Key Considerations and Recommended Strategies for Conducting a School-Based Longitudinal RE-AIM Evaluation: Insights From a 28-School Cluster Randomized Trial.

RE-AIM is an implementation science framework that provides a structure to promote data collection and analysis in the domains of Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance. The RE-AIM approach promotes more data collection and reporting than typical evaluations so potential adopters can determine the potential program fit for their setting. RE-AIM has been used to evaluate a variety of programs; however, there are few resources that provide strategies for conducting a RE-AIM evaluation in the school setting. The purpose of this article is to inform future studies by elucidating experiences conducting a large, complex, multisite, longitudinal RE-AIM evaluation in schools in partnership with the state's Departments of Education and Health, and to share strategies for overcoming obstacles. With the long-term goal of facilitating the translation of school-based intervention research into practice, we provide key considerations and recommend strategies for school-based RE-AIM evaluation success.

Evaluating Smart Assistant Responses for Accuracy and Misinformation Regarding Human Papillomavirus Vaccination: Content Analysis Study.

BACKGROUND: Almost half (46%) of Americans have used a smart assistant of some kind (eg, Apple Siri), and 25% have used a stand-alone smart assistant (eg, Amazon Echo). This positions smart assistants as potentially useful modalities for retrieving health-related information; however, the accuracy of smart assistant responses lacks rigorous evaluation. OBJECTIVE: This study aimed to evaluate the levels of accuracy, misinformation, and sentiment in smart assistant responses to human papillomavirus (HPV) vaccination-related questions. METHODS: We systematically examined responses to questions about the HPV vaccine from the following four most popular smart assistants: Apple Siri, Google Assistant, Amazon Alexa, and Microsoft Cortana. One team member posed 10 questions to each smart assistant and recorded all queries and responses. Two raters independently coded all responses (κ=0.85). We then assessed differences among the smart assistants in terms of response accuracy, presence of misinformation, and sentiment regarding the HPV vaccine. RESULTS: A total of 103 responses were obtained from the 10 questions posed across the smart assistants. Google Assistant data were excluded owing to nonresponse. Over half (n=63, 61%) of the responses of the remaining three smart assistants were accurate. We found statistically significant differences across the smart assistants (N=103, χ22=7.807, P=.02), with Cortana yielding the greatest proportion of misinformation. Siri yielded the greatest proportion of accurate responses (n=26, 72%), whereas Cortana yielded the lowest proportion of accurate responses (n=33, 54%). Most response sentiments across smart assistants were positive (n=65, 64%) or neutral (n=18, 18%), but Cortana's responses yielded the largest proportion of negative sentiment (n=7, 12%). CONCLUSIONS: Smart assistants appear to be average-quality sources for HPV vaccination information, with Alexa responding most reliably. Cortana returned the largest proportion of inaccurate responses, the most misinformation, and the greatest proportion of results with negative sentiments. More collaboration between technology companies and public health entities is necessary to improve the retrieval of accurate health information via smart assistants.

Young adult US-born Latina women's thoughts, feelings and beliefs about unintended pregnancy.

Current measures of unintended pregnancy underestimate the co-occurring, complex set of social, cultural, economic and structural factors that influence how women interpret unintended pregnancy. The purpose of this study was to prospectively explore young adult US-born Latinas' thoughts, feelings and beliefs about pregnancy, specifically unintended pregnancies and the sociocultural factors identified as contributors to those beliefs. In-depth interviews (n = 20) were conducted with US-born, English-speaking Latinas aged 18-25 years in south Florida. Seventeen participants did not intend to get pregnant, while the remaining participants (n = 3) reported that their intentions kept changing. Participants' beliefs regarding their unintended pregnancy were influenced by social and economic hardship and cultural factors such as fatalism and familismo. Ideas and the meaning of pregnancy differed based on the woman's pregnancy resolution decision. Many women felt the term 'unintended pregnancy' placed blame on women and was stigmatising. When discussing pregnancy planning, most participants felt that women should not plan their pregnancies and doing so was going against fate. Findings suggest that salient influences such as culture and the social determinants related to unintended pregnancy should be incorporated into measurements examining unintended pregnancy.

Towards an Information Motivation and Behavioral Skills Model for New Sex Partners: Results of a Study of Condom Use as an HIV Prevention Method for Emerging Adults Who Met Partners on Dating and Sex-Seeking Platforms or Offline.

The information, motivation, behavioral Skills (IMB) model was used to identify factors that affect condom use with new sex partners that were met offline or online. Mixed methods data were collected from adults between the ages of 18 and 29 years who reported a new sex partner. A model was composed of participants' IMB scale scores to determine the effect of these variables on condom use. A subset of 20 survey participants completed interviews exploring how IMB model elements may have influenced their condom use. Mixed methods results showed condom use skills were influential for condom use during the first sexual encounter between new partners. Qualitative findings suggest the information and motivation may also influence condom use with new sex partners. The IMB model for new partners may be relevant model for the development of interventions that encourage emerging adults to use condoms at first sex with new sex partners.

Rural and Urban Differences in Sexual Behaviors Among Adolescents in Florida.

The national teen birth rate is higher in rural compared to urban areas. While national data suggest rural areas may present higher risk for adverse sexual health outcomes among adolescents, it is unknown whether there are differences within the state of Florida. Overall, Florida has poorer sexual health indicators for adolescents compared to national rates. The purpose of this study was to assess differences in sexual behaviors among Florida adolescents by rural-urban community location. This study includes baseline data from a randomized controlled trial conducted in Florida high schools. Of the 6316 participants, 74% were urban and 26% were rural. Participants responded to questions on sexual behaviors, sexual behavior intentions, and demographics. We estimated the effect of rural-urban status on risk outcomes after controlling for demographic variables using generalized linear mixed models. More teens from rural areas reported ever having sex (24.0%) compared to urban teens (19.7%). No significant differences were observed for most of sexual behaviors assessed. Nonetheless, urban participants were less likely to intend to have sex without a condom in the next year compared to rural participants (aOR = 0.76, 95% CI 0.63-0.92). Overall, there were no major differences in sexual behaviors between rural and urban adolescents in Florida. However, sexual intentions differed between rural and urban adolescents; specifically, rural adolescents were more likely to intend to have sex without a condom in the next year compared to urban adolescents. Understanding the specific disparities can inform contraception and sexual health interventions among rural youth.

"Okay, We Get It. You Vape": An Analysis of Geocoded Content, Context, and Sentiment regarding E-Cigarettes on Twitter.

The current study examined conversations on Twitter related to use and perceptions of e-cigarettes in the United States. We employed the Social Media Analytic and Research Testbed (SMART) dashboard, which was used to identify and download (via a public API) e-cigarette-related geocoded tweets. E-cigarette-related tweets were collected continuously using customized geo-targeted Twitter APIs. A total of 193,051 tweets were collected between October 2015 and February 2016. Of these tweets, a random sample of 973 geocoded tweets were selected and manually coded for information regarding source, context, and message characteristics. Our findings reveal that although over half of tweets were positive, a sizeable portion was negative or neutral. We also found that, among those tweets mentioning a stigma of e-cigarettes, most confirmed that a stigma does exist. Conversely, among tweets mentioning the harmfulness of e-cigarettes, most denied that e-cigarettes were a health hazard. These results suggest that current efforts have left the public with ambiguity regarding the potential dangers of e-cigarettes. Consequently, it is critical to communicate the public health stance on this issue to inform the public and provide counterarguments to the positive sentiments presently dominating conversations about e-cigarettes on social media. The lack of awareness and need to voice a public health position on e-cigarettes represents a vital opportunity to continue winning gains for tobacco control and prevention efforts through health communication interventions targeting e-cigarettes.

Scalability of an Evidence-Based Adolescent Pregnancy Prevention Program: New Evidence From 5 Cluster-Randomized Evaluations of the Teen Outreach Program.

OBJECTIVES: To determine if the Teen Outreach Program (TOP), a youth development and service learning program, can reduce sexual risk-taking behaviors compared with a business as usual or benign counterfactual. METHODS: We synthesized results of 5 independent studies conducted in 5 geographically and ethnically diverse locations between 2011 and 2015 with 17 194 middle and high school students. Each study cluster-randomized classes, teachers, or schools to treatment or control groups and included the students enrolled in those clusters at baseline in an intent-to-treat analysis. Multilevel models tested impacts on recent sexual activity, recent unprotected sexual activity, and sexual initiation among the sexually inexperienced at baseline at approximately 1 and 2 years after baseline. RESULTS: Precision-weighted average effect sizes showed nonsignificant reductions of 1 percentage point or less in recent sexual activity (5 studies: -0.6; P = .32), recent unprotected sex (5 studies: -0.2; P = .76), and sexual initiation (4 studies: -1.1; P = .10) after 1 year. CONCLUSIONS: There was little evidence of the effectiveness of TOP in reducing sexual risk-taking behaviors. Results underscored the importance of continually evaluating evidence-based programs that have previously been shown to be effective.

Effectiveness of healthy relationships video-group-A videoconferencing group intervention for women living with HIV: preliminary findings from a randomized controlled trial.

INTRODUCTION: Expanded access to efficacious interventions is needed for women living with human immunodeficiency virus (WLH) in the United States. Availability of "prevention with (human immunodeficiency virus [HIV)] positives" interventions in rural/remote and low HIV prevalence areas remains limited, leaving WLH in these communities few options for receiving effective behavioral interventions such as Healthy Relationships (HR). Offering such programs via videoconferencing groups (VGs) may expand access. This analysis tests the effectiveness of HR-VG (versus wait-list control) for reducing sexual risk behavior among WLH and explores intervention satisfaction. SUBJECTS AND METHODS: In this randomized controlled trial unprotected vaginal/anal sex occasions over the prior 3 months reported at the 6-month follow-up were compared across randomization groups through zero-inflated Poisson regression modeling, controlling for unprotected sex at baseline. Seventy-one WLH were randomized and completed the baseline assessment (n=36 intervention and n=35 control); 59 (83% in each group) had follow-up data. RESULTS: Among those who engaged in unprotected sex at 6-month follow-up, intervention participants had approximately seven fewer unprotected occasions than control participants (95% confidence interval 5.43-7.43). Intervention participants reported high levels of satisfaction with HR-VG; 84% reported being "very satisfied" overall. CONCLUSIONS: This study found promising evidence for effective dissemination of HIV risk reduction interventions via VGs. Important next steps will be to determine whether VGs are effective with other subpopulations of people living with HIV (i.e., men and non-English speakers) and to assess cost-effectiveness. Possibilities for using VGs to expand access to other psychosocial and behavioral interventions and reduce stigma are discussed.

Mpox knowledge in the U.S.: Results from a nationally representative survey.

Development and testing of a scale assessing mpox knowledge in a national survey of U.S. adults (aged ≥18 years) was conducted. Address-based sampling methods ensured full coverage of all households. Between September 16-22, 2022, N = 1018 participants self-administered the Internet-based survey that included a 15-item knowledge scale. Responses "yes," "no," and "I do not know," were scored as correct= 1, incorrect= -1, and "I do not know"= 0. Knowledge was dichotomized into good/poor based on modified Bloom's cutoff points (i.e. correctly answering at least 9 of the 15 total questions=good knowledge). We assessed psychometric characteristics and chi-square/one-way ANOVAs examining differences by demographic groups, applying sampling weights to analyses. Score reliability was strong (α = .82). All items but one ("Diarrhea is one of the symptoms of monkeypox") had statistically significant point biserial correlations, indicating a correlation between a correctly answered item and higher knowledge score. Only 35% of respondents were categorized as having good knowledge. Differences in knowledge by racial/ethnic, education, household income, sexual orientation, and MSA status groups were statistically significant. Mpox knowledge was lowest among heterosexually identified, rural, and low education/income respondents. Findings may be used in mpox prevention interventions, as the scale shows promise for assessing mpox knowledge in other groups/settings.

A theory-based assessment of mpox: Findings from a nationally representative survey of U.S. adults.

The purpose of this research was to examine individual differences related to fear of, perceived susceptibility to, and perceived severity of mpox as well as mpox knowledge, fear, perceived susceptibility, and perceived severity as predictors of vaccine intention in a national survey of U.S. adults (aged ≥18 years). Address-based sampling (ABS) methods were used to ensure full coverage of all households in the nation, reflecting the 2021 March Supplement of the Current Population Survey. Internet-based surveys were self-administered by Ipsos between September 16-26, 2022. N = 1018 participants completed the survey. The survey included items, based partially on the Health Belief Model, assessing vaccine intention (1 item; responses from 1 [Definitely not] to 5 [Definitely]), fear of mpox (7-item scale; α = .89; theoretical mean = 7-35), perceived susceptibility to mpox (3-item scale; α = .85; theoretical mean = 3-15), and perceived severity of mpox (4-item scale; α = .65; theoretical mean = 4-20). Higher scores indicate greater fear, susceptibility, and severity. One-way ANOVAs were run to examine mean score differences by demographic groups (e.g., gender, race/ethnicity, sexual orientation), and multiple regression analyses assessed the relationship between predictors (mpox knowledge, susceptibility/severity, fear) and a single outcome (vaccination intention), while controlling for demographic covariates. Sampling weights were applied to all analyses. Only 1.8% (n = 18) of respondents reported having received the mpox vaccine. While mpox vaccine intention was low (M = 2.09, SD = 0.99), overall differences between racial/ethnic, sexual orientation, education, and household income groups were statistically significant. Fear of mpox was very low (M = 13.13, SD = 5.33), and there were overall statistically significant differences in both fear and perceived severity among gender, race/ethnicity, sexual orientation, education, and household income groups. While respondents reported not feeling very susceptible to mpox (M = 5.77, SD = 2.50), they generally rated mpox as just above the theoretical mean in terms of severity (M = 11.01, SD = 2.85). Mpox knowledge, fear, severity, and susceptibility, as well as race/ethnicity, were all statistically significant predictors of intention to vaccinate, with susceptibility representing the strongest predictor. Overall, Americans' vaccination for mpox/vaccine intent was low. Gay/lesbian and racial/ethnic minority respondents felt more susceptible to and viewed mpox more severely, compared with heterosexual and White respondents, respectively. These data may be used to tailor risk and prevention (e.g., vaccination) interventions, as cases continue to surge in the current global mpox outbreak. Greater perceptions of susceptibility, severity, and fear about mpox exist largely among minority populations. While public health messaging to promote mpox vaccination can focus on improving knowledge, as well as addressing fear and perceived severity of, and susceptibility to, mpox, such messages should be carefully crafted to prevent disproportionate negative effects on marginalized communities.

Promoting Healthy Adolescent Romantic Relationships: Results of a Multisite, Two-group Parallel Randomized Clinical Trial.

PURPOSE: To examine the impact of About Us, an innovative healthy relationships intervention that promotes positive adolescent romantic relationships and the use of effective contraceptives, on improving behavior, attitudes, and intentions related to sexual intercourse, relationship communication, and conflict resolution at 3- and 9-month follow-up, compared to services as usual. METHODS: This was a multi-site, two-group, parallel, randomized-controlled trial with an intervention/comparison allocation ratio of 3:2 conducted at seven high schools in California between February 2018 and May 2021. RESULTS: Overall, our study did not find statistically significant evidence of improved behavior, attitudes, and intentions related to sexual intercourse, relationship communication, and conflict resolution among participants (14-18 years old) randomized to the intervention group (n = 316) compared to services as usual (n = 217) during follow-up (group x time; p > .05). Exploratory within group analyses showed that, compared to baseline, at the 3-month follow-up, the prevalence of reporting having had sex increased in the control group relative to intervention group (+19% vs. +9%, p < .01). Our sub-group analyses showed that changes in condom use intentions scores differed across school sites (group x time x school; p < .01); mixed (positive and negative) trends were observed for intervention effect, and schools with positive intervention effect trends tended to have greater program participation. DISCUSSION: About Us did not show statistically significant positive impacts on primary or secondary outcomes as anticipated. Our exploratory findings show evidence of some promising trends of intervention effects at the school-level, suggesting a need for better tailored intervention components and/or delivery to address the unique environmental contexts of participants. Overall, the context of study implementation was negatively affected by the COVID-19 pandemic and challenges related to using a non-classroom delivery intervention approach. Combined, these factors may have contributed to the study null findings. Moreover, it is difficult to know (or determine) the intervention's impact under more ideal conditions (i.e., no COVID pandemic).

Teens' use of digital technologies and preferences for receiving STD prevention and sexual health promotion messages: implications for the next generation of intervention initiatives.

This study examined teens' digital device ownership, online activities, and usage/frequency of communication modalities. Teens with a current sexually transmitted disease were more likely to report willingness to use a text messaging service to have sexual health questions answered. Next-generation sexually transmitted disease prevention initiatives must use newer communication technologies to maximize effectiveness.

Evaluating the Internet as a sexually transmitted disease risk environment for teens: findings from the communication, health, and teens study.

BACKGROUND: Few studies have examined the association between sexual health risks and online sex-seeking among teenagers. The purpose of this study was to assess the associations between meeting sex partners online and a range of sexual risk behaviors and outcomes among adolescents. METHODS: Participants aged 13 to 19 years were recruited from a publicly funded teen clinic in Florida. After obtaining informed consent/assent, 273 participants completed an audio computer-assisted self-interview that included questions on demographics, sexual behavior, sexually transmitted disease (STD) history, and online sex-seeking behaviors and experiences. Participants also provided urine samples for chlamydia and gonorrhea testing. Data were analyzed using logistic regression to identify the association between having an online sex partner and sexual behaviors/outcomes. RESULTS: After adjusting for significant bivariate correlates, teens reporting online sex partners were more likely to be male, be multiracial, have a history of same-sex sexual activity, report a higher number of vaginal sex partners, and report a lower age at first vaginal sex. However, teens with online sex partners were no more likely to have ever had an STD or a current biological STD. CONCLUSIONS: This study is one of the first to correlate biological STD results to online sexual partnering data in a youth population. Although meeting a sex partner online was not associated with past or current STDs, it was associated with other sexual risk behaviors. Future research is needed to examine the complex nature of online sexual partnering among adolescents and to develop intervention approaches.

HPV-related information sharing and factors associated with U.S. men's disclosure of an HPV test result to their female sexual partners.

OBJECTIVES: Prevalence of human papillomavirus (HPV) is high in both men and women, yet men have seldom been involved in HPV education/prevention programmes, and their disclosure of known HPV infection has rarely been studied. This analysis sought to determine factors associated with men's HPV test result disclosure and HPV-related information sharing with partners. METHODS: From 2007 to 2010, men enrolled in a psychosocial study of responses to HP testing who reported having a female main sexual partner (N=251) completed surveys including questions about HPV test results, disclosure of HPV test results to partner(s), relationship characteristics and stigma (for those who reported HPV-positive results) approximately 3 weeks after receiving an HPV test result. Logistic regression was conducted to determine factors associated with disclosure of HPV test results in cross-sectional analysis. RESULTS: Most men disclosed their test results to a main partner (82%). Self-reported HPV-negative test result, a high school education and a higher commitment to a sexual partner were significantly associated with increased disclosure in multivariable analysis. Men who disclosed (vs those who did not) were significantly more likely to provide their partners with HPV-related information. Among men who disclosed to their main partner, nearly half reported that partner asked them questions about HPV. CONCLUSIONS: Results from this study highlight the critical role that men who are symptomatic for, who are tested for or who are vaccinated against HPV can play in educating their sexual partners, independent of whether they actually disclose their test results.

Does the Internet represent a sexual health risk environment for young people?

This study examined sexual risk behaviors/outcomes among college students with online partners only, offline partners only, and both online/offline partners. Students with both online/offline partners were more likely to report sexually transmitted diseases, unintended pregnancy, and more vaginal/oral sex partners. Sex with online partners was not riskier than sex with offline partners.

Skin Cancer Narratives on Instagram: Content Analysis.

Background: Skin cancer is among the deadliest forms of cancer in the United States. The American Cancer Society reported that 3 million skin cancer cases could be avoided every year if individuals are more aware of the risk factors related to sun exposure and prevention. Social media platforms may serve as potential intervention modalities that can be used to raise public awareness of several diseases and health conditions, including skin cancer. Social media platforms are efficient, cost-effective tools for health-related content that can reach a broad number of individuals who are already using these spaces in their day-to-day personal lives. Instagram was launched in 2010, and it is now used by 1 billion users, of which 90% are under the age of 35 years. Despite previous research highlighting the potential of image-based platforms in skin cancer prevention and leveraging Instagram's popularity among the priority population to raise awareness, there is still a lack of studies describing skin cancer-related content on Instagram. Objective: This study aims to describe skin cancer-related content on Instagram, including the type of account; the characteristics of the content, such as the kind of media used; and the type of skin cancer discussed. This study also seeks to reveal content themes in terms of skin cancer risks, treatment, and prevention. Methods: Through CrowdTangle, a Facebook-owned tool, we retrieved content from publicly available accounts on Instagram for the 30 days preceding May 14, 2021. Out of 2932 posts, we randomly selected 1000 posts for review. Of the 1000 posts, 592 (59.2%) met the following inclusion criteria: (1) content was focused on human skin cancer, (2) written in English language only, and (3) originated from the United States. Guided by previous research and through an iterative process, 2 undergraduate students independently coded the remaining posts. The 2 coders and a moderator met several times to refine the codebook. Results: Of the 592 posts, profiles representing organizations (n=321, 54.2%) were slightly more common than individual accounts (n=256, 43.2%). The type of media included in the posts varied, with posts containing photos occurring more frequently (n=315, 53.2%) than posts containing infographics (n=233, 39.4%) or videos (n=85, 14.4%). Melanoma was the most mentioned type of skin cancer (n=252, 42.6%). Prevention methods (n=404, 68.2%) were discussed in Instagram posts more often than risk factors (n=271, 45.8%). Only 81 out of 592 (13.7%) posts provided a citation. Conclusions: This study's findings highlight the potential role of Instagram as a platform for improving awareness of skin cancer risks and the benefits of prevention practices. We believe that social media is the most promising venue for researchers and dermatologists to dedicate their efforts and presence that can widely reach the public to educate about skin cancer and empower prevention.

Understanding Melanoma Talk on Twitter: The Lessons Learned and Missed Opportunities.

BACKGROUND: Melanoma is the third most common cause of cancer and the deadliest form of skin cancer among 17-39 year-olds in the United States. Melanoma is a critical public health issue with a substantial economic burden. Cases and associated burdens, however, could be prevented with a greater awareness of, and interventions related to, skin cancer and melanoma-related preventive behaviors. In fact, as social media use is close to ubiquitous, it represents a potential communication modality. However, more research is needed to understand the current state of melanoma-related information exchanged between Twitter users. This study aimed to understand the different types of users controlling the melanoma-related information diffusion and conversation themes on Twitter. METHODS: Tweets (n = 692) were imported from Twitter between 1 and 31 May 2021 using the Twitter public API; and uploaded to NodeXL to conduct a social network analysis. RESULTS: Health professionals and organizations with medical backgrounds were the main content producers, disseminators, and top influencers. However, information diffusion is slow and uneven among users. Additionally, conversations lacked a focus on preventive behaviors. CONCLUSION: Twitter is a potential platform for the targeted outreach of individuals in melanoma awareness campaigns. This study provides insights maximizing the effectiveness of Twitter as a communication modality. Our findings can help guide the development of customized content and interventions during melanoma awareness campaigns.

"While You're Down There": The Unexplored Role of Estheticians in the Health of Their Clients.

Young women (18-25 years) are more likely to engage in pubic hair removal and experience higher rates of negative sexual health outcomes (e.g., sexually transmitted infections [STIs]). Hair removal salons may serve as novel environments for health interventions. The Sexual Health and Esthetician (SHE) Study aimed to better understand the pubic hair removal profession, explore the esthetician-client relationship, and assess potential for esthetician offices/salons serving as health promotion/sexual health promotion intervention settings. Using an exploratory qualitative design, in-depth interviews (N = 28) were conducted with licensed estheticians who provided pubic waxing services. In a large urban area in Southern California, the catchment area of salons included five unique neighborhoods, each with high reported STI rates. Data were analyzed using a social constructivist perspective and emergent themes from interviews. Synthesis of data showed estheticians provide a variety of waxing services for young women; during appointments, sex-related discussions occur, creating "sexy spaces" where otherwise taboo conversations happen with ease; they notice clients' possible health concerns, including STIs, but have no protocols/procedures for handling these occurrences; and interactions with clients often result in the development of an intimate bond. Results indicate estheticians may be effective conveyors of sexual health promotion and risk reduction interventions.