Proximity to Hospital-Based Obstetric Care in a Maternity Desert in the Deep South.

Objectives. To examine the accessibility of hospital facilities with maternity care services in 1 rural county in Alabama in preparation for the initiation of prenatal care services at a federally qualified health center. Methods. We analyzed driving distance (in miles) from maternal city of residence in Conecuh County, Alabama to hospital of delivery, using 2019-2021 vital statistics data and geographic information system (GIS) software. Results. A total of 370 births to mothers who have home addresses in Conecuh County were reported, and 368 of those were in hospital facilities. The majority of deliveries were less than 30 miles (median = 23 miles) from the maternal city of residence. Some women traveled more than 70 miles for obstetrical care. Conclusions. Pregnant patients in Conecuh County experience significant geographic barriers related to perinatal care access. Using GIS for this analysis is a promising approach to better understand the unique challenges of pregnant individuals in this rural population. Public health policy efforts need to be geographically tailored to address these disparities. (Am J Public Health. 2024;114(S4):S330-S333. https://doi.org/10.2105/AJPH.2024.307692).

Evaluating the implementation and impact of navigator-supported remote symptom monitoring and management: a protocol for a hybrid type 2 clinical trial.

BACKGROUND: Symptoms in patients with advanced cancer are often inadequately captured during encounters with the healthcare team. Emerging evidence demonstrates that weekly electronic home-based patient-reported symptom monitoring with automated alerts to clinicians reduces healthcare utilization, improves health-related quality of life, and lengthens survival. However, oncology practices have lagged in adopting remote symptom monitoring into routine practice, where specific patient populations may have unique barriers. One approach to overcoming barriers is utilizing resources from value-based payment models, such as patient navigators who are ideally positioned to assume a leadership role in remote symptom monitoring implementation. This implementation approach has not been tested in standard of care, and thus optimal implementation strategies are needed for large-scale roll-out. METHODS: This hybrid type 2 study design evaluates the implementation and effectiveness of remote symptom monitoring for all patients and for diverse populations in two Southern academic medical centers from 2021 to 2026. This study will utilize a pragmatic approach, evaluating real-world data collected during routine care for quantitative implementation and patient outcomes. The Consolidated Framework for Implementation Research (CFIR) will be used to conduct a qualitative evaluation at key time points to assess barriers and facilitators, implementation strategies, fidelity to implementation strategies, and perceived utility of these strategies. We will use a mixed-methods approach for data interpretation to finalize a formal implementation blueprint. DISCUSSION: This pragmatic evaluation of real-world implementation of remote symptom monitoring will generate a blueprint for future efforts to scale interventions across health systems with diverse patient populations within value-based healthcare models. TRIAL REGISTRATION: NCT04809740 ; date of registration 3/22/2021.

Quantifying treatment preferences and their association with financial toxicity in women with breast cancer.

BACKGROUND: The objective of the current study was to understand treatment preferences and their association with financial toxicity in Patient Advocate Foundation clients with breast cancer. METHODS: This choice-based conjoint analysis used data from a nationwide sample of women with breast cancer who received assistance from the Patient Advocate Foundation. Choice sets created from 13 attributes of 3 levels each elicited patient preferences and trade-offs. Latent class analysis segmented respondents into distinct preference archetypes. The Comprehensive Score for Financial Toxicity (COST) tool captured financial toxicity. Adjusted generalized linear models estimated COST score differences by preference archetype. RESULTS: Of 220 respondents (for a response rate of 10%), the median age was 58 years (interquartile range, 49-66 years); 28% of respondents were Black, indigenous, or people of color; and approximately 60% had household incomes <$40,000. The majority of respondents were diagnosed with early-stage cancer (91%), 38% had recurrent disease, and 61% were receiving treatment. Treatment choice was most affected by preferences related to affordability and impact on activities of daily living. Two distinct treatment preference archetypes emerged. The "cost-prioritizing group" (75% of respondents) was most concerned about affordability, impact on activities of daily living, and burdening care partners. The "functional independence-prioritizing group" (25% of respondents) was most concerned about their ability to work, physical side effects, and interference with life events. COST scores were found to be similar between the archetypes in adjusted models (cost-prioritizing group COST score, 12 [95% confidence interval, 9-14]; and functional independence-prioritizing COST score, 11 [95% confidence interval, 9-13]). CONCLUSIONS: Patients with breast cancer prioritized affordability or maintaining functional independence when making treatment decisions. Because of this variability, preference evaluation during treatment decision making could optimize patients' treatment experiences.

Enrolling a rural community pharmacy as a Vaccines for Children provider to increase HPV vaccination: a feasibility study.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. with over 80 million infected individuals. High-risk strains are associated with 6 different cancers. Although infection is preventable, U.S. vaccination rates remain suboptimal and there are noted disparities between urban and rural communities due to economic barriers, lack of access, and low awareness and education. METHODS: The current pilot study sought to overcome these barriers through an interprofessional collaborative enrolling a community pharmacy in a rural, medically underserved Alabama county as a Vaccines for Children (VFC) provider to provide free vaccines to eligible adolescents. Program evaluation was conducted to determine the intervention's feasibility. Potential efficacy was assessed by analyzing county-level HPV vaccination uptake and completion rates using state immunization registry data. RESULTS: Over the 8-month study, 166 total vaccines were administered to 89 adolescents ages 10-18, including 55 doses of HPV vaccine, 53 doses of Tdap vaccine, 45 doses of meningococcal vaccine, and 13 doses of influenza vaccine. Among these adolescents, mean age was 12.6 years old, and 64 (71.9%) were VFC patients. The pharmacy recorded an increase in total vaccine administration of 158.8%, an increase in prescription revenue of 34.8%, and an increase in total revenue by 24.4% during the course of the study, compared to the previous year. CONCLUSIONS: Findings from the current work demonstrate the potential of this strategy and can serve as a blueprint for statewide and national dissemination and implementation to ultimately increase access to vaccination services, increase vaccination rates, and reduce urban-rural vaccine disparities.

HPV and HPV Vaccination Knowledge and Attitudes Among Medical Students in Alabama.

In addition to being the most common sexually transmitted infection, the human papillomavirus (HPV) is associated with six types of cancer in men and women. The HPV vaccine provides long-lasting, effective protection from high-risk HPV infection, thus serving as a means of cancer prevention. An effective healthcare provider recommendation is well-established as the most significant influence on HPV vaccine uptake, and, as emerging providers, it is critical that medical students receive comprehensive training in this area. However, the type and extent of such training for current medical students in the USA is unclear. An online survey assessing HPV and HPV vaccine knowledge, attitudes, and vaccine status was distributed to all medical students at an Alabama university. Scales were developed to assess composite HPV and HPV knowledge scores and HPV vaccination intentions. Of those age-eligible, 32.1% reported completion of the HPV vaccine series while 15.2% reported partial completion. Knowledge of both HPV and HPV vaccination significantly increased with program year (p < 0.0001 and p = 0.0069, respectively); however, there were knowledge gaps across all years regarding HPV-associated cancers. Attitudes and intentions showed a similar association, with more advanced students demonstrating more positive attitudes toward HPV vaccination (p = 0.0003). There is a need within the current curriculum to include more education and training on HPV, HPV vaccination, and counseling-particularly for students in the first 2 years of their program. Implementation of a classroom module or interactive workshop would likely improve knowledge and attitudes, better preparing students for their future role as potential immunizers.

Factors Associated with HPV Vaccination Uptake and HPV-Associated Cancers: A County-Level Analysis in the State of Alabama.

Despite availability of a safe, effective vaccination, uptake and completion rates of human papillomavirus (HPV) vaccination remain low in the United States. This is particularly true in the southeast, which also sees some of the highest rates of HPV-associated (HPVa) cancers. We aimed to identify areas in Alabama in need of intervention with respect to HPVa cancers and HPV vaccination, and factors potentially associated with these rates by performing county-level secondary data analysis using state and national data sources. Alabama ranks 15th nationally in HPVa cancer rates, with 66.7% and 80.8% of counties having higher HPVa cancer rates than the national incidences of males and females, respectively. Regarding HPV vaccination, 95.5% and 98.5% of Alabama's counties have uptake rates less than the national averages for males and females, respectively. The seven counties with the highest HPV vaccination uptake ranged in rates from 60.2 to 73.6%. Counties with the highest HPV vaccination rates for adolescents were majority African American with low adult educational attainment rates and high rates of poverty and publicly-insured children/adolescents. These counties were also located in Alabama's Black Belt region, traditionally known for low socioeconomics, reduced access to social services, and negative health outcomes. Some counties with the highest rates of HPVa cancers also had among the highest rates of HPV vaccination, indicating a potential association between perceived susceptibility and desire to get HPV vaccine in these communities, warranting further investigation. Future work is needed to translate these findings into actionable intervention practices to increase HPV vaccination.

Twenty-five-Year Follow-up of Short-term Cancer Research Trainees at the University of Alabama at Birmingham: a Brief Report.

Long-term follow-up is needed to evaluate the impact of short-term cancer research programs on the career trajectories of medical and graduate students. Participation in these programs may be crucial in fostering the next generation of cancer research scientists. This report presents the career outcomes and research productivity of 77 medical and public health students with 25 years of tracking data following their participation in a summer cancer research training program at the University of Alabama at Birmingham (UAB) in 1990-1998. Of 64 summer trainees with contact information, complete survey responses were received from 55 (86.0%) individuals. Over half reported clinical care of cancer patients and 18.2% stated that they were engaged in cancer research. Literature searches confirmed that 23.4% (18/77) of trainees have published cancer research papers. Future studies should explore the optimal timing of short-term post-baccalaureate academic cancer training experiences to identify participant characteristics and institutional factors that influence career choices and determine research productivity.

Intentional tanning behaviors among undergraduates on the United States' Gulf Coast.

BACKGROUND: Rates of melanoma have dramatically increased among adolescents and young adults in recent years, particularly among young women. Exposure to ultraviolet radiation from intentional tanning practices is likely a major contributor to this epidemic. Southern and coastal regions have higher melanoma mortality rates among non-Hispanic whites in other parts of the U.S., yet little is known about tanning practices of adolescents and young adults in these regions. This study determines the prevalence and methods of intentional tanning utilized by an undergraduate population located on the United States' Gulf Coast. METHODS: Undergraduate students enrolled at a university on the Gulf Coast completed an online survey from March-April 2016, self-reporting their engagement, knowledge, and attitudes regarding outdoor tanning (OT), indoor tanning (IT) and spray tanning (ST). Univariate and multivariate analyses were performed to identify factors associated with tanning behaviors. RESULTS: 2668 undergraduates completed the survey. Of these, 64.9% reported OT tanning, 50.7% reported ever IT, and 21.2% reported ever ST. CONCLUSIONS: In the largest study to date of intentional tanning behaviors of adolescents and young adults from coastal regions, we found high rates of intentional tanning behaviors. There was also significant engagement in spray tanning by this population, not previously reported for adolescents and young adults in a sample of this size. We also identified a high association between different tanning methods, indicating this population engages in multiple tanning behaviors, a phenomenon whose health consequences are not yet known.

Significant Engagement in Tanning Behaviors by Men at a U.S. University.

Adolescent and young adult men are a potentially overlooked population with respect to risky tanning behaviors. This study sought to determine the prevalence of various modes of tanning and associated variables among young men in a university setting in the southeastern United States. Undergraduate students at a public institution in Mobile, Alabama were surveyed electronically in March 2016. Of the 818 undergraduate men surveyed, over 90% reported tanning behaviors, with 37% reporting engaging in indoor tanning. Additionally, over 25% reported engaging in two or more types of tanning concurrently. These findings indicate that early intervention efforts targeting young men are needed to reduce risky tanning behaviors and associated negative health outcomes.

Dihydroxyacetone induces G2/M arrest and apoptotic cell death in A375P melanoma cells.

The active ingredient in sunless tanning products (STPs) is a simple sugar, dihydroxyacetone (DHA). Several studies have demonstrated that DHA is absorbed within the viable layers of skin and not fully contained within the stratum corneum. Additionally, spray tanning and other aerosolized application methods have increased the risk of internal exposure through mucous membranes and inhalation. Beyond its presence in STPs, DHA also occurs as an endogenous by-product of fructose metabolism, and an excess of DHA in cells can induce advanced glycation end (AGE) products and oxidative stress. Therefore, exogenous and endogenous exposures to DHA may be harmful to cells, and it has already been demonstrated that exogenous exposure to DHA is cytotoxic in immortalized keratinocytes. Still, little is known about the exogenous DHA exposure effects on other skin components. In this study, we explore the effects of exogenous DHA exposure in a human melanoma cell line, A375P. Melanoma cells were sensitive to DHA and displayed a transient burst of reactive oxygen species within an hour of exposure. Cell cycle arrest at G2/M was observed within 24 h of exposure, and apoptosis, monitored by the cleavage of PARP-1 and Caspase-3, was detected within 72 h of exposure to DHA. Together, these demonstrate that exogenous exposure to DHA has cytotoxic effects in our selected cell model and indicates the need to further investigate the exogenous exposure effects of DHA in other relevant exposure models.

College tanning behaviors, attitudes, beliefs, and intentions: A systematic review of the literature.

Despite well-established links between exposure to ultraviolet radiation (UVR) and skin cancer, UVR-based tanning behaviors persist among college students. Understanding tanning motivations, perceptions, barriers, and demographic characteristics of this population is critical to modifying these behaviors, but is limited by variability in study design, sample size, and outcomes measured in the current literature. To help clarify the tanning behaviors of this population and provide a concise reference for future studies, this review examines existing reports to determine the comparability of tanning behaviors across multiple U.S. college populations. A systematic review of the literature was performed in July 2016 to identify studies investigating tanning behaviors among U.S. college students. Twenty-three studies met inclusion criteria. High rates of indoor tanning (IT) and outdoor tanning (OT) were found among college students. Key motivators included appearance, emotion, health perceptions, and the influence of parents, peers, and the media. Misconceptions regarding skin protection, low rates of sun protective behaviors, and tanning dependence were barriers against safe UVR exposure. Understudied demographic factors may account for variance in observed tanning behaviors, emphasizing the need for standardization efforts to consistently identify trends associated with geographical region, age, year in college, and sex. The findings presented in this review reaffirm that college students are at high risk for tanning-associated skin cancer, emphasizing the critical need for effective, targeted interventions. Improved interventions will reduce the burden of skin cancer within this group, ultimately contributing to longer, healthier lives.

Friendly tanning: young adults' engagement with friends around indoor tanning.

Indoor tanning (IT), particularly during early adulthood, increases risk for melanoma and is exceedingly common among youth. Social influence, including social norms, promotes IT but little is known about young adults' engagement with friends around tanning. We examined IT behaviors and tanning-related communication with friends at three universities. Of 837 participants, 261 (31%) reported ever tanning (90% female, 85% White). Of those, 113 (43%) were former tanners and 148 (57%) current tanners. Current tanners reported more social tanning and discussions with friends about tanning, more frequent outdoor tanning, high propensity to tan, and greater lifetime IT exposure than former tanners. Risks-to-benefits discussion ratios were greater for former tanners. In adjusted analyses, current tanners were more likely to make plans to tan and to talk about tanning benefits with friends. Findings confirm IT is a social experience. Future work should examine social tanning's role in the promotion and reduction of IT among youth.

An Evaluation Methodology for Longitudinal Studies of Short-Term Cancer Research Training Programs.

The need to familiarize medical students and graduate health professional students with research training opportunities that cultivate the appeal of research careers is vital to the future of research. Comprehensive evaluation of a cancer research training program can be achieved through longitudinal tracking of program alumni to assess the program's impact on each participant's career path and professional achievements. With advances in technology and smarter means of communication, effective ways to track alumni have changed. In order to collect data on the career outcomes and achievements of nearly 500 short-term cancer research training program alumni from 1999-2013, we sought to contact each alumnus to request completion of a survey instrument online, or by means of a telephone interview. The effectiveness of each contact method that we used was quantified according to ease of use and time required. The most reliable source of contact information for tracking alumni from the early years of the program was previous tracking results, and for alumni from the later years, the most important source of contact information was university alumni records that provided email addresses and telephone numbers. Personal contacts with former preceptors were sometimes helpful, as were generic search engines and people search engines. Social networking was of little value for most searches. Using information from two or more sources in combination was most effective in tracking alumni. These results provide insights and tools for other research training programs that wish to track their alumni for long-term program evaluation.

Career Outcomes of Graduates of R25E Short-Term Cancer Research Training Programs.

The efficacy of short-term cancer research educational programs in meeting its immediate goals and long-term cancer research career objectives has not been well studied. The purpose of this report is to describe the immediate impact on, and the long-term career outcomes of, 499 medical students and graduate students who completed the Cancer Research Experiences for Students (CaRES) program at the University of Alabama at Birmingham (UAB) from 1999 to 2013. In summer 2014, all 499 program alumni were located and 96.4 % (481 of 499) agreed to complete a longitudinal tracking survey. About 23 % of CaRES alumni (110 of 499) have published at least one cancer-related paper. Overall 238 cancer-related papers have been published by CaRES alumni, one third of this number being first-authored publications. Nearly 15 % (71 of 481 respondents) reported that their current professional activities include cancer research, primarily clinical research and outcomes research. Of these 71 individuals, 27 (38 %) have completed their training and 44 (62 %) remain in training. Of all respondents, 58 % reported that they administered care to cancer patients and 30 % reported other cancer-related professional responsibilities such as working with a health department or community group on cancer control activities. Of the 410 respondents not currently engaged in cancer research, 118 (29 %) stated intentions to conduct cancer research in the next few years. Nearly all respondents (99.6 %) recommended CaRES to today's students. Challenging short-term educational cancer research programs for medical students and graduate health professional students can help them refine and solidify their career plans, with many program alumni choosing cancer research careers.

Predictors of colorectal cancer surveillance among survivors of childhood cancer treated with radiation: a report from the Childhood Cancer Survivor Study.

BACKGROUND: Childhood cancer survivors treated with radiotherapy to a field including the colon or rectum have an elevated risk of developing radiation-induced colorectal cancer (CRC). The Children's Oncology Group recommends colonoscopy every 5 years beginning at age 35 years for at-risk survivors. METHODS: Analyses included 702 five-year survivors (Childhood Cancer Survivor Study) aged ≥36 years who received ≥30 gray of abdominal, pelvic, or spinal radiotherapy. Multivariate generalized linear models were used to calculate relative risks (RR) with 95% confidence intervals (95% CI) for adherence to the Children's Oncology Group's CRC surveillance recommendations. RESULTS: With a median age of 43 years (range, 36-58 years), 29.5% of the survivors (207 of 702 survivors) met surveillance recommendations. In multivariate analyses, age ≥50 years versus age 36 to 49 years (RR, 2.6; 95% CI, 2.0-3.4), reporting a routine cancer follow-up visit within 1 year before the study (RR, 1.5; 95% CI, 1.0-2.2), reporting ≥10 physician visits within the past year versus 0 to 9 visits (RR, 1.4; 95% CI, 1.1-1.7), and discussing future cancer risk with a physician at the time of the most recent follow-up visit (RR, 1.4; 95% CI, 1.1-1.7) were found to be associated with adherence to CRC surveillance recommendations. CONCLUSIONS: Greater than 70% of survivors at an increased risk of CRC were not screened as recommended. Regular physician contact and discussion of screening were associated with a 60% increase in CRC surveillance. Educational interventions targeted at survivors and their primary care physicians are needed to heighten knowledge of CRC risk after radiotherapy and the importance of appropriate surveillance.

Human papillomavirus vaccine beliefs and intentions Post-COVID-19 vaccine release among mothers in Alabama.

PURPOSE: The current study sought to determine if the release of COVID-19 vaccines influenced Alabama mothers' attitudes and behaviors regarding HPV vaccination of their adolescent children. METHODS: A social media survey was conducted August - September 2022 among mothers of adolescents ages 9-18, who self-identified as Alabama residents and their child(ren)'s primary medical decision maker. The survey assessed demographics, vaccine knowledge and opinions, vaccination history, influences on vaccination decisions, and how COVID-19 vaccine release affected vaccine opinions. Univariable and multivariable analyses were conducted. RESULTS: Of 241 responses, most participants were white (82.0 %, n = 196), non-Hispanic (96.6 %, n = 230), and privately insured (64.5 %, n = 151), with annual household incomes ≥$61,000 (45.4 %, n = 103). The majority (60.8 %) reported that their child either had or planned to receive the HPV vaccine. The release of COVID-19 vaccines did not change the majority of parental opinions towards HPV, with 78.5 % (n = 161) reporting no change. Among those who experienced a change, 25 % (n = 5) reported an increased likelihood of having their child vaccinated for HPV and 75 % (n = 15) reported a decrease in likelihood. Moderate and high HPV knowledge scores were associated in multivariable analysis with increased likelihood of having their child vaccinated for HPV ("moderate" knowledge AOR: 12.4, 95 % CI: 1.98-78.1; "high" knowledge AOR: 12.8, 95 % CI: 2.00-82.1). Positive HPV opinion scores in the univariable analysis similarly showed increased odds (AOR = 1.5). CONCLUSIONS: These findings indicate that, in this population, COVID-19 vaccine release did not significantly impact subsequent HPV vaccination decision making. Parental perceptions regarding vaccination are critical to informing future interventions.

Rural Americans' COVID-19 Vaccine Perceptions and Willingness to Vaccinate against COVID-19 with Their Community Pharmacists: An Exploratory Study.

In early 2022 in the U.S., rural adults were the least likely to vaccinate against COVID-19 due to vaccine hesitancy and reduced healthcare access. This study explored the factors influencing rural adults' COVID-19 vaccine perceptions and their acceptance of pharmacist-administered vaccination. We utilized phone-based semi-structured interviews with 30 adults living in rural regions of one southwestern state and analyzed the data using a team-based thematic analysis approach. Vaccine-willing participants described knowing other people affected by the virus and their desired protection from the virus. They reported trusting scientific institutions and the government to provide safe vaccines. Vaccine-hesitant populations, however, feared that the COVID-19 vaccine development process had been rushed, compromising the safety of these newer vaccines. Although they differed in the news sources they preferred for receiving COVID-19 vaccine information, both vaccine-willing and vaccine-hesitant participants described trusting local authorities, such as healthcare providers and county government officials, to provide accurate COVID-19 vaccine information. Regarding the acceptability of pharmacist-administered COVID-19 vaccinations, all but one participant described their acceptance of this healthcare delivery approach. Future outreach should leverage rural adults' trust in local sources, including community pharmacists, deemed more convenient access points to healthcare, when addressing vaccine hesitancy.

HPV Vaccination among College Students in the South: The Role of HPV Knowledge on Vaccine Initiation and Completion.

BACKGROUND: The purpose of this study was to examine factors related to HPV vaccination initiation and completion, especially the role of health knowledge, among college students in a southern state. METHODS: College students ages 17-45 (n=1,708) were analyzed in this study. Primary outcomes were HPV vaccine series initiation and completion; binary logistic regressions were performed to identify associated factors. RESULTS: Among total participants, students who were aware that HPV could be transmitted even without symptoms were less likely to initiate HPV vaccination. However, among students who have initiated the vaccine series, those who were aware that HPV could be transmitted without symptoms and that men should receive the HPV vaccine were more likely to complete the vaccine series. Other significant variables included age, gender, race, and international student status. CONCLUSION: Future studies are needed to investigate students' concerns regarding initiating HPV vaccination and how to effectively motivate students to initiate and complete the HPV vaccine series.