed a 19-item survey to 2000 randomly sampled LA County dentists for this cross-sectional study. The primary outcome variable was a summary opinion score of 7 opinion statements. We ran descriptive, bivariate comparisons and adjusted linear regression models. Overall, 261 dentists completed the survey. A majority (58.5%) worried they would lose patients if they recommended the vaccine; 49% thought dentists were not appropriate to educate, counsel, or advise on HPV-related issues; 42% were concerned about the safety of the vaccine; and 40% did not feel comfortable recommending the vaccine. The mean summary opinion score was 21.4 ± 5.4 for the total sample. Regression analysis showed no differences in opinions between dentists whose primary patient population was only adults versus children and adults (Coefficient = 0.146, p = 0.83). Overall, the responding dentists were not very favorable about discussing oral health-related HPV issues and recommending the HPV vaccine to their patients. Additionally, the overall opinions were similar between dentists whose primary patient population was only adults versus children and adults.

Community Collaboration to Advance Racial/Ethnic Equity in Colorectal Cancer Screening: Protocol for a Multilevel Intervention to Improve Screening and Follow-up in Community Health Centers.

INTRODUCTION: Colorectal cancer (CRC) screening utilization is low among low-income, uninsured, and minority populations that receive care in community health centers (CHCs). There is a need for evidence-based interventions to increase screening and follow-up care in these settings. METHODS: A multilevel, multi-component pragmatic cluster randomized controlled trial is being conducted at 8 CHCs in two metropolitan areas (Boston and Los Angeles), with two arms: (1) Mailed FIT outreach with text reminders, and (2) Mailed FIT-DNA with patient support. We also include an additional CHC in Rapid City (South Dakota) that follows a parallel protocol for FIT-DNA but is not randomized due to lack of a comparison group. Eligible individuals in participating clinics are primary care patients ages 45-75, at average-risk for CRC, and overdue for CRC screening. Participants with abnormal screening results are offered navigation for follow-up colonoscopy and CRC risk assessment. RESULTS: The primary outcome is the completion rate of CRC screening at 90 days. Secondary outcomes include the screening completion rate at 180 days and the rate of colonoscopy completion within 6 months among participants with an abnormal result. Additional goals are to enhance our understanding of facilitators and barriers to CRC risk assessment in CHC settings. CONCLUSIONS: This study assesses the effectiveness of two multilevel interventions to increase screening participation and follow-up after abnormal screening in under-resourced clinical settings, informing future efforts to address CRC disparities. TRIAL REGISTRATION: NCT05714644.

Evaluating Racial Disparities in Implementation and Monitoring of a Remote Blood Pressure Program in a Pregnant Population-A Retrospective Cohort Study.

Background: Whether remote blood pressure (BP) monitoring can decrease racial disparities in BP measurement during pregnancy and the postpartum period remains unclear. This study evaluated whether Black and White patients enrolled in the Connected Maternity Online Monitoring (CMOM) program showed improvements in BP ascertainment and interval. Methods: A retrospective cohort of 3,976 pregnant patients enrolled in CMOM were compared to matched usual care patients between January 2016 and September 2022 using electronic health record data. The primary outcomes were BP ascertainment (number of BP measurements) and BP interval (time between BP measurements) during pregnancy and the postpartum period. The proportion of patients with a hypertensive disorder of pregnancy who checked their BP within 7 days of discharge following delivery was also assessed. Results: Enrollment in CMOM was lower among Black patients than White patients (42.1% vs 54.7%, P<0.0001). Patients in the CMOM group had more BP measurements than patients in the usual care group during pregnancy (rate ratio=1.78, 95% CI 1.74-1.82) and the postpartum period (rate ratio=1.30, 95% CI 1.23-1.37), with significant improvements for both Black and White patients enrolled in CMOM compared to patients in usual care. The CMOM intervention did not result in an improvement in 7-day postpartum adherence to checking BP for Black patients (risk ratio=1.03, 95% CI 0.94-1.11) as it did for White patients (risk ratio=1.09, 95% CI 1.01-1.17). Conclusion: Remote BP monitoring programs are a helpful tool to improve the frequency of BP measurements and shorten intervals between measurements during the prenatal and postpartum periods for all patients. Future evaluation is needed to determine the barriers to offering the program to and enrolling Black patients.

Adapting E-cigarette prevention programming to reach the latinx community.

PURPOSE: E-cigarettes are the most commonly used tobacco product among youth in the United States. Yet evidence-based prevention programming is limited due to the rapid onset of this threat. Community-based efforts to address vaping largely target youth in school settings. Although parents can play an important role in youth tobacco control efforts, messages about the dangers of vaping, use among adolescents, and strategies for intervening have not reached many Spanish-speaking parents in low-income Latinx communities. Our community-academic team developed e-cigarette prevention programming for use by promotor/as de salud to address this unmet need. METHODS: During the 1-year project, the team worked closely with a Project Advisory Committee to: review existing evidence-informed materials; conduct focus groups with parents, youth and promotor/as to guide program development; develop a curriculum to prepare promotor/as to educate low-literacy, Spanish-speaking parents about vaping; craft Spanish language resources for promotor/as to use in community education sessions; train 61 promotor/as to deliver the program; and support program delivery to 657 community members. RESULTS: Focus groups with promotor/as and community members, key-informant interviews, and brief surveys informed program development and assessment. Community member feedback was essential to development of appropriate materials. Promotor/as demonstrated significant pre- to post- training increases in e-cigarette knowledge and confidence in delivering vaping prevention education. Community members demonstrated a mastery of basic e-cigarette concepts and expressed intention to discuss vaping with their children. CONCLUSIONS: Promotor/a-led programming for parents represents a promising approach to vaping prevention and control in the Latinx community.

Consent document translation expense hinders inclusive clinical trial enrolment.

Patients from historically under-represented racial and ethnic groups are enrolled in cancer clinical trials at disproportionately low rates in the USA1-3. As these patients often have limited English proficiency4-7, we hypothesized that one barrier to their inclusion is the cost to investigators of translating consent documents. To test this hypothesis, we evaluated more than 12,000 consent events at a large cancer centre and assessed whether patients requiring translated consent documents would sign consent documents less frequently in studies lacking industry sponsorship (for which the principal investigator pays the translation costs) than for industry-sponsored studies (for which the translation costs are covered by the sponsor). Here we show that the proportion of consent events for patients with limited English proficiency in studies not sponsored by industry was approximately half of that seen in industry-sponsored studies. We also show that among those signing consent documents, the proportion of consent documents translated into the patient's primary language in studies without industry sponsorship was approximately half of that seen in industry-sponsored studies. The results suggest that the cost of consent document translation in trials not sponsored by industry could be a potentially modifiable barrier to the inclusion of patients with limited English proficiency.

A semi-Markov multistate cure model for estimating intervention effects in stepped wedge design trials.

Multistate models are useful for studying exposures that affect transitions among a set of health states. However, they can be challenging to apply when exposures are time-varying. We develop a multistate model and a method of likelihood construction that allows application of the model to data in which interventions or other exposures can be time-varying and an individual may to be exposed to multiple intervention conditions while progressing through states. The model includes cure proportions, reflecting the possibility that some individuals will never leave certain states. We apply the approach to analyze patient vaccination data from a stepped wedge design trial evaluating two interventions to increase uptake of human papillomavirus vaccination. The states are defined as the number of vaccine doses the patient has received. We model state transitions as a semi-Markov process and include cure proportions to account for individuals who will never leave a given state (e.g. never receive their next dose). Multistate models typically quantify intervention effects as hazard ratios contrasting the intensities of transitions between states in intervention versus control conditions. For multistate processes, another clinically meaningful outcome is the change in the percentage of the study population that has achieved a specific state (e.g. completion of all required doses) by a specific point in time due to an intervention. We present a method for quantifying intervention effects in this manner. We apply the model to both simulated and real-world data and also explore some conditions under which such models may give biased results.

Effectiveness and feasibility of three types of parent reminders to increase adolescent human papillomavirus (HPV) vaccination.

Parent reminders have produced modest improvements in human papillomavirus (HPV) vaccination among adolescents. However, little prior research has compared the effectiveness and feasibility of different HPV reminder types in resource-limited settings. We conducted a quasi-experimental study (2016-2017) to evaluate the effectiveness of three parent reminder types (mailed letters, robocalls, text messages) on next-dose HPV vaccine receipt among 12-year-olds in a large Federally Qualified Health Center in Los Angeles County. Six clinics were matched into three pairs: randomly assigning one clinic within each pair to intervention and control. Intervention clinics were randomly assigned to deliver one of the three parent reminder types. We calculated rates of next-dose vaccine receipt and assessed intervention effects using logistic regression models. We calculated the proportion of each type of reminder successfully delivered as a feasibility measure. The study sample comprised 877 12-year-olds due for an HPV vaccine dose (47% female, >85% Latino). At 4-month follow-up, 23% of intervention patients received an HPV vaccine dose compared to only 12% of control patients. Overall, receipt of any reminder increased rates of the next-needed HPV vaccine compared to usual care (p = 0.046). Significant improvements were observed for text reminders (p = 0.036) and boys (p = 0.006). Robocalls were the least feasible reminder type. Text message reminders are feasible and effective for promoting HPV vaccination. Future research is needed to assess the effectiveness and feasibility of reminders compared to other vaccine promotion strategies.

Melanoma awareness and prevention among latinx and non-latinx white adults in urban and rural California: A qualitative exploration.

BACKGROUND: Melanoma mortality rates in the US are highest among older men, individuals of lower socioeconomic status (SES), and people of color. To better understand these inequities, a qualitative exploratory study was conducted in Northern and Southern California to generate knowledge about barriers and facilitators of awareness, prevention, and early detection of melanoma in lower SES Latinx and non-Latinx White (NLW) individuals living in urban and semi-rural areas. METHODS: Nineteen focus groups were conducted (N = 176 adult participants), stratified by race/ethnicity (Latinx, low-income NLW), geography (semi-rural, urban), and language (English and Spanish). Inductive and deductive thematic analysis was conducted, and the findings were organized using the socioecological model framework: individual, interpersonal, community, and health system/policy levels. RESULTS: Four socioecological themes describe how key factors affect knowledge, perceived risk, preventive behaviors, and melanoma screening. Individual level findings revealed that many participants were not familiar with melanoma, yet were willing to learn through trusted sources. Having brown or darker skin tone was perceived as being associated with lower risk for skin cancer. Interpersonally, social relationships were important influences for skin cancer prevention practice. However, for several Latinx and semi-rural participants, conversations about melanoma prevention did not occur with family and peers. At the community level, semi-rural participants reported distance or lack of transportation to a clinic as challenges for accessing dermatology care. Healthcare systems barriers included burdens of additional healthcare costs for dermatology visits and obtaining referral. CONCLUSIONS: Varying factors influence the awareness levels, beliefs, and behaviors associated with knowledge, prevention, and early detection of melanoma among low-income Latinx and NLW individuals and in semi-rural areas. Results have implications for health education interventions. Navigation strategies that target individuals, families, and health care settings can promote improved prevention and early detection of melanoma in these communities.

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.

Trends in HPV vaccine administration and HPV vaccine coverage in children by race/ethnicity and socioeconomic status during the COVID-19 pandemic in an integrated health care system in California.

BACKGROUND: We sought to evaluate the trends of HPV vaccination between 03/2019-09/2021 and whether the impact of the COVID pandemic on HPV vaccination varied by race/ethnicity and neighborhood deprivation index (NDI). METHODS: Electronic medical records at Kaiser Permanente Southern California were used to assess monthly volume of HPV vaccine doses administered among children aged 9-12.9yrs, and up-to-date coverage (% vaccinated) by age 13 between 03/2019-09/2021. Modified Poisson models were used to evaluate the interactions between race/ethnicity, NDI and the pandemic periods on HPV vaccine coverage. RESULTS: HPV vaccine doses administered in 2020/2021 have returned to the 2019 level after the initial drop. The average up-to-date coverage in 05/2021-09/2021 (54.8%) remained lower than the pre-pandemic level (58.5%). The associations between race/ethnicity, NDI and HPV vaccine coverage did not vary due to the pandemic. CONCLUSION: HPV vaccine promotion efforts are needed to address COVID-19 pandemic's lasting impact on HPV vaccination coverage.

Impact of a Multi-Level, Multi-Component, System Intervention on HPV Vaccination in a Federally Qualified Health Center.

BACKGROUND: Human papillomavirus (HPV) vaccines can significantly reduce the burden of HPV-associated cancers, but remain underutilized. We evaluated a multi-component, system-level intervention to improve HPV vaccination in a large Federally Qualified Health Center (FQHC) that serves a primarily low income Latino population. METHODS: From January 2015 through March 2017, we evaluated the effectiveness of a multi-component, system-level intervention to improve HPV vaccination rates in eight clinics randomly assigned to study condition (four intervention, four usual care). The intervention included parent reminders for HPV vaccine series completion, provider training, clinic-level audit and feedback, and workflow modifications to reduce missed opportunities for vaccination. Using a difference-in-differences approach, we compared HPV vaccination rates among patients, ages 11 to 17 during a 12-month preintervention period and a 15-month intervention period. Linear mixed models were used to estimate intervention effects on vaccine initiation and completion. RESULTS: The sample included approximately 15,000 adolescents each quarter (range 14,773-15,571; mean age 14 years; 51% female, 88% Latino). A significantly greater quarterly increase in HPV vaccine initiation was observed for intervention compared with usual care clinics (0.75 percentage point greater increase, P < 0.001), corresponding to 114 additional adolescents vaccinated per quarter. The intervention led to a greater increase in HPV vaccine completion rates among boys (0.65 percentage point greater increase, P < 0.001), but not girls. CONCLUSIONS: Our system-level intervention was associated with modest improvements in HPV vaccine initiation overall and completion among boys. IMPACT: Study findings have implications for reducing HPV-related cancers in safety net populations.

Racial/ethnic inequalities in cervical cancer screening in the United States: An outcome reclassification to better inform interventions and benchmarks.

In the United states (U.S.), prevailing understanding suggests significant racial/ethnic inequalities in cervical cancer screening exist. However, recent findings elsewhere in North America indicate the magnitude of these inequalities depend on the way screening is defined: lifetime screening versus up-to-date screening. As those who have never been screened are most at risk for invasive cancer, an improved understanding of inequalities in this outcome is necessary to better inform interventions. To describe racial/ethnic inequalities in 1) never screening and 2) not being up-to-date with screening among women who have been screened at least once in their lifetime, three years (2014-2016) of the U.S. Behavioral Risk Factor Surveillance Survey were utilized to estimate cervical cancer screening prevalence ratios via Poisson regression (N = 123,070). The sample was limited to women age 21 to 65 years. Women from racial/ethnic minority groups were more likely to never have been screened in comparison to White women, particularly women of Asian descent (Prevalence Ratio (PR) = 3.8, 95% CI = 3.3-4.3). However, among women who had been screened at least once in their lifetime, an inverse association was observed between being a member of a racial/ethnic minority group and not being up-to-date with screening (e.g. PRasian vs white = 0.7, 95% CI = 0.6-0.9). Physicians and public health institutions concerned with monitoring racial/ethnic inequalities should consider adding lifetime screening as a primary benchmark, as this outcome implies different intervention targets to address inequalities and the differential burden of cervical cancer.

Increasing HPV Vaccination among Low-Income, Ethnic Minority Adolescents: Effects of a Multicomponent System Intervention through a County Health Department Hotline.

BACKGROUND: Introduction of the human papillomavirus (HPV) vaccine in 2006 was a game-changing advance in cancer control. Despite the vaccine's potential cancer prevention benefits, uptake remains low. We utilized a randomized design to evaluate a multicomponent intervention to improve HPV vaccine uptake among low-income, ethnic minority adolescents seeking services through a county health department telephone hotline. METHODS: Hotline callers who were caregivers of never-vaccinated adolescents (11-17 years) were randomized by call-week to intervention or control conditions. The intervention included brief telephone and print education, delivered in multiple languages, and personalized referral to a low-cost/free vaccine provider. Participants completed baseline (n = 238), 3-month (n = 215), and 9-month (n = 204) telephone follow-up surveys. RESULTS: HPV vaccine initiation rates increased substantially by 9-month follow-up overall, although no differences were observed between intervention and control groups (45% vs. 42%, respectively, P > 0.05). We also observed significant improvements in perceived HPV risk, barriers to vaccination, and perceived knowledge in both study conditions (P < 0.05). CONCLUSIONS: A low-intensity county hotline intervention did not produce a greater increase in HPV vaccination rates than routine practice. However, 44% of unvaccinated adolescents in both conditions received at least one dose of the vaccine, which can be viewed as a successful public health outcome. Future studies should evaluate more intensive interventions that address accessing and utilizing services in complex safety net settings. IMPACT: Study results suggest the need for investigators to be aware of the potential priming effects of study participation, which may obscure the effect of low-intensity interventions.

Serum lipids are associated with nonalcoholic fatty liver disease: a pilot case-control study in Mexico.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease and cirrhosis. NAFLD is mediated by changes in lipid metabolism and known risk factors include obesity, metabolic syndrome, and diabetes. The aim of this study was to better understand differences in the lipid composition of individuals with NAFLD compared to controls, by performing direct infusion lipidomics on serum biospecimens from a cohort study of adults in Mexico. METHODS: A nested case-control study was conducted with a sample of 98 NAFLD cases and 100 healthy controls who are participating in an on-going, longitudinal study in Mexico. NAFLD cases were clinically confirmed using elevated liver enzyme tests and liver ultrasound or liver ultrasound elastography, after excluding alcohol abuse, and 100 controls were identified as having at least two consecutive normal alanine aminotransferase (ALT) and aspartate aminotransferase (AST) (< 40 U/L) results in a 6-month period, and a normal liver ultrasound elastography result in January 2018. Samples were analyzed on the Sciex Lipidyzer Platform and quantified with normalization to serum volume. As many as 1100 lipid species can be identified using the Lipidyzer targeted multiple-reaction monitoring list. The association between serum lipids and NAFLD was investigated using analysis of covariance, random forest analysis, and by generating receiver operator characteristic (ROC) curves. RESULTS: NAFLD cases had differences in total amounts of serum cholesterol esters, lysophosphatidylcholines, sphingomyelins, and triacylglycerols (TAGs), however, other lipid subclasses were similar to controls. Analysis of individual TAG species revealed increased incorporation of saturated fatty acyl tails in serum of NAFLD cases. After adjusting for age, sex, body mass index, and PNPLA3 genotype, a combined panel of ten lipids predicted case or control status better than an area under the ROC curve of 0.83. CONCLUSIONS: These preliminary results indicate that the serum lipidome differs in patients with NAFLD, compared to healthy controls, and suggest that assessing the desaturation state of TAGs or a specific lipid panel may be useful clinical tools for the diagnosis of NAFLD.

Human papillomavirus (HPV) vaccination in the transition between adolescence and adulthood.

PURPOSE: Young adulthood is characterized by changes in health care decision-making, insurance coverage, and sexual risk. Although the human papillomavirus (HPV) vaccine is now approved for adults up to age 45, and catch-up vaccination is currently recommended up through age 26, vaccination rates remain low in young adults. This study explored perspectives on HPV vaccination among young adults receiving care at the student health center of a large public university. METHODS: We conducted semi-structured interviews (n = 27) and four focus groups with female and male undergraduate and graduate students (n = 18) and semi-structured interviews with health care providers (n = 6). Interviews and focus groups explored perceived risk of HPV infection, benefits of the HPV vaccine, and motivations for and barriers to HPV vaccination. RESULTS: Many young adults cited their parents' views and recommendations from medical providers as influential on their decision-making process. Students perceived that cervical cancer prevention was a main benefit of the HPV vaccine and sexual activity was a risk factor for HPV infection. Students often lacked knowledge about the vaccine's benefits for males and expressed some concerns about the safety and side effects of a vaccine perceived as new. Logistical barriers to vaccination included uncertainty over vaccination status and insurance coverage for the vaccine, and concerns about balancing the vaccine schedule with school obligations. Providers' vaccine recommendations were impacted by health system factors, including clinical infrastructure, processes for recommending and documenting vaccination, and office visit priorities. Suggested vaccination promotion strategies included improving the timing and messaging of outreach efforts on campus and bolstering clinical infrastructure. CONCLUSIONS: Although college may be an opportune time to reach young adults for HPV vaccination, obstacles including navigating parental influence and independent decision-making, lack of awareness of vaccination status, and numerous logistical and system-level barriers may impede vaccination during this time.