Comparative Effectiveness of Two Interventions to Increase Colorectal Cancer Screening for Those at Increased Risk Based on Family History: Results of a Randomized Trial.

BACKGROUND: First-degree relatives (FDR) of patients with colorectal cancer are at risk for colorectal cancer, but may not be up to date with colorectal cancer screening. We sought to determine whether a one-time recommendation about needing colorectal cancer screening using patient navigation (PN) was better than just receiving the recommendation only. METHODS: Participants were FDRs of patients with Lynch syndrome-negative colorectal cancer from participating Ohio hospitals. FDRs from 259 families were randomized to a website intervention (528 individuals), which included a survey and personal colorectal cancer screening recommendation, while those from 254 families were randomized to the website plus telephonic PN intervention (515 individuals). Primary outcome was adherence to the personal screening recommendation (to get screened or not to get screened) received from the website. Secondary outcomes examined who benefited from adding PN. RESULTS: At the end of the 14-month follow-up, 78.6% of participants were adherent to their recommendation for colorectal cancer screening with adherence similar between arms (P = 0.14). Among those who received a recommendation to have a colonoscopy immediately, the website plus PN intervention significantly increased the odds of receiving screening, compared with the website intervention (OR: 2.98; 95% confidence interval, 1.68-5.28). CONCLUSIONS: Addition of PN to a website intervention did not improve adherence to a colorectal cancer screening recommendation overall; however, the addition of PN was more effective in increasing adherence among FDRs who needed screening immediately. IMPACT: These findings provide important information as to when the additional costs of PN are needed to assure colorectal cancer screening among those at high risk for colorectal cancer.

Nativity status and genital HPV infection among adults in the U.S.

Over 43 million immigrants live in the United States (U.S.). Foreign-born populations experience multiple disparities related to human papillomavirus (HPV), including higher cervical cancer mortality rates, yet little research has examined the prevalence of genital HPV infection among this population. We used data from 1,822 women and 1,622 men ages 20-59 in the U.S. who participated in the 2013-2014 National Health and Nutrition Examination Survey (NHANES). Participants reported their nativity status (foreign- vs. U.S.-born) and provided biospecimens for HPV testing. We assessed nativity differences in the prevalence of three HPV infection outcomes (any HPV type, high-risk HPV type, and vaccine-preventable HPV type) using weighted logistic regression. Overall, 40% of women and 46% of men tested positive for any type of HPV. Compared to women born in the U.S., foreign-born women had a lower prevalence of infection with any HPV type (32% vs. 42%, p < .01). Compared to men born in the U.S., foreign-born men had a lower prevalence of all HPV infection outcomes (any type: 39% vs. 48%; high-risk: 22% vs. 34%; vaccine-preventable: 12% vs. 16%; all p < .05). Multivariable models attenuated several of these differences, though foreign-born men had lower odds of infection with a high-risk HPV type (OR = 0.75; 95% CI: 0.60-0.93, p < .01) after adjusting for covariates. Although lower than among their U.S.-born counterparts, HPV infection is prevalent among foreign-born women and men in the U.S. Findings can help inform strategic communication campaigns and targeted HPV vaccination and cervical cancer screening efforts for immigrant populations.

Outsmart HPV: Acceptability and short-term effects of a web-based HPV vaccination intervention for young adult gay and bisexual men.

BACKGROUND: Effective interventions to promote human papillomavirus (HPV) vaccination are needed, particularly among populations at increased risk of HPV-related disease. We developed and pilot tested a web-based intervention, Outsmart HPV, to promote HPV vaccination among young gay and bisexual men (YGBM). METHODS: In 2016, we recruited a national sample (n = 150) of YGBM ages 18-25 in the United States who had not received any doses of HPV vaccine. Participants were randomized to receive either standard HPV vaccination information (control) or population-targeted, individually-tailored content (Outsmart HPV intervention). We assessed between group differences in HPV vaccination attitudes and beliefs immediately following the intervention using multiple linear regression. RESULTS: There were no differences in HPV vaccination attitudes, beliefs and intentions between groups at baseline. Compared to participants in the control group, intervention participants reported: greater perception that men who have sex with men are at higher risk for anal cancer relative to other men (b = 0.34); greater HPV vaccination self-efficacy (b = 0.15); and fewer perceived harms of HPV vaccine (b = -0.34) on posttest surveys (all p < .05). Overall, intervention participants reported high levels of acceptability and satisfaction with the Outsmart HPV intervention (all > 4.4 on a 5-point scale). CONCLUSIONS: Findings from this study provide preliminary support for a brief, tailored web-based intervention in improving HPV vaccination attitudes and beliefs among YGBM. An important next step is to determine the effects of Outsmart HPV on HPV vaccine uptake. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov identifier NCT02835755.

Belief About Mandatory School Vaccinations and Vaccination Refusal Among Ohio Appalachian Parents: Do Demographic and Religious Factors, General Health, and Political Affiliation Play a Role?

PURPOSE: To examine how demographic, general health, religious, and political characteristics influenced beliefs about mandatory school vaccinations and history of vaccination refusal for children among Ohio Appalachian parents. METHODS: In 2013 and 2014, baseline data were obtained from parents (n = 337) of girls aged 9-17 from 12 counties in rural Ohio Appalachia enrolled in the Community Awareness, Resources and Education (CARE II) Project. Multivariate logistic regression models were used to identify correlates of parental beliefs about mandatory school vaccinations and history of refusing a doctor-recommended vaccine for their child(ren). RESULTS: About 47% of parents agreed that parents should have the right to refuse mandatory school vaccinations for their child(ren). Participants who reported their political affiliation as Republican (OR = 2.45, 95% CI: 1.28-4.66) or Independent (OR = 3.31, 95% CI: 1.70-6.44) were more likely to agree that parents should have the right to refuse school-mandated vaccinations than parents who reported their political affiliation as Democrat. Approximately 39% of parents reported ever refusing a vaccine for their child(ren). Participants who were female (OR = 3.90, 95% CI: 1.04-14.58) and believed that parents should have the right to refuse mandatory school vaccinations (OR = 3.27, 95% CI: 1.90-5.62) were more likely to report ever refusing a vaccine for their child(ren). CONCLUSION: The study findings provide information to better understand factors related to vaccination refusal among parents in Appalachia Ohio that can be used to design interventions to improve vaccination uptake.

Receipt of Recommended Adolescent Vaccines Among Youth With Special Health Care Needs.

We examined vaccination coverage among youth with special health care needs (YSHCN) using data from parents of adolescents (11-17 years) who responded to a statewide survey in 2010-2012 (n = 2156). Using a validated screening tool, we identified 29% of adolescents as YSHCN. Weighted multivariable logistic regression assessed associations between special health care needs and receipt of tetanus booster, meningococcal, and human papillomavirus (HPV) vaccines. Only 12% of youth had received all 3 vaccines, with greater coverage for individual vaccines (tetanus booster, 91%; meningococcal, 32%; HPV, 26%). YSHCN had greater odds of HPV vaccination than other youth (33% vs 23%, OR = 1.70, 95% CI = 1.16-2.50) but vaccination coverage was similar ( P ≥ .05) for other outcomes. In subgroup analyses, HPV vaccination also differed depending on the number and type of special health care needs identified. Findings highlight low levels of vaccination overall and missed opportunities to administer recommended vaccines among all youth, including YSHCN.

Socioeconomic and Racial-ethnic Disparities in Prosocial Health Attitudes: The Case of Human Papillomavirus (HPV) Vaccination for Adolescent Males.

Research on prosocial attitudes, social networks, social capital, and social stratification suggest that lower-socioeconomic status (SES), Hispanic, and nonwhite individuals will be more likely than their higher-SES and non-Hispanic white counterparts to engage in health behaviors that serve a social good. Analyzing data from the University of North Carolina Human Papillomavirus (HPV) Immunization in Sons Study, we test whether SES and race-ethnicity are associated with willingness to vaccinate via prosocial attitudes toward HPV vaccination among adolescent males (n = 401) and parents (n = 518). Analyses revealed that (a) parents with lower education and (b) black and Hispanic parents and adolescent males reported higher prosocial vaccination attitudes, but only some attitudes were associated with higher willingness to vaccinate. We discuss these findings in terms of how prosocial attitudes may motivate certain health behaviors and serve as countervailing mechanisms in the (re)production of health disparities and promising targets of future public health interventions.

Collaborative patient-provider communication and uptake of adolescent vaccines.

RATIONALE: Recommendations from healthcare providers are one of the most consistent correlates of adolescent vaccination, but few studies have investigated other elements of patient-provider communication and their relevance to uptake. OBJECTIVE: We examined competing hypotheses about the relationship of patient-driven versus provider-driven communication styles with vaccination. METHODS: We gathered information about vaccine uptake from healthcare provider-verified data in the 2010 National Immunization Survey-Teen for tetanus, diphtheria, and pertussis (Tdap) booster, meningococcal vaccine, and human papillomavirus (HPV) vaccine (initiation among females) for adolescents ages 13-17. We categorized communication style in parents' conversations with healthcare providers about vaccines, based on parents' reports (of whether a provider recommended a vaccine and, if so, if conversations were informed, shared, or efficient) (N = 9021). RESULTS: Most parents reported either no provider recommendation (Tdap booster: 35%; meningococcal vaccine: 46%; and HPV vaccine: 31%) or reported a provider recommendation and shared patient-provider communication (43%, 38%, and 49%, respectively). Provider recommendations were associated with increased odds of vaccination (all ps < 0.001). In addition, more provider-driven communication styles were associated with higher rates of uptake for meningococcal vaccine (efficient style: 82% vs. shared style: 77% vs. informed style: 68%; p < 0.001 for shared vs. informed) and HPV vaccine (efficient style: 90% vs. shared style: 70% vs. informed style: 33%; p < 0.05 for all comparisons). CONCLUSION: Efficient communication styles were used rarely (≤2% across vaccines) but were highly effective for encouraging meningococcal and HPV vaccination. Intervention studies are needed to confirm that efficient communication approaches increase HPV vaccination among adolescents.

Correlates of receiving recommended adolescent vaccines among youth with special health care needs: Findings from a statewide survey.

BACKGROUND: Many youth with special health care needs (YSHCN) have not received recommended adolescent vaccines, yet data are lacking on correlates of vaccination among this population. Such information can identify subgroups of YSHCN that may be at risk for under-immunization and strategies for increasing vaccination. METHODS: We analyzed weighted data from a population-based sample of parents with an 11- to 17-year-old child with a special health care need from the 2010-2012 North Carolina Child Health Assessment and Monitoring Program (n=604). We used ordinal logistic regression to identify correlates of how many recommended vaccines (tetanus booster, meningococcal, and HPV [at least one dose] vaccines) adolescents had received. RESULTS: Only 12% of YSHCN (18% of females and 7% of males) had received all three vaccines. More YSHCN had received tetanus booster vaccine (91%) than meningococcal (28%) or HPV vaccines (32%). In multivariable analyses, YSHCN who were female (OR=2.59, 95% CI: 1.57-4.24), ages 16-17 (OR=2.06, 95% CI: 1.10-3.87), or who had a preventive check-up in the past year (OR=2.98, 95% CI: 1.24-7.21) had received a greater number of the vaccines. YSHCN from households that contained a person with at least some college education had received fewer of the vaccines (OR=0.57, 95% CI: 0.33-0.96). Vaccine coverage did not differ by type of special health care need. CONCLUSIONS: Vaccine coverage among YSHCN is lacking and particularly low among those who are younger or male. Reducing missed opportunities for vaccination at medical visits and concomitant administration of adolescent vaccines may help increase vaccine coverage among YSHCN.

Correlates of human papillomavirus vaccine coverage: a state-level analysis.

BACKGROUND: We tested the hypothesis that states with higher rates of cancers associated with human papillomavirus (HPV) would have lower HPV vaccine coverage. METHODS: We gathered state-level data on HPV-related cancer rates and HPV vaccine initiation coverage for girls and boys, separately, and HPV vaccine follow-through (i.e., receipt of 3 doses among those initiating the series) for girls only. In addition, we gathered state-level data on demographic composition and contact with the health care system. We calculated Pearson correlations for these ecological relationships. RESULTS: Human papillomavirus vaccine initiation among girls was lower in states with higher levels of cervical cancer incidence and mortality (r = -0.29 and -0.46, respectively). In addition, vaccine follow-through among girls was lower in states with higher levels of cervical cancer mortality (r = -0.30). Other cancer rates were associated with HPV vaccine initiation and follow-through among girls, but not among boys. Human papillomavirus vaccine initiation among girls was lower in states with higher proportions of non-Hispanic black residents and lower proportions of higher-income residents. Human papillomavirus vaccine follow-through was higher in states with greater levels of adolescents' contact with the health care system. CONCLUSIONS: Human papillomavirus vaccine coverage for girls was lower in states with higher HPV-related cancer rates. Public health efforts should concentrate on geographic areas with higher cancer rates. Strengthening adolescent preventive health care use may be particularly important to increase vaccine follow-through. Cost-effectiveness analyses may overestimate the benefits of current vaccination coverage and underestimate the benefits of increasing coverage.

The Vaccination Confidence Scale: a brief measure of parents' vaccination beliefs.

PURPOSE: The success of national immunization programs depends on the public's confidence in vaccines. We sought to develop a scale for measuring confidence about adolescent vaccination in diverse populations of parents. METHODS: Data came from 9623 parents who completed the 2010 National Immunization Survey-Teen, an annual, population-based telephone survey. Parents reported on a 13- to 17-year-old child in their households. We used exploratory and confirmatory factor analysis to identify latent constructs underlying parents' responses to 8 vaccination belief survey items (response scale 0-10) conceptualized using the Health Belief Model. We assessed the scale's psychometric properties overall and across demographic subgroups. RESULTS: Parents' confidence about adolescent vaccination was generally high. Analyses provided support for three factors assessing benefits of vaccination (mean=8.5), harms of vaccination (mean=3.3), and trust in healthcare providers (mean=9.0). The model showed good fit both overall (comparative fit index=0.97) and across demographic subgroups, although internal consistency was variable for the three factors. We found lower confidence among several potentially vulnerable subpopulations, including mothers with lower levels of education and parents whose children were of Hispanic ethnicity (both p<0.05). CONCLUSIONS: Our brief, three-factor scale offers an efficient way to measure confidence in adolescent vaccination across demographic subgroups. Given evidence of lower confidence by educational attainment and race/ethnicity, program planners should consider factors such as health literacy and cultural competence when designing interventions to promote adolescent vaccination to ensure these programs are fully accessible.

Provider-verified HPV vaccine coverage among a national sample of Hispanic adolescent females.

BACKGROUND: Hispanic females have the highest cervical cancer incidence rate of any racial or ethnic group in the United States, yet relatively little research has examined human papillomavirus (HPV) vaccination among this fast-growing population. We examined HPV vaccination among a national sample of Hispanic adolescent females. METHODS: We analyzed provider-verified vaccination data from the 2010-2011 National Immunization Survey-Teen for Hispanic females ages 13 to 17 years (n = 2,786). We used weighted logistic regression to identify correlates of HPV vaccine initiation (receipt of one or more doses), completion (receipt of three doses), and follow-through (receipt of three doses among those who initiated the series). RESULTS: HPV vaccine initiation was 60.9%, completion was 36.0%, and follow-through was 59.1%. Initiation and completion were more common among older daughters and those whose parents had received a provider recommendation to vaccinate (all P < 0.05). Completion was less common among daughters who had moved from their birth state (P < 0.05). All vaccination outcomes were less common among daughters without health insurance (all P < 0.05). Vaccination did not differ by parents' preferred language (all P > 0.05), although intent to vaccinate was higher among Spanish-speaking parents (P < 0.01). Spanish-speaking parents were more likely to indicate lack of provider recommendation (20.2% vs. 5.3%) and cost (10.9% vs. 1.8%) as main reasons for not intending to vaccinate (both P < 0.05). CONCLUSIONS: Many Hispanic females have not received HPV vaccine. Several factors, including provider recommendation and health insurance, are key correlates of vaccination. IMPACT: HPV vaccination programs targeting Hispanics are needed and should consider how potential barriers to vaccination may differ by preferred language.

Parents' and sons' beliefs in sexual disinhibition after human papillomavirus vaccination.

BACKGROUND: The concern that adolescent girls who receive human papillomavirus (HPV) vaccine may be more likely to have sex (ie, sexual disinhibition) has been commonplace in media coverage, but this belief is not held by many parents of adolescent girls. Because no studies have addressed this topic for adolescent boys, we examined parents' and their adolescent sons' beliefs in sexual disinhibition occurring after boys receive HPV vaccine. METHODS: A national sample of parents of adolescent boys (n = 547) and their sons (aged 15-17 years; n = 176) completed online surveys in fall 2010. We used multi-item scales to measure parents' and sons' beliefs in sexual disinhibition after HPV vaccination. We used multivariate linear regression to identify correlates of beliefs in sexual disinhibition. RESULTS: Less than a quarter of parents or sons agreed with statements suggesting that HPV vaccination leads to sexual disinhibition among adolescent boys (range, 20%-24%). Parents who had more liberal political affiliations (ß = -0.11), had a daughter who had received HPV vaccine (ß = -0.12), or had no daughter (ß = -0.10) reported weaker beliefs in sexual disinhibition. Parents who reported higher anticipated regret if their sons got HPV vaccine and fainted (ß = 0.18) indicated stronger beliefs in sexual disinhibition. Sons who perceived higher peer acceptance of HPV vaccination (ß = 0.44) or were Hispanic (ß = 0.21) had stronger beliefs in sexual disinhibition. CONCLUSIONS: Most parents and sons did not believe that HPV vaccination leads to sexual disinhibition among boys. Understanding the characteristics of parents and sons who hold these beliefs may help inform efforts to increase HPV vaccine uptake among boys.

Correlates of HPV vaccination among adolescent females from Appalachia and reasons why their parents do not intend to vaccinate.

Limited research has examined HPV vaccination in Appalachia, a region with cervical cancer disparities. We analyzed 2008-2010 National Immunization Survey-Teen data for adolescent females ages 13-17 from Appalachia (n=1951) to identify correlates of HPV vaccination and reasons why their parents do not intend to vaccinate. HPV vaccine initiation was 40.8%, completion was 27.7%, and follow-through was 67.8%. Vaccination outcomes tended to be higher among females who were older, had visited their healthcare provider in the last year, or whose parents reported receiving a provider recommendation to vaccinate. Only 41.0% of parents with unvaccinated daughters intended to vaccinate in the next year. The most common reasons for not intending to vaccinate were believing vaccination is not needed or not necessary (21.5%) and lack of knowledge (18.5%). Efforts to reduce missed opportunities for vaccination at healthcare visits and address reasons why parents are not vaccinating may help increase HPV vaccination in Appalachia.

Advertisements promoting human papillomavirus vaccine for adolescent boys: does source matter?

OBJECTIVES: Many parents recall hearing of human papillomavirus (HPV) vaccine through drug company advertisements. This study sought to examine whether parents accurately recall the source (ie, sponsor) of advertisements promoting HPV vaccine and the impact of drug company advertisements. METHODS: A U.S. national sample of 544 parents of adolescent boys aged 11-17 participated in an online between-subjects experiment. Parents viewed an advertisement encouraging HPV vaccination for boys with a logo from a randomly assigned source. Parents rated trust, likability and motivation for vaccination while viewing the advertisement and later indicated who they believed sponsored it. RESULTS: Nearly half (43%) of parents who viewed a hypothetical advertisement containing a logo incorrectly identified the advertisement source. More parents correctly identified the source of drug company advertisements than advertisement from other sources (62% vs. 25%, OR 4.93, 95% CI 3.26 to 7.46). The majority of parents who saw a logo-free advertisement believed a drug company created it (60%). Among parents who correctly identified the advertisement source, drug company advertisements decreased motivation to vaccinate their sons, an association mediated by reduced liking of and trust in the advertisements. CONCLUSIONS: Parents were more accurate in identifying drug company advertisements, primarily because they tended to assume any advertisement was from a drug company. Public health organisations may need to take special measures to ensure their messages are not perceived as sponsored by drug companies.

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

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

Gay and bisexual men's willingness to receive anal Papanicolaou testing.

OBJECTIVES: We assessed the willingness of gay and bisexual men, who have high rates of anal cancer that might be prevented through regular screening, to receive anal Papanicolaou tests. METHODS: We surveyed a national sample of men aged 18 to 59 years who self-identified as gay (n = 236) or bisexual (n = 70). RESULTS: Most respondents were willing to accept free screening (83%), but fewer would pay for the test (31%; McNemar's chi(2) = 158.02; P < .001). Willingness to pay for screening was higher among men who reported greater worry about getting anal cancer (OR [odds ratio] = 1.70; 95% confidence interval [CI] = 1.06, 2.72), higher perceived likelihood of anal cancer (OR = 1.88; 95% CI = 1.18, 2.99), and higher income (OR = 2.17; 95% CI = 1.18, 3.98), in adjusted analyses. Only 33% (17 of 51) of HIV-positive respondents, who have the highest risk for anal cancer, had received anal Papanicolaou tests. CONCLUSIONS: Anal cancer screening was highly acceptable to gay and bisexual men, although cost was a major barrier. Efforts to reduce anal cancer disparities should target beliefs about anal cancer and barriers to anal Papanicolaou testing in this population.

Are rural Ohio Appalachia cancer survivors needs different than urban cancer survivors?

INTRODUCTION: Limited information is available about rural cancer survivors' needs and if they differ from urban cancer survivors. METHODS: A convenience sample of cancer survivors completed a self-administered survey. RESULTS: Rural Appalachia (n = 99) and urban non-Appalachia (n = 107) cancer survivors completed the survey. Urban survivors reported more needs than rural survivors (p < 0.001), but worry about cancer recurrence and concern about fatigue were reported most often by both urban and rural survivors. Urban survivors (n = 87; 81.3%) and rural survivors (n = 72; 72.9%) indicated that they searched for cancer information, but rural survivors were more likely to obtain information from family members and healthcare providers (p < 0.05). Rural survivors differed from urban survivors by reporting less effort to get the information they needed (p < 0.05) and less concern about the quality of the information (p < 0.01), but they reported having a harder time understanding the information they found (p < 0.05). DISCUSSION: Rural and urban survivors' most frequent needs focused on cancer recurrence and fatigue. Rural survivors reported fewer needs compared to urban survivors; however, our findings suggest certain needs may be more important to rural survivors. While most survivors reported searching for information about cancer, rural and urban survivors use different sources for finding information and have varying experiences in their searches. IMPLICATIONS FOR CANCER SURVIVORS: There is an ongoing need to provide survivorship care that is tailored to the unique needs of cancer survivors. It is essential to provide educational materials for all cancer survivors, but using different communication channels for urban versus rural survivors may be beneficial.

Human papillomavirus (HPV) vaccine availability, recommendations, cost, and policies among health departments in seven Appalachian states.

Telephone interviews of health department personnel in six states and review of an immunization database from one state were conducted to assess human papillomavirus (HPV) vaccine availability, recommendations, cost, policies, and educational materials in health departments in seven Appalachian states. Most (99.1%) health departments (n=234) reported receiving patient requests for the HPV vaccine, and only two (1%) health departments reported that they did not provide the vaccine for patients. HPV vaccine supply was reported to not meet the demand in 10.5% (24/228) of health departments due to high costs. Level (state, region, county) at which policy about the HPV vaccine was determined, vaccine recommendations, costs, and available educational materials varied among states. This study documented variation in vaccine availability, recommendations, cost, policies, and educational materials in Appalachian health departments that could significantly affect vaccine distribution. Findings highlight the need for more comprehensive and consistent policies that maximize accessibility of the HPV vaccine to women, especially those in underserved areas.