Participation in COVID-19 clinical trials, willingness to participate, and trust in sources of information among persons with and without cancer in Puerto Rico

Introduction: Cancer patients have a high risk of severe COVID-19 and complications from it. Although the COVID-19 pandemic has led to an increase in the conduction of clinical trials (CTs), there is a scarcity of data on CT participation among cancer patients. We aimed to describe the level of participation in a COVID-19 CT, willingness to participate, as well as trust in sources of information for CTs among persons with and without a previous cancer diagnosis in Puerto Rico. Method(s): Data collected from November 2021 to March 2022 from two cross-sectional studies were merged and used for analysis. Informed consent, telephone, face-to-face, and online interviews were conducted among participants >=18 years old living in Puerto Rico (n=987). Descriptive statistics and bivariate analysis (Fisher's exact text and chi-squared test) was done to describe the outcomes of interest, overall and by cancer status. Result(s): Mean age of participants was 41+/-15.5 years. Most participants were women (71.3%), with an educational level greater than high school (89.5%) and with an annual family income below $20,000 (75.1%). Overall, 4.4% of participants (n=43) reported history of cancer diagnosis. Only 1.8% of the population reported to have participated in a COVID-19 CT to receive either a treatment or vaccine;stratifying by cancer, none of the cancer patients had participated in a COVID-19 CT, and only 1.9% of non-cancer patients participated. While 37.0% of the participants indicated being very willing to sign up for a CT assessing COVID-19 treatment, willingness was higher in cancer patients (55.8%) than among participants without cancer (36.1%). Regarding trust in sources of information for CTs, the level of trust ("a great deal/a fair amount") was higher for their physicians (87.6%), researchers (87.0%), the National Institute of Health (86.7%), their local clinics (82.9%), and a university hospital (82.7%), while it was lower for a pharmaceutical company (64.0%), and for friend, relative, or community leader (37.6%);no differences were observed by cancer status. Conclusion(s): While participation in COVID-19 CTs was extremely low in the study population, the willingness to participate was higher among cancer patients. Education on CTs and their availability are necessary to increase participation in this understudied group. Such efforts will enhance the representation of Hispanic and vulnerable populations, such as cancer patients, on COVID-19 CTs, and thus proper generalizability of study findings in the future.

The impact of COVID-19 on colorectal screening in Puerto Rico

INTRODUCTION: Puerto Rico has endured three major environmental and public health crises (Hurricane Irma, Hurricane Maria, the unprecedented seismic activity of January 2020) and the coronavirus disease 2019 (COVID-19) pandemic during the past 5 years. All these events might lead to an unquestionable deleterious impact in the prevention of cancer and across the cancer continuum, exacerbating cancer health disparities in the future. Cancer screening plays a critical role in early cancer detection. COVID-19 has significantly hampered screening programs in many countries' cancer screening infrastructure and services, affecting adherence. Cancer is the leading cause of morbidity and mortality in Puerto Rico. Limited information is available about the impact the current pandemic on colorectal cancer screening. In this study, we aim to describe the impact of the COVID-19 pandemic on colorectal cancer screening in 2020 and assess if this impact varied by health regions. METHOD(S): This study analyzed administrative data claims from the Public Health System of Puerto Rico which is managed by the Government of Puerto Rico through the Health Insurance Administration. The Current Procedural Terminology (CPT) codes included for this study were (81528, 82270, G0104, G0105, G0121, G0328, G0464). To assess changes in the numbers of colorectal cancer screening claims between the incurred year (2016 and 2020), Poisson regression was used. Initially, we fitted this model with only the incurred year as the predictor and offsetting the model with the annual average of total insured (univariate model). Based on this model, we estimate the magnitude of association between the number of claims and incurred year using the Prevalence Ratio (PR) of claims. Lastly, Poisson univariate regression model were used for each of the seven health regions (Ponce, Bayamon, Caguas, Mayaguez, Metro, Arecibo and Fajardo) to assess potential geographic disparities. RESULT(S): The numbers of colorectal cancer screening claims significantly decreased by 40% (PRcrude: 0.60, 95%CI: 0.59, 0.62) in 2020 when compared to 2016. However, when adjusting for claim incurred month, sex, health region and offsetting the model with the annual average of total insured, the numbers of colorectal cancer screening claims significantly decreased by 34%, (PRadj: 0.66, 95%CI: 0.64, 0.67). The numbers of colorectal cancer screening claims significantly decreased in all health regions in 2020 when compared to 2016 (p<0.05). However, the most impacted region was the Eastern region, Fajardo, with a 64% (PRFajardocrude: 0.36, 95%CI: 0.30, 0.42) significant decrease in numbers of colorectal cancer screening claims. CONCLUSION(S): COVID-19 had a profound negative effect on colorectal screening in Puerto Rico. Moreover, despite the beneficiaries of this governmental health plan sharing similar sociodemographic and socioeconomic background, regional differences were observed.

Measuring the impact of the COVID-19 pandemic on breast cancer screening in Puerto Rico

Introduction: The COVID-19 pandemic has caused major changes to healthcare services, especially those related to early detection and screening practices like breast cancer. In Puerto Rico, breast cancer is the main cause of death, representing 18.9% of cancer deaths in women, making early detection even more important to prevent morbidity and mortality. This study aims to describe the impact of COVID-19 on breast cancer screening and assess differences in health utilization by age group and health regions in Puerto Rico. Method(s): This study used data on breast cancer screening medical claims from Puerto Rico Track, a project in collaboration with the Puerto Rico Public Health System and the Puerto Rico Institute of Statistics that aims to assess health access and utilization patterns in Puerto Rico. Claims including unilateral and bilateral mammography, sonommamography, and MRI were analyzed. Descriptive statistics and percentual changes between the COVID-19 baseline year (2016) compared with 2020 and 2021 were performed (overall, by age-group and health region). Result(s): A total of 193,793 screening tests were performed in 2016, compared to 66,463 in 2020, and 89,322 in 2021. Overall, a third of the medical claims for breast cancer screening (33.2%) were in the age group of 51-60 years. An overall decreasing percentual change was observed comparing 2016 vs. 2020 (65.7%), where the age group with the broadest gap reduction were among women 41-50 years old (68.2%). When comparing medical claims of 2016 (193,750) versus 2021 (89,320) (pre and post pandemic), an important decreasing change (53.9%) was observed. The age group with the highest decrease comparing 2016 to 2021 was the 41-50 years one (68.2%). The Western region of Mayaguez/Aguadilla had the highest decreasing percentual change, with a reduction of 73.6% in 2020 compared to 2016, and 62.6% when compared 2021 with 2016. Conclusion(s): Breast cancer screening was notably affected by the COVID-19 pandemic in Puerto Rico. A pattern of decreasing breast cancer screening was observed by health regions and by age. These efforts provide evidence of the need of tailored evidence-based interventions to increase breast cancer screening in the island.

Stakeholders' perceptions on the impact of the COVID-19 pandemic on the implementation of the HPV vaccine school-entry requirement in Puerto Rico

Background: The human papillomavirus (HPV) vaccine is a cancer prevention tool, yet vaccination coverage among adolescents remains suboptimal in the United States. Research shows significant disparate incidence and mortality rates of HPV-related cancers in Puerto Rico (PR). In 2018, the PR Department of Health (DOH) enacted an HPV vaccine school-entry requirement for adolescents 11 to 12 years old, and on August 2020 extended the requirement to include adolescents up to 16 years old. Amid the COVID-19 pandemic in the US, during March-August 2020, national data showed that HPV vaccine uptake rates decreased about 75%. Public health measures, such as stay-at-home orders, may have caused this decline by limiting access to preventive services. Our study explored, using a qualitative assessment, the impact of the COVID-19 pandemic on the implementation of the HPV vaccine school-entry requirement in PR. Method(s): We conducted 26 interviews with stakeholders from schools, DOH employees, Department of education staff, health providers, and community-based organizations from 08/2021-03/2022. Interviews were recorded and transcribed in Spanish. Data were analyzed using applied thematic techniques by two trained coders using Atlas-ti 8. We discussed eight of these interviews among the team to identify major barriers related to the HPV school-entry implementation during the pandemic. Result(s): Our analysis identified the following preliminary emergent themes including: (1) lockdown limitations and access barriers to the vaccine and (2) shifting immunization priorities. Most participants noted that the March 2020 lockdown limited parents' ability to get their kids vaccinated and for schools to monitor the vaccine requirements;however, as vaccination centers and schools re-opened, gradually, vaccination processes increased. Participants described how during the pandemic, public health agencies prioritized the COVID-19 vaccine missing other vaccines that are required for school-entry, including the HPV vaccine. Discussion(s): Continuation of the implementation of the HPV vaccine school-entry requirement was challenging during early stages of the pandemic due to public health measures enacted to stop the spread of COVID-19. Moreover, once the COVID-19 vaccine was available, public heath vaccination priorities shifted. Nonetheless these barriers, efforts to increase HPV vaccine to pre-pandemic rates should continue, including providing educational support to parents, increase vaccine promotion, and creating community collaborations. As new guidelines recommend COVID-19 boosters, for everyone ages 5 years and older, this opportunity could serve to vaccinate against HPV as part of the bundling implementation of the HPV vaccine school-entry requirement.

HPV and COVID-19 vaccines attitudes and preferred sources of information among adults living in Puerto Rico

Prior to the COVID-19 pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. Yet, widespread misleading information about the COVID19 vaccine might negatively impact HPV vaccine attitudes. This study aims to assess and compare HPV and COVID-19 vaccines attitudes toward school-entry policies among adults living in PR. A convenience sample of 222 adults (>=21 years old) living in PR were recruited through social media and completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID-19 vaccines knowledge (ranging from 0=none to 3=high knowledge), attitudes toward vaccination policies for school-entry, and perceptions of trusted and untrusted sources of information. Descriptive statistics were computed to identify the demographics characteristics of the participants. We also estimated the prevalence ratio (PRadjusted) using a logistic regression model to assess the magnitude of association between COVID-19 vaccination for the school-entry policy and HPV vaccination for school-entry policy agreement, adjusting for different confounders. The mean age of the study sample was 36.73 +/- 11.18 years. The majority of the sample were female (87%, n=194), with at least some college of education (92%;n=205) and employed (61%;n=165). One-fifth of the participants reported having children between ages 11 and 16 (n=46). Participants' perceived knowledge about the HPV vaccine was moderate (mean=1.72;SD=1.12), while for COVID-19 vaccine was moderately high (mean=2.47;SD=.68). The most trusted form of information for HPV and COVID-19 vaccines were health care providers (42% and 17%, respectively), the Centers for Disease Control and Prevention (35% and 55%, respectively), and the Department of Health (15% and 19%, respectively). The least trusted source of information included social media (40% and 39%, respectively), friends and family (23% n=47, and 17% n=33, respectively), and the Department of Health (15% n=30, and 18% n=36, respectively). More than half of the participants agreed that HPV (76% n=156) and COVID vaccines (69% n=136) should be required for school-entry. Agreement with COVID-19 vaccination for the school-entry policy was significantly associated with HPV vaccination for school-entry policy agreement (PRadjusted:1.96;95% CI:1.48-2.61) after controlling for age, sex, education, and having children between age 11 and 16. Findings suggest that adults living in PR have an overall positive attitude about mandatory HPV and COVID-19 vaccination school-entry policies, and these attitudes are interrelated. Yet, it is concerning that the Department of Health is identified as one of the least trusted sources of information, as it has a prominent role in implementing HPV and COVID-19 vaccine policies in PR. Further research should elucidate why the Department of Health is considered an untrusted source of information among adults living in PR and evaluate the implications of the COVID-19 pandemic on HPV vaccine attitudes and adherence rates.

Cervical, breast, and colorectal cancer screening by COVID-19 booster and influenza vaccination status in a sample of women in Puerto Rico

Background: Recommendation by a healthcare provider is essential for women to seek preventative cancer screening. Research has shown patients are receptive to information about cancer screening given by health professionals administering influenza vaccines. Promotion of cancer screening during vaccination may be particularly important in Puerto Rico (PR), which, relative to the continental United States, has low cervical and colorectal cancer screening rates. Objective(s): This study aims to determine if receiving the influenza vaccine in the past year or ever receiving the COVID-19 booster is associated with an increased likelihood of women participating in cervical, breast, and colorectal cancer screening in the past year. Method(s): Women older than 18 are recruited weekly in different ongoing community outreach events throughout Puerto Rico as part of the Puerto Rico Community Engagement Alliance (PR-CEAL) against COVID-19 disparities. The PR-CEAL outreach team completes an online community survey as part of their field activities. Initial data was collected from February 17th 2022 through May 28th 2022, with data collection currently ongoing. Pearson chi2 test or Fisher exact test, as appropriate, was used to quantify the association between participation in cancer screening and vaccination status. Result(s): As of May 31st, 253 women with a median age of 59 had been recruited. Of these, 56.1% had received the influenza vaccine in the past year, and 52.6% had received a COVID-19 booster. Nearly 52% of women with the booster and 65% without the booster received cervical cancer screening (p-value =0.29). Women with the booster and those without the booster (75% each) received breast cancer screening (p-value = 0.99). Only 16.1% of women with the booster and 11.8% without the booster had received colorectal cancer screening (p-value = 0.99). Receipt of cancer screening according to influenza vaccine status was as follows: 59.3% vaccinated and 51.5% unvaccinated received cervical cancer screening (p-value = 0.35);31.4% vaccinated and 41.2% unvaccinated received breast cancer screening (p-value = 0.56);and 13.1% vaccinated and 9.3% unvaccinated received colorectal cancer screening (p-value = 0.46). Conclusion(s): No differences in receipt of cancer screening were found by influenza or COVID-19 booster vaccination status among adult women in Puerto Rico. Routine vaccination appointments may therefore represent a missed opportunity to promote cancer screening.

A Puerto Rico free of preventable diseases: An online education intervention for school staff during the COVID-19 pandemic era in Puerto Rico

Introduction:?Puerto Rico Libre de Enfermedades Prevenibles (Puerto Rico Free of Preventable Diseases) was an online, community-based initiative consisting of eight educational training programs regarding school entry vaccines, including HPV vaccine as the most recent requirement. The Community Advisory Board of the HPV-PIVac study (CAB-PIVac) developed this activity in response to barriers identified on school personnel by the HPV-PIVac study: lack of knowledge about the HPV vaccine and its school entry requirement and need for training. In February 2020, CAB-PIVac members collected data through a self-administrated survey to identify potential topics. After several meetings, members identified the topics and resources for these webinar series. Our purpose is to present how the integration of community members into an ongoing research study allowed rapid response to developing an educative initiative to impact school staff concerning preventable diseases and the HPV vaccine. Methods: Eight webinars in four weeks were transmitted in-live through the Zoom platform from June 26 to July 17, 2020. They were on-demand until July 24, 2020. Theme per week: World without vaccine: COVID-19;Teenager vaccine in School;Future free of HPV-related cancer;and Legal aspects of vaccination for the school-entry. The participants received via email an evaluation form to assess the impact of these webinars. Using data from the registration form, we collected the following participants' characteristics: sex, age, education sector, and role in the school. We performed a thematic analysis collecting all the messages posted in the Q & A section of each webinar to identify the topics in which the participants had doubts or more interest. Results: A unique participation of 954 participants were registered, and the range of involvement on the education webinars was 588 to 780 participants. Based on the type of education, 28.8% were private, and 70.9% were from public education. Most of the participants were females (89.6%) and with an average age of 42 years (range: 21 -74). Of the participants who reported their role at their schools (n=648), 31.4% were school nurses, followed by the school director (22.7%). Twelve percent of the participants were teachers. The evaluation was satisfactory (99.7%) considering the tools offered and the clear information presented. The thematic analysis results showed that the two topics discussed in the Q &A section were the immunization registry (problems with system access) and the vaccination series (age to initiate the series). Conclusion: This initiative was developed and performed in less than five months. Many national and international organizations, coalitions, and government agencies are working to achieve the same goal: eradicated HPV-related cancers and strengthen the awareness for HPV prevention. Involve these community members in the research is crucial to secure how the results of the investigation studies could impact the community quickly and accurately.

Impact of COVID-19 public policies on utilization on cervical cancer screening in Puerto Rico during March 15, 2020 to July 31, 2020

Introduction: Among jurisdictions of the United States, Puerto Rico (PR) has the highest incidence of cervical cancer, and cervical cancer screening (CCS) is below 80%. Public health emergencies have an impact on people's access to health care services. We examined the impact of the public policy implemented by the government of Puerto Rico during the first 5 months of the COVID-19 pandemic in the utilization of CCS for participants of the Government's Public Health Plan. Methodology: This was a retrospective cohort study. A total of 40 government executive orders (issued between March 15 to July 31, 2020) were analyzed according to the level of restrictions they imposed on the population. Three periods with the greatest restrictions were identified: two of them in the government's initial response phase (March 15-30th & March 31st -April 12th ) and one in the re-opening phase (July 17-July 31st ). We examined the utilization of all modalities of CCS (pap test only and pap + HPV contesting). Rate ratios (RRs) were estimated to compare to CCS rates during periods of 2020 and compared to 2018-2019. Results: In comparison to 2019, CCS decreased during the most restricted period (March 31st-April 12th) of the response phase (RR= 0.19, 95% CI=0.15-0.24 for women 21-29 years;RR= 0.04 95% CI= 0.03-0.05 for women 30-65 years). During the re-opening phase, screening services started to rebound. However, an increase in COVID-19 cases led to another restriction (July 17-July31st), which led to a second phase of decrease in utilization of CCS (RR=0.17 95% CI=0.13-0.21 for women 21-29 years (RR= 0.09, 95% CI=0.08-0.10 for women 30-65 years). Conclusion: Our results evidence how the public policy implemented as a result of the COVID-19 pandemic in Puerto Rico had a direct impact on the utilization of CCS services in this Hispanic population. Future studies should examine screening patterns and social barriers of service utilization after July 2020 in Puerto Rico.

Understanding views against the HPV vaccine school-entry requirement in Puerto Rico

Introduction: Individuals and groups against vaccination have used various outlets, such as mass media, social media, and legislative hearings to express doubts about the human papillomavirus (HPV) vaccine. In 2018, the Puerto Rico Department of Health included the HPV vaccine as a school-entry requirement for children ages 11-12. Currently, the requirement extends to students ages 11-16. Since the announcement in 2017 of the new school-entry requirement as a preventive cancer strategy, many groups have expressed opposition. Although studies have documented the barriers and facilitators for implementing this policy on the island, qualitative studies assessing stakeholders' views against the implementation of the new requirement are lacking. We aimed to describe stakeholders' perspectives who opposed the HPV vaccine and the implementation as a school-entry requirement in PR. Methods: In-depth interviews (n=8) were conducted between March 2019-January 2020. Healthcare providers, religious leaders, and coalition spokespersons were interviewed. The Consolidated Framework for Research Implementation (CFIR) was used to develop the semi-structured interview guide. CFIR domains (and constructs) included were characteristics of individuals (knowledge, attitudes, and beliefs about the HPV vaccination, school-entry requirement, and exemptions), intervention characteristics (current practices, advantages and disadvantages of the implementation), and implementation procedures (planning, commitment of implementers and evaluation). Interviews were audio-recorded and transcribed in Spanish. Transcripts were analyzed using qualitative thematic analysis. Additional constructs were derived from CFIR constructs and emergent codes were included. Results: The most common CFIR domain observed was individual characteristics (knowledge and beliefs), of which HPV hesitancy and vaccine distrust were emergent themes. Arguments against the policy also cited the adverse effects of the vaccine under the intervention characteristics domain (evidence strength and quality). Lastly, excessive government interference was discussed by stakeholders in which concerns regarding the HPV vaccine school-entry requirement and how this policy does not align with their values of religious freedom, parental, educational and sexual rights were mentioned. Conclusion: Despite the recent documented positive impact of the school-entry requirement in HPV immunization rates in PR, many continue to oppose the vaccine mandate. Stakeholders' arguments against the HPV vaccine policy, including knowledge and beliefs, and excessive government interference, echo concerns of other mandated vaccines reported in the literature. Understanding arguments against school-entry requirements is necessary to tailor educational campaigns to increase vaccination rates, which were affected by the COVID-19 pandemic, prevent HPV-related cancers, and reduce the hesitancy in of school-entry policies in the future.