Willingness to participate in various nontherapeutic cancer research activities among urban and rural African American and Latinx healthy volunteers.

PURPOSE: Inclusion of racial/ethnic minorities in cancer research can reduce disparities in health outcomes; however, data regarding barriers and motivators to participation are sparse. This study assessed African American (AA) and Latinx healthy volunteers' perspectives regarding willingness to participate in noninvasive and invasive research activities. METHODS: Using a 38-item questionnaire adapted from the Tuskegee Legacy Project Questionnaire, we assessed willingness to participate in 12 research activities, offering 27 possible barriers and 14 motivators. The sample was segmented into four subgroups by AA/Latinx and rural/urban. RESULTS: Across five states and Puerto Rico, 533 participants completed questionnaires. Overall, participants were more willing to participate in noninvasive versus invasive procedures, although, all subgroups were willing to participate in research if asked. Rural AA were most willing to complete a survey or saliva sample, while rural Latinx were least willing. Urban AA were least willing to provide cheek swab, while rural counterparts were most willing. Self-benefit and benefit to others were among the top three motivators for all subgroups. Curiosity was a primary motivator for urban AA while obtaining health information motivated rural Latinx. Primary barriers included fears of side effects and being experimented on, lack of information, and lack of confidentiality. CONCLUSIONS: Latinx and AAs are willing to participate in the continuum of nontherapeutic research activities suggesting their lack of participation may be related to not being asked. Inclusive enrollment may be achieved by assessing needs of participants during the design phase of a study in order to reduce barriers to participation.

Healthcare Access in Rural Alabama: Patients' Perspective on Access and Utilization.

OBJECTIVES: Increasing healthcare access is a Healthy People 2030 priority. This study examined healthcare access from the residents' perspective in the two most rural counties in the United States and compared the findings with data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) in rural and urban counties in Alabama. METHODS: We conducted an in-person population-based survey using cluster sampling within census tracts assessing health insurance coverage, having a usual primary care provider, having had a routine healthcare visit within the past year, and barriers to care. RESULTS: Among the 395 participants, 81.4% indicated having health insurance coverage, which was slightly lower than the BRFSS data for rural (87.6%) and urban counties in Alabama (87%); 89.6% of respondents indicated having a usual primary care provider compared with 84.3% of rural and 77.2% of urban residents; and 83.2% of participants indicated having had a routine healthcare visit in the last year compared with 77.3% of rural and 77.6% of urban residents. These indicators varied significantly across age, sex, and educational attainment and were consistent with BRFSS findings. CONCLUSIONS: Healthcare access, as indicated by health insurance coverage and healthcare utilization, among residents in the two most rural US counties is comparable to access among rural and urban Alabamians. Primary care is a highly used resource in rural areas, and further research should characterize other social/behavioral factors that may explain the poor health outcomes seen in rural areas. In addition, BRFSS data continue to offer a reliable picture of healthcare access in rural areas.

Oncology Patient Smoking Cessation Treatment Preferences: Perceptions Across Former and Current Cigarette Smokers.

Although the benefits of smoking cessation following a cancer diagnosis have been well-established, up to 50% of cancer patients continue to smoke. Continued smoking through oncology treatment leads to increased risk of adverse events including reduced effectiveness of treatment, recurrence of additional malignancies, and reduced survival rates. Upon the cancer diagnosis, oncology healthcare providers become the primary trusted source of information and support, which represents a great opportunity to assist these patients to quit smoking. However, it remains unclear how oncology healthcare providers can best address smoking cessation from a patient-centered perspective. The present study surveyed oncology patients from Birmingham, AL, classified as either former (n = 174) or current smokers (n = 81) to identify their perceptions regarding the role of oncology healthcare providers in their smoking cessation efforts. Current smokers were more likely to be younger, received their cancer diagnosis within the past 3 years, and have a cancer diagnosis with high smoking-related public awareness (i.e., head, neck, or lung) compared to former smokers. Additionally, 81% of current smokers reported experiencing smoking cessation discussions with their oncology healthcare providers with the most prominent recommendations being use of nicotine replacement therapies (46.9%) and medication (35.8%). These smoking cessation experiences align with patient preferences. However, despite the frequency of smoking cessation discussions, current smokers demonstrated an ambivalence in understanding the risks of continued smoking during their medical treatment. Overall, this study highlights the important role of oncology healthcare providers on implementing smoking cessation intervention for their patients who continue to smoke.

It Takes Two to Tango: Patients' and Providers' Perspectives in Tobacco Cessation and Head/Neck Cancer.

BACKGROUND: Tobacco cessation among patients with head/neck cancer continues to be challenging despite evidence that cessation improves treatment outcomes. The purpose of this study was to understand barriers/facilitators to tobacco cessation among patients with head/neck cancer and health care providers and to obtain perspectives toward the development of a patient-centered tobacco cessation intervention. MATERIALS AND METHODS: In-depth qualitative interviews with 10 health care providers and 21 patients with head/neck cancer (12 inpatients and 9 outpatients) who were current or former smokers. RESULTS: Health was a common motivator to quit among patients. Although most patients indicated that their health care provider asked and advised them to quit, they were unaware of cessation resources. Suggestions for a tobacco cessation program included involvement of former smokers, health care provider involvement/counseling, supporting written materials, and incorporating follow-up and family support. Health care providers identified patients' anger/frustration associated with the disease, social/demographic issues, and poor quality of life as the three most frequent challenges in treating patients. Although all providers reported asking about tobacco use, 70% emphasized a lack of formal training in tobacco cessation and lack of time. Their suggestions for a cessation program included having a "quarterback" responsible for this component with support from the entire health care team and continuity between outpatient and inpatient services to promote cessation, prevent relapse, and highlight the importance of follow-up and social support. CONCLUSION: There is great interest and need, both from patients and providers, for tobacco cessation services in the oncology setting tailored for patients with head/neck cancer in the context of cancer care. IMPLICATIONS FOR PRACTICE: Although the combination of pharmacotherapy and cognitive-behavioral intervention is the standard evidence-based treatment for tobacco dependence, it must be adapted to meet the needs and wants of patients and providers to be effective. This study provides an in-depth examination of such needs among patients with head and neck cancer and providers in the context of cancer care. Providers and patients emphasized the need of having a trained health care provider dedicated to providing tobacco cessation through seamless integration between outpatient and inpatient services as well as follow-up with an emphasis on family involvement throughout the process.

Given a choice between self-sampling at home for HPV testing and standard of care screening at the clinic, what do African American women choose? Findings from a group randomized controlled trial.

The goals of this study were to: (1) evaluate adherence to cervical cancer screening using a patient-centered approach that provided a choice of self-sampling at home for human papillomavirus (HPV) testing or standard of care screening at the local health department ('Choice') versus only standard of care screening at the local health department ('SCS') among un/under-screened African-American women; and (2) examine whether women given a choice were more likely to choose and adhere to self-sampling for HPV testing. We conducted a group randomized trial among un/under-screened African-American women in the Mississippi Delta, with "town" as the unit of randomization (12 towns). Both interventions (i.e., 'Choice' versus 'SCS') were delivered by Community Health Workers (CHWs) through a door-to-door approach. A total of 335 women were enrolled in the study from 2016 to 2019. The 'Choice' arm had a significantly (p = 0.005) higher adherence to screening compared to the 'SCS' arm after adjusting for the cluster effect and other relevant behavioral variables. Participants in the 'Choice' arm were 5.62 (95% CI 1.71-18.44) times more likely to adhere to cervical cancer screening compared to participants in the 'SCS' arm. Women in the 'Choice' arm were significantly more likely to choose (76%) and adhere to self-sampling at home for HPV testing (48% adherence) compared to standard of care screening at the local health department (7.5% adherence). A theory-driven, CHW-led intervention can effectively promote cervical cancer screening among un/under-screened African-American women in a rural setting when women are provided with a choice between two screening modalities. Clinical Trials Registration: NCT03713710.

A Cluster-Randomized Controlled Trial to Evaluate a Community-Based Healthy Eating and Nutrition Label Interpretation Intervention Among Latinx Immigrant Mothers and Their Daughters.

We evaluated outcomes from a healthy eating/nutrition label interpretation intervention among Latinx immigrant mothers and their daughters, aged 9-12 years, in Alabama. Between May 2013-October 2017, this cluster randomized controlled trial assigned 299 mother-daughter dyads to either a healthy eating (intervention) or HPV vaccination (control) study arm. Participants attended four group sessions delivered in Spanish by Lay Health Educators covering portion sizes, healthy eating/cooking strategies, and nutrition label reading/interpretation. An individual session in participants' homes reviewed pantries and developed healthy eating plans. Identical interviewer-administered surveys were completed at baseline and 7-month follow-up by both study arms. Retention rate at follow-up was 93.4% in intervention arm (92.6% in control arm). Positive changes in healthy eating behaviors and proficiency in nutrition label interpretation were assessed. Adjusting for marital status, employment status, and health insurance coverage status, when compared to controls, mothers in the intervention arm had greater odds of increasing daily fruit and vegetable consumption (OR 3.66, 95% CI 2.14-6.27, p < 0.001), decreasing weekly fried food intake (OR 4.3, 95% CI 2.3-8.04, p < 0.001), decreasing daily sweetened beverages (OR 2.07, 95% CI 1.22-3.52, p < 0.01), increasing frequency of reading nutrition labels (OR 12.58, 95% CI 6.81-23.22, p < 0.001), and correctly interpreting nutrition labels (OR 4.45, 95% CI 2.64-7.48, p < 0.001). Significant positive changes in targeted behaviors were not observed among daughters. A community-based, culturally relevant intervention that includes nutrition label interpretation can positively influence eating habits among Latinx immigrant mothers.

Factors Associated with Perceived Susceptibility to COVID-19 Among Urban and Rural Adults in Alabama.

We examined factors associated with and reasons for perceived susceptibility to COVID-19 among urban and rural adults in Alabama. We surveyed 575 eligible participants' engagement in preventive behaviors, concern about COVID-19 in their communities, perceived susceptibility to the virus, and reasons for susceptibility across three response options (Yes, No, and Don't Know/Not Sure). Bivariate analyses compared characteristics by level of perceived susceptibility to COVID-19. A multinomial logistic regression model evaluated the association of demographics, health insurance coverage, and chronic illness status with perceived susceptibility. Participants' race, gender, and educational attainment were significantly associated with perceived susceptibility to COVID-19. African Americans and males had higher odds of responding 'No', compared to 'Yes' and 'Don't Know/Not Sure' than Whites and females. Participants with a high school education and lower had higher odds of responding 'Don't Know/Not Sure' versus 'Yes' compared to those with college or higher education. Those unconcerned about COVID-19 in their community had higher odds of responding 'No' (OR = 2.51, CI 1.35-4.68) and 'Don't Know/Not Sure' (OR = 2.51, CI 1.26-4.99) versus 'Yes', as compared to those who were concerned. Possibility of exposure at work was the most frequent reasons for perceiving themselves susceptible to COVID-19, engagement in recommended preventive measures was the most frequent reason among respondents who indicated 'No', and uncertainty/perception that everyone is at risk was the most frequent reason among the ones who indicated 'Don't Know/Not Sure'. Results indicate that tailored efforts to heighten perceived susceptibility to COVID-19 among specific demographics are needed.

Impact of screening on cervical cancer incidence: A population-based case-control study in the United States.

Cervical cancer is widely preventable through screening, but little is known about the duration of protection offered by a negative screen in North America. A case-control study was conducted with records from population-based registries in New Mexico. Cases were women diagnosed with cervical cancer in 2006-2016, obtained from the Tumor Registry. Five controls per case from the New Mexico HPV Pap Registry were matched to cases by sex, age and place of residence. Dates and results of all cervical screening and diagnostic tests since 2006 were identified from the pap registry. We estimated the odds ratio of nonlocalized (Stage II+) and localized (Stage I) cervical cancer associated with attending screening in the 3 years prior to case-diagnosis compared to women not screened in 5 years. Of 876 cases, 527 were aged 25-64 years with ≥3 years of potential screening data. Only 38% of cases and 61% of controls attended screening in a 3-year period. Women screened in the 3 years prior to diagnosis had 83% lower risk of nonlocalized cancer (odds ratio [OR] = 0.17, 95% CI: 0.12-0.24) and 48% lower odds of localized cancer (OR = 0.52, 95% CI: 0.38-0.72), compared to women not screened in the 5 years prior to diagnosis. Women remained at low risk of nonlocalized cancer for 3.5-5 years after a negative screen compared to women with no negative screens in the 5 years prior to diagnosis. Routine cervical screening is effective at preventing localized and nonlocalized cervical cancers; 3 yearly screening prevents 83% of nonlocalized cancers, with no additional benefit of more frequent screening. Increasing screening coverage remains essential to further reduce cervical cancer incidence.

Designing an Effective Colorectal Cancer Screening Program in Egypt: A Qualitative Study of Perceptions of Egyptian Primary Care Physicians and Specialists.

BACKGROUND: In Egypt more than one-third of colorectal cancer (CRC) cases occur in individuals aged 40 years and younger, and are diagnosed at advanced stages; currently, CRC screening is not done as a routine part of preventive care. To lay the foundation for the development of a CRC multilevel screening program in Egypt, this qualitative study aimed to explore the perspectives of Egyptian physicians. MATERIALS AND METHODS: The PRECEDE-PROCEED model, which focuses on predisposing (intrapersonal), reinforcing (interpersonal), and enabling (structural) factors inherent in health behaviors, served as our theoretical framework. Primary health care physicians, oncologists, and gastroenterologists practicing in Alexandria, Egypt, participated in 1 one-hour semistructured interview. Interviews were audio recorded, transcribed, translated into English, and analyzed by thematic analysis. RESULTS: Seventeen physicians participated (n = 8 specialists and n = 9 primary care physicians). Barriers to CRC screening included socioeconomic status, a lack of emphasis on prevention, fear, and cost (predisposing); a belief that only high risk patients should be screened and a lack of confidence in providers to perform and interpret screening tests appropriately (reinforcing); and cost, lack of availability of the tests, and inadequate training for laboratory technicians and providers (enabling). Potential facilitators included implementing a media campaign emphasizing early detection, curability and prevention (predisposing); educating physicians and eliciting physician engagement (reinforcing); and decreasing costs, making screening tests widely available, and providing well-trained providers (enabling). CONCLUSION: A CRC screening program is needed in Egypt, and to be successful it would likely need to address barriers at multiple levels. IMPLICATIONS FOR PRACTICE: In Egypt, colorectal screening is not a routine part of preventive care, and colorectal cancer is often diagnosed at an advanced stage in individuals aged 40 years or younger. Screening can prevent and detect colorectal cancer in its early stages, but before designing any screening program, understanding the context is important as cultural beliefs may impact the acceptability of screening methods. By exploring the perspectives of Egyptian physicians, this study found important insights into how screening program components should be considered in the Egyptian culture and lays the foundation for the development of a multilevel colorectal screening program in Egypt.

A state-wide population-based evaluation of cervical cancers arising during opportunistic screening in the United States.

OBJECTIVE: Despite widespread cervical screening, an estimated 13,800 women will be diagnosed with cervical cancer in the United States in 2020. To inform improvements, the screening histories of women diagnosed with cervical cancer in New Mexico were assessed. METHODS: Data were collected on all cervical screening, diagnostic tests and treatment procedures for all women diagnosed with cervical cancer aged 25-64 yrs. in New Mexico from 2006 to 2016. Women were categorized by their screening attendance in the 5-40 months (screening interval) and 1-4 months (peri-diagnostic interval) prior to cancer diagnosis. RESULTS: Of the 504 women diagnosed between May 2009-December 2016, 64% were not screened or had only inadequate screening tests in the 5-40 months prior to diagnosis, and 90 of 182 screened women (49%) had only negative screens in this period. Only 32% (N = 162) of cervical cancers were screen-detected. Women with adenocarcinomas were more likely to have had a recent negative screen (41/57 = 722%) than women with squamous cancers (50/112 = 45%). Both older women (aged 45-64 years) and women with more advanced cancers were less likely to have been screened, and if screened, were more likely to have a false-negative outcome. Only 9% of cancers were diagnosed in women who did not attend biopsy or treatment after positive tests requiring clinical management. Screening currently prevents 35% of cancers, whereas full screening coverage could prevent 61% of cervical cancers. CONCLUSION: Improved screening coverage has the largest potential for reducing cervical cancer incidence, though there is also a role for improved recall procedures and screening sensitivity.

Development of a gender-relevant tobacco cessation intervention for women in Brazil-an intervention mapping approach to planning.

The purpose of this article is to describe the development of a theory-based, culturally and gender-relevant Community Health Worker (CWH)-led tobacco cessation intervention for low-income Brazilian women who augments the tobacco cessation program offered through the public health system using Intervention Mapping (IM). We began with the establishment of a network of representatives from different segments of society followed by comprehensive needs assessments. We then established a logical planning process that was guided by a theoretical framework (Social Cognitive Theory) and existing evidence-based tobacco cessation programs, taking into account socio-political context of a universal health care system. Given the gender-relevance of our intervention and the importance of social support in tobacco cessation among women, we chose an intervention that would be delivered within the public health system but augmented by CHWs that would be trained in behavior change by researchers. One of major advantages of utilizing IM was that decisions were made in a transparent and supportive manner with involvement of all stakeholders throughout the process. Despite the fact that this process is very taxing on researchers and the health care system as it takes time, resources and negotiation skills, it builds trust and promotes ownership which can assure sustainability.

Training Community Health Workers to promote breast cancer screening in Brazil.

Although it has been show that early detection through mammograms is the most effective way to reduce breast cancer mortality, breast cancer is the leading cause of cancer deaths among women worldwide with survival rates being even lower in low- and middle-income countries as compared to high-income countries. Despite the availability of breast cancer screening programs in Brazil through the public health system, some women do not participate in these programs due to structural and/or inter/intrapersonal barriers. The Community Health Worker (CHW) model is a promising approach to reach these women who have not been reached through other efforts. This paper describes a participatory approach for capacity building of CHWs to promote breast cancer screening among low-income women 50 years of age and older in a southern city in Brazil as a combined effort between two academic institutions, the municipal health care system, and a local non-profit organization. The capacity building program consisted of an 8-hour training focusing on knowledge (e.g., breast cancer and screening) and skills (e.g., communication skills, basic principles of behavior change) to promote breast cancer screening among community members. Pre- and post-test questionnaires assessed changes in breast cancer knowledge and self-perceived knowledge and confidence (N=44). There was a significant increase in objective knowledge regarding breast cancer overall, risk factors, and behavior change strategies between pre- and post-test. There was also a significant increase in self-perceived knowledge and confidence, items related to knowledge about breast cancer, breast cancer early detection methods, and the ability to solve problems between pre- and post-test as well as a significant increase in their confidence to motivate women to get a mammogram. Overall, this study demonstrates the importance of welldeveloped capacity building programs to promote breast cancer screening among health care professionals, especially those with limited educational attainment, such as CHWs.

The challenge of HPV vaccination uptake and opportunities for solutions: Lessons learned from Alabama.

The human papillomavirus (HPV) vaccine is an important tool for cancer prevention. However, vaccination rates in Alabama, a state with high rates of HPV-related cancers, remain below the national average. Our objective was to develop a comprehensive assessment of HPV vaccination in our state, with the goal to make recommendations for tailored multilevel interventions. A multimodal approach with quantitative and qualitative data was used to determine barriers and facilitators to HPV vaccination in Alabama. This included a survey of pediatric care providers and structured interviews with pediatricians, parents, nurses and community stakeholders. Two separate investigators evaluated the interview transcripts for major themes that occurred in 65% or more interviews. Major barriers included lack of knowledge, concerns about vaccine safety, and the link between the HPV vaccine and sexuality. Qualitative interviews further revealed barriers such as misinformation received from the internet and parental vaccine hesitancy. Opportunities for increasing vaccination include parental education, establishment of a reminder system, increasing access to HPV vaccine providers, and education for providers. Additional facilitators revealed through interviews included: trust in physicians, using the internet or social media to propagate positive messaging, physicians and clinical staff education, utilizing existing technology more effectively, highlighting nurses' roles as partners in HPV prevention, and the potential of schools as a venue for promotion of the vaccine. Our data are consistent with prior research showing major barriers to HPV vaccination. Several recommendations for optimizing HPV vaccination uptake in Alabama on the patient, provider and system level are given.

Development of a Participatory Capacity-Building Program for Congregational Health Leaders in African American Churches in the US South.

African Americans are disproportionately affected by diabetes and colorectal cancer. Although studies have shown the effectiveness of spiritually based health interventions delivered by community health workers to African Americans, few have described the development of the capacity-building component. This article describes this process. The development of the Healthy Congregations Healthy Communities Program (HCHC) was guided through a community-based participatory research lens and included: 1) establishment of a community coalition; 2) identification by coalition members of churches as the best venues for health promotion strategies among African Americans; 3) recruitment of churches; 4) development of a training manual; 5) recruitment and training of congregational health leaders (CHLs); and 6) "Passing of the torch" from the coalition to the CHLs who implemented the intervention in their congregations. We trained 35 CHLs to promote awareness about diabetes and colorectal cancer using a culturally relevant, spiritually based curriculum. Pre- and post-test paired t-tests showed significant increases in CHLs' knowledge of wellness (P<.001), colorectal cancer (P<.002), nutrition (P<.004), and lifestyle changes (P<.005). The community-academic partnership was successful in developing a culturally relevant, spiritually based capacity-building program for African American CHLs to implement health promotion strategies in their congregations and communities.

Determinants of Obesity in Two Urban Communities: Perceptions and Community-Driven Solutions.

Objective: In the search of solutions to the rising rates of obesity, community perspectives are important because they highlight areas of need and help determine the level of community support for potential interventions. This study aimed to identify community perceptions of factors associated with obesity in two urban municipalities - one racially mixed and one predominantly African American - and to explore community-driven solutions to the problem of obesity. Methods: The study used Photovoice methodology to understand what community members perceived as obesity-promoting factors in their residential environments. Results: A total of 96 photographs of factors relevant to obesity were discussed. Most commonly depicted were restaurants, grocery stores, fast food, and fitness centers. In 10 race-stratified focus groups, participants made 592 comments on 12 themes, the most common being restaurants, physical activity, food stores, and proposed solutions. The top three themes - restaurants, physical activity, and food stores - accounted for 58% of all barriers to healthy weight. Proposed solutions ranged from personal efforts and peer support, to educating adults and children, to community action. Conclusions: Interventions addressing the immediate food and physical activity environment - restaurants, grocery stores, and resources for physical activity - may have high likelihood of success as they align with community needs and understanding of priorities. Health education and promotion programs that increase food-related knowledge and skills are also needed and likely to receive strong community support.

Prospective associations of breastfeeding and smoking cessation among low-income pregnant women.

Although low-income pregnant women have high rates of smoking and low rates of breastfeeding, few studies have examined prospective associations between these risk factors in community samples. Doing so may help improve breast-feeding support programs in this population. We used a secondary analysis of 247 low-income pregnant smokers in Memphis, Tennessee, who were interviewed up to 4 times (twice during pregnancy and twice through 6 months postpartum). Smoking cessation during prepartum and postpartum was defined as a self-report of not smoking for ≥1 week and an expired carbon monoxide level of <10 ppm. Multivariable logistic regression analyses were used to determine whether intent to breastfeed was associated with smoking cessation and whether smoking cessation was associated with actual breastfeeding. Models were adjusted for sociodemographic, pregnancy-related, and smoking-related confounders. Thirty-nine percent of participants intended to breastfeed, and 38% did so. Women who intended to breastfeed were 2 times more likely to quit smoking prepartum (adjusted OR = 1.99, 95% CI [1.06, 3.74]), but not postpartum (adjusted OR = 1.27, 95% CI [0.57, 2.84]). Quitting smoking at baseline and during pregnancy was associated with subsequent breastfeeding (adjusted OR 2.27, 95% CI [1.05, 4.94] and adjusted OR = 2.49, 95% CI [1.21, 5.11]). Low-income women who intended to breastfeed were more likely to quit smoking during pregnancy and those who quit smoking at baseline and prepartum were more likely to breastfeed. Simultaneously supporting breastfeeding and smoking cessation may be very useful to change these important health behaviours among this high-risk population.

Preventing human papillomavirus-related cancers: we are all in this together.

Human papillomavirus-related cancers, which include cervical, vulvovaginal, anal, and oropharyngeal cancers, are on the rise in the United States. Although the human papillomavirus vaccine has been on the market for 10 years, human papillomavirus vaccination rates are well below national goals. Research identified many barriers and facilitators to human papillomavirus vaccination, and provider recommendation remains the most important factor in parental and patient decisions to vaccinate. While much of the burden of human papillomavirus vaccine provision falls on pediatricians and primary care providers, they cannot do it alone. As clinicians who care for a large proportion of human papillomavirus-related conditions, obstetrician-gynecologists and other women's health care providers must share the responsibility for vaccination of eligible patients. Obstetrician-gynecologists can support the efforts to eradicate human papillomavirus-related disease in their patients and their families via multiple avenues, including providing the human papillomavirus vaccine and being community leaders in support of vaccination.

A socio-ecological approach for examining factors related to contraceptive use among recent Latina immigrants in an emerging Latino state.

Using the Social Ecological Model, the individual, partner, social, and structural factors related to recent Latina immigrants' contraceptive use in an emerging immigrant community were explored. During September 2013-January 2014, door-to-door sampling was used in Birmingham, Alabama to recruit Latina immigrants who had lived in the United States (U.S.) for less than 5 years. Ten women with foreign-born children and 10 with only U.S.-born children completed in-depth interviews about their contraceptive use following migration. Women's narratives revealed interrelated barriers to using highly effective contraception after migrating to the U.S. Women had nuanced concerns about using hormonal contraception, which, when combined with other factors, led them to rely on condoms and withdrawal. Limited partner communication was a barrier to effective method use for some women, but partner attitudes that women should be responsible for contraception were less important. Weak female networks made it difficult for immigrants to learn about the U.S. health-care system, especially those with only U.S.-born children. Even once women accessed services, a full range of highly effective methods was not available or affordable. In emerging communities, integrated strategies that address immigrants' need for information and ensure access to affordable contraception would help women achieve their reproductive life goals.