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1.
PLoS One ; 19(6): e0300450, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-38870142

RESUMEN

BACKGROUND: Family caregivers often play a key role in medical decision-making for patients with cancer. Adult-children account for nearly half of caregivers, but often have less experience with serious illness care and decision-making and face unique relational challenges as the patient's child. Yet little research explores the potentially distinctive decision-making, involvement in decisions, and support needs of adult-child caregivers. METHODS: Analysis of survey data of U.S. cancer caregivers conducted by CancerCare® in 2021. Chi-square tests and multivariable regression models assessed whether adult-child and spousal caregivers differed on the type of medical decisions they participated in (e.g., treatment planning, medication management), who made the decision (e.g., caregiver or joint decision), and the resources that informed decisions (e.g., friends and family, education materials). RESULTS: Adult-children (N = 892) were less likely than spouses (N = 314) to participate in treatment planning (beta = -0.41; 95%CI = -0.81,-0.01), but more likely to be involved in decisions about whether to challenge medical authority (e.g., seeking alternative treatment, second opinion) (beta = 0.50; 95%CI = 0.22,0.78). Compared to spouses, adult-children made joint decisions with patients less often (-13.2-percentage points; 95%CI = -19.64,-6.67) and acted as primary decision-maker more frequently (5.60-percentage points; 95%CI = 0.01,10.43). More adult-children than spouses sought help and information regarding decisions from the oncology team (8.42-percentage points; 95%CI = 1.98,14.87) and friends and family (7.91-percentage points; 95%CI = 1.34,14.48). CONCLUSIONS: How cancer caregivers and patients are related to each other shapes caregivers' medical decision-making. Adult-children's and spouses' probabilities of participating in and influencing decisions differed for certain types of decisions while adult-children were more likely to seek information and social support regarding decisions. These findings highlight the importance of the patient's and caregiver's relationship type in medical decision-making, suggesting that decision support programs may be more effective if they tailor programs by relationship type.


Asunto(s)
Cuidadores , Neoplasias , Esposos , Humanos , Cuidadores/psicología , Femenino , Masculino , Persona de Mediana Edad , Neoplasias/terapia , Neoplasias/psicología , Adulto , Esposos/psicología , Hijos Adultos/psicología , Anciano , Toma de Decisiones , Encuestas y Cuestionarios
2.
J Pain Symptom Manage ; 65(1): 16-25, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-36198337

RESUMEN

CONTEXT: Family caregivers of patients with advanced cancer are integrally involved in communications regarding prognosis and end-of-life (EOL) planning and care. Yet little research has examined caregivers' communication experiences or the impact of these experiences on patients and caregivers at EOL. OBJECTIVES: Investigate cancer caregivers' communication experiences and potential impact on patient and caregiver outcomes. METHODS: Semistructured interviews with bereaved family cancer caregivers (N=19) about their communication needs and experiences as their loved one approached EOL and died. Audiotaped interviews were transcribed and thematically analyzed for communication-related themes. RESULTS: Caregivers described fulfilling many important communication roles including information gathering and sharing, advocating, and facilitating-often coordinating communication with multiple partners (e.g., patient, family, oncology team, hospital team). Caregivers reported that, among the many topics they communicated about, prognosis and EOL were the most consequential and challenging. These challenges arose for several reasons including caregivers' and patients' discordant communication needs, limited opportunity for caregivers to satisfy their personal communication needs, uncertainty regarding their communication needs and responsibilities, and feeling unacknowledged by the care team. These challenges negatively impacted caregivers' abilities to satisfy their patient-related communication responsibilities, which shaped many outcomes including end-of-life decisions, care satisfaction, and bereavement. CONCLUSION: Caregivers often facilitate essential communication for patients with advanced cancers yet face challenges successfully fulfilling their own and patients' communication needs, particularly surrounding prognostic and end-of-life conversations. Future research and interventions should explore strategies to help caregivers navigate uncertainty, create space to ask sensitive questions, and facilitate patient-caregiver discussions about differing informational needs.


Asunto(s)
Aflicción , Neoplasias , Cuidado Terminal , Humanos , Cuidadores , Pronóstico , Investigación Cualitativa , Neoplasias/terapia , Muerte , Comunicación
3.
Support Care Cancer ; 30(11): 9625-9633, 2022 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-36190556

RESUMEN

PURPOSE: Black and Hispanic cancer patients experience many worse care quality and health outcomes than non-Hispanic White patients, yet less is known about disparities in caregiving responsibilities and burden among cancer caregivers. METHODS: We analyzed cross-sectional data from Cancer Care Outcomes Research and Surveillance consortium, a large multi-regional, population-based study of colorectal and lung cancer patients and their caregivers. Bivariate and multivariable regression models assessed differences by racial and ethnic groups in caregiving responsibilities and social/emotional, financial, and health burdens. Structural equation models estimated whether sociocultural resources (social support, caregiving preparedness, caregiver-patient communication) mediated racial and ethnic differences in caregiver burden. RESULTS: Compared with non-Hispanic White caregivers (N = 1,169), Black (N = 220) and Hispanic (N = 84) caregivers spent more time caregiving (18 vs. 26 vs. 26 h/week; P < 0.001), completed more tasks (6.8 vs. 7.6 vs. 8.7; P < 0.05), and reported greater financial burden (P = 0.02). Yet, compared to non-Hispanic Whites, Hispanic caregivers reported similar social/emotional and health burdens, while Black caregivers reported lower levels (P < 0.01). In adjusted models, disparities in financial burden disappeared, and Hispanic caregivers had less health burden than non-Hispanic White caregivers (P = 0.01). Social support and/or caregiving preparedness partially mediated the Black-White gap for all three types of burdens. CONCLUSIONS: Black and Hispanic cancer caregivers perform more caregiving and report greater financial burden than non-Hispanic White caregivers, but experience lower or equivalent social/emotional and health burdens. Racial differences in caregivers' social support and caregiving preparedness levels partially explain Black-White burden differences. Research and policy should address Black and Hispanic caregivers' increased financial burden.


Asunto(s)
Etnicidad , Neoplasias , Humanos , Carga del Cuidador , Estudios Transversales , Grupos Raciales , Cuidadores/psicología , Neoplasias/terapia
4.
J Hosp Med ; 17(10): 819-826, 2022 10.
Artículo en Inglés | MEDLINE | ID: mdl-35920080

RESUMEN

BACKGROUND: During the COVID-19 pandemic, hospitals did not allow caregiver visitation. Little is known about how caregivers' absence affected patients' care. OBJECTIVE: This study aimed to describe visitation restrictions' impact on patients and their caregivers experiences. DESIGN: We used a sequential explanatory mixed-methods study design. First, we randomly selected 200 adult patients with cancer or heart failure hospitalized before (n = 100) and during visitor restrictions (n = 100) and abstracted data from the electronic medical record on communication between medical teams and caregivers and the topics discussed. Results from the quantitative analysis guided our thematic analysis of semi-structured interviews conducted with a subsample of patients hospitalized during visitor restrictions and their caregivers to understand the impact of visitor restrictions on their experiences. RESULTS: Compared to prerestrictions, caregivers under visitation restrictions communicated less frequently with the medical team (29% vs. 37% of hospitalized days; p = .04), fewer received discharge counseling (37% vs. 52%; p = .04), and disproportionately more had no contact with the medical team (36% vs. 17%; p < .01). Video conferencing was documented for caregivers of only five patients. Qualitative analysis revealed that both caregivers and patients experienced emotional distress, increased conflict, and decreased perception of quality of care because of visitation restrictions. CONCLUSIONS: Hospital visitor restrictions significantly reduced caregivers' communication with patients' medical team, causing caregivers and patients emotional distress. Protocols that facilitate communication between caregivers and care teams may benefit caregivers who cannot be physically present at care facilities, including distance caregivers.


Asunto(s)
COVID-19 , Cuidadores , Adulto , Cuidadores/psicología , Hospitalización , Humanos , Pandemias , Alta del Paciente
5.
Cancer ; 128(10): 2015-2024, 2022 05 15.
Artículo en Inglés | MEDLINE | ID: mdl-35285946

RESUMEN

BACKGROUND: Adult-children caring for a parent with cancer comprise a significant segment of caregivers. Yet less is known about adult-child caregivers, their burden, or caregivers' and patients' gender's impact, which may differ from the well-studied spousal caregiver. This knowledge gap may hinder efforts to ameliorate adult-children's caregiver burden. METHODS: We analyzed caregiver surveys from the Cancer Care Outcomes Research and Surveillance Consortium, a multi-regional population-based study of patients with colorectal or lung cancer. Using t tests and multivariate regression models, we assessed whether adult-child and spousal caregivers' caregiving responsibilities and social/emotional and financial burdens differed and used structural equation models (SEMs) to examine mediating factors. RESULTS: Compared with spouses/partners (N = 1007), adult-children (N = 227) spent less time caregiving (14 vs 23 hours/week; P < .001), but experienced higher social/ emotional burden (P < .01). In models adjusted for objective caregiving burden measures and demographics, adult-children's social/emotional (P < .05) and financial burdens (P < .01) were greater than spouses'. Poor communication quality was associated with greater social/emotional burden for both groups (P < .05). SEMs indicated that gender concordance between caregivers and patients (eg, daughters caring for mothers) and caregiver employment increased the difference between adult-child and spouses' social/emotional burden, whereas caregiver-patient relationship quality reduced it. CONCLUSIONS: Adult-children spend less time caregiving than spouses/partners, but have higher social/emotional and financial caregiving burdens, partially due to adult-children's employment, caregiver-patients' gender concordance, and relationship quality. Gender concordance's contribution to greater social/emotional burden adds important context to prior findings, indicating female caregivers experience the most burden. Interventions that improve caregiver-patient communication may reduce both adult-child and spousal caregiver burden.


Asunto(s)
Carga del Cuidador , Costo de Enfermedad , Adulto , Hijos Adultos/psicología , Cuidadores/psicología , Femenino , Humanos , Esposos/psicología
6.
J Palliat Med ; 25(9): 1367-1375, 2022 09.
Artículo en Inglés | MEDLINE | ID: mdl-35297744

RESUMEN

Introduction: Peritoneal carcinomatosis (PC) afflicts women with advanced gynecologic cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate symptoms, yet patients and caregivers report feeling unprepared to manage these devices. The purpose of this study was to develop and field test the Building Out Lifelines for Safety, Trust, Empowerment, and Renewal (BOLSTER) intervention to support patients and their caregivers after hospitalization for PC. Materials and Methods: We adapted components of the Standard Nursing Intervention Protocol with stakeholders and topical experts. We developed educational content; built a smartphone application to assess patients' symptoms; and assessed preliminary feasibility and acceptability in two single-arm prepilot studies. Eligible participants were English-speaking adults hospitalized for gynecologic cancer-associated PC and their caregivers. Feasibility criteria were a ≥50% consent-to-approach ratio and ≥80% outcome measure completion. The acceptability criterion was ≥70% of participants recommending BOLSTER. Results: During the first prepilot, BOLSTER was a 10-week intervention. While 7/8 (87.5%) approached patients consented, we experienced high attrition to hospice. Less than half of patients (3/7) and caregivers (3/7) completed outcome measures. For the second prepilot, BOLSTER was a four-week intervention. All (7/7) approached patients consented. Two withdrew before participating in any study activity because they were "too overwhelmed." We excluded data from one caregiver who completed baseline measures with the patient's assistance. All remaining patients (5/5) and caregivers (4/4) completed outcome measures and recommended BOLSTER. Conclusion: BOLSTER is a technology-enhanced, nurse-led intervention that is feasible and acceptable to patients with gynecologic cancer-associated PC and their caregivers.


Asunto(s)
Neoplasias de los Genitales Femeninos , Neoplasias Peritoneales , Adulto , Cuidadores , Estudios de Factibilidad , Femenino , Hospitalización , Humanos , Rol de la Enfermera
7.
BMC Cancer ; 21(1): 1273, 2021 Nov 25.
Artículo en Inglés | MEDLINE | ID: mdl-34823486

RESUMEN

PURPOSE: Large-panel genomic tumor testing (GTT) is an emerging technology with great promise but uncertain clinical value. Previous research has documented variability in academic oncologists' perceptions and use of GTT, but little is known about community oncologists' perceptions of GTT and how perceptions relate to clinicians' intentions to use GTT. METHODS: Community oncology physicians (N = 58) participating in a statewide initiative aimed at improving access to large-panel GTT completed surveys assessing their confidence in using GTT, attitudes regarding the value of GTT, perceptions of barriers to GTT implementation, and future intentions to use GTTs. Descriptive and multivariable regression analyses were conducted to characterize these perceptions and to explore the relationships between them. RESULTS: There was substantial variability in clinicians' perceptions of GTT. Clinicians generally had moderate confidence in their ability to use GTT, but lower confidence in patients' ability to understand test results and access targeted treatment. Clinicians had positive attitudes regarding the value of GTT. Clinicians' future intentions to use GTT were associated with greater confidence in using GTT and greater perceived barriers to implementing GTT, but not with attitudes about the value of GTT. CONCLUSIONS: Community oncologists' perceptions of large-panel genomic tumor testing are variable, and their future intentions to use GTT are associated with both their confidence in and perceived barriers to its use, but not with their attitudes towards GTT. More research is needed to understand other factors that determine how oncologists perceive and use GTT in clinical practice.


Asunto(s)
Actitud del Personal de Salud , Pruebas Genéticas/estadística & datos numéricos , Neoplasias/genética , Oncólogos/psicología , Comprensión , Femenino , Predicción , Encuestas de Atención de la Salud/estadística & datos numéricos , Hematología/estadística & datos numéricos , Humanos , Intención , Maine , Masculino , Análisis de Regresión , Servicios de Salud Rural , Autoimagen , Incertidumbre
8.
Artículo en Inglés | MEDLINE | ID: mdl-34632254

RESUMEN

Large-panel genomic tumor testing (GTT) is an emerging technology that promises to make cancer treatment more precise. Because GTT is novel and complex, patients may have unrealistic expectations and limited knowledge of its benefits. These problems may limit the clinical value of GTT, but their prevalence and associated factors have not been explored. METHODS: Patients with cancer enrolled in a large initiative to disseminate GTT in community oncology practices completed surveys assessing their expectations, knowledge, and attitudes about GTT. The study sample (N = 1,139) consisted of patients with a range of cancer types (22% gynecologic, 14% lung, 10% colon, 10% breast, and 46% other malignancies) and cancer stages (4% stage I, 3% stage II, 15% stage III, and 74% stage IV). Mean age was 64 years (standard deviation = 11); 668 (59%) were women; 71% had no college degree; 57% came from households with less than $50,000 US dollars household income; and 73% lived in a rural area. RESULTS: Generally, patients had high expectations that they would benefit from GTT (M = 2.81 on 0-4 scale) and positive attitudes toward it (M = 2.98 on 0-4 scale). Patients also had relatively poor knowledge about GTT (48% correct answers on an objective test of GTT knowledge). Greater expectations for GTT were associated with lower knowledge (b = -0.46; P < .001), more positive attitudes (b = 0.40; P < .001), and lower education (b = -0.53; P < .001). CONCLUSION: This research suggests patients have high expectations that they will benefit from GTT, which is associated with low knowledge, positive attitudes, and low education. More research is needed to understand the concordance between expectations and actual clinical outcomes.


Asunto(s)
Oncología Médica/métodos , Neoplasias/genética , Pacientes/psicología , Anciano , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Oncología Médica/estadística & datos numéricos , Persona de Mediana Edad , Neoplasias/diagnóstico , Pacientes/estadística & datos numéricos , Población Rural/estadística & datos numéricos , Encuestas y Cuestionarios
9.
J Contin Educ Health Prof ; 41(3): 195-201, 2021 07 01.
Artículo en Inglés | MEDLINE | ID: mdl-33973928

RESUMEN

INTRODUCTION: Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. METHODS: Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. RESULTS: Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. DISCUSSION: Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.


Asunto(s)
Infecciones por Papillomavirus , Niño , Comunicación , Personal de Salud , Humanos , Liderazgo , Infecciones por Papillomavirus/prevención & control
10.
Vaccine ; 39(6): 1018-1023, 2021 02 05.
Artículo en Inglés | MEDLINE | ID: mdl-33446387

RESUMEN

OBJECTIVE: To determine whether providers' vaccine recommendation style affects length of the adolescent vaccine discussions. METHODS: We analyzed vaccine discussions using audio-recordings of clinical encounters where adolescents were eligible for HPV vaccines ± meningococcal vaccines. We measured length of vaccine discussions, the provider's use of an "indicated" (vaccination due at visit) or "elective" (vaccination is optional) recommendation style, and vaccine receipt. Parent and child demographics, parental vaccination intentions, and parental satisfaction with vaccine discussion were collected from pre- and post-visit surveys. We used linear and logit regressions with random effects to estimate recommendation style's association with discussion length and with vaccine receipt, respectively. RESULTS: We analyzed 106 vaccine discussions (82 HPV; 24 meningococcal) across 82 clinical encounters and 43 providers. Vaccine discussions were longer when providers presented vaccination as elective versus indicated (140 vs. 74 s; p-value < 0.001). Controlling for vaccine type, parental vaccination intent, and patient characteristics, an elective style was associated with 41 seconds longer vaccine discussion (p-value < 0.05). Providers used the indicated style more frequently with the meningococcal vaccine than with the HPV vaccine (96% vs. 72%; p-value < 0.05). Parents' odds of vaccinating were 9.3 times higher following an indicated versus an elective presentation (p-value < 0.05). Vaccine discussion length and presentation style were not associated with parental satisfaction. CONCLUSIONS: Our results suggest that using an indicated recommendation improves vaccine discussions' efficiency and effectiveness, but this style is used more often with meningococcal than HPV vaccines. Increasing providers' use of indicated styles for HPV vaccines has the potential to increase vaccination rates and save time during medical visits.


Asunto(s)
Vacunas Meningococicas , Infecciones por Papillomavirus , Vacunas contra Papillomavirus , Adolescente , Niño , Conocimientos, Actitudes y Práctica en Salud , Humanos , Infecciones por Papillomavirus/prevención & control , Padres , Vacunación
11.
Patient Educ Couns ; 104(1): 3-11, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-32690398

RESUMEN

OBJECTIVE: To compare clinicians' and patients' preferences for disclosure of genomic tumor testing (GTT) results; to determine the sensitivity of these disclosure preferences to uncertainty about the actionability of results; and to explore factors associated with disclosure preferences. METHODS: Community-based oncology clinicians (n = 94) and patients (n = 1121) were surveyed about their preferences for disclosing GTT results with varying levels of uncertainty (Tiers 1, 2, 3). Descriptive and multivariable regression analyses were used to compare clinicians' and patients' disclosure preferences and their sensitivity to uncertainty, and to explore associations between disclosure preferences and sociodemographic, clinical, and psychological factors. RESULTS: Relatively more patients than clinicians preferred disclosure, and their preferences were less sensitive to the uncertainty of GTT results. For patients and clinicians, lower uncertainty sensitivity was associated with positive GTT attitudes; for patients it was also associated with greater uncertainty tolerance and knowledge of uncertainty in GTT. CONCLUSION: Relatively more cancer patients than clinicians prefer disclosure of GTT results, and their preferences are less sensitive to result uncertainty. Uncertainty sensitivity in disclosure preferences is associated with GTT-related attitudes and uncertainty tolerance. PRACTICE IMPLICATIONS: Differences in cancer patients' and clinicians' preferences for disclosure of uncertain GTT results warrant greater attention in cancer care.


Asunto(s)
Revelación , Neoplasias , Genómica , Humanos , Neoplasias/diagnóstico , Neoplasias/genética , Prioridad del Paciente , Incertidumbre
12.
Gynecol Oncol ; 160(1): 227-233, 2021 01.
Artículo en Inglés | MEDLINE | ID: mdl-33190931

RESUMEN

OBJECTIVE: Oral PARP inhibitors (PARPi) have dramatically changed the treatment landscape for patients with advanced ovarian cancer. However, a subset of patients discontinue PARPi due to treatment-related fatigue. The current study sought to explore patients' lived experiences with fatigue on PARPi. METHODS: We conducted individual semi-structured interviews with N = 23 women receiving PARPi for advanced ovarian cancer who reported moderate to severe fatigue. Audiotaped interviews were transcribed and we used thematic analysis to code transcripts for emergent themes. RESULTS: Four overarching themes emerged. First, participants described their fatigue as milder than what they experienced on intravenous chemotherapy, but noted it consistently limited their daily activities, including work, and interfered with participation in family and social events. Second, fatigue negatively impacted participants' sense of self and identity. Third, most wanted to continue treatment and believed discontinuing PARPi would lead to a cancer recurrence or death. Finally, many participants reported that their support networks were unaware of their ongoing cancer treatment or the resulting fatigue; a situation that may prove isolating and result in reduced social support. CONCLUSIONS: Our findings underscore patients' persistent experience of fatigue on PARPi, the impact of fatigue on multiple domains of functioning, and a lack of understanding of side effects resulting from oral maintenance treatments among patients' social networks. Our findings highlight the need for interventions to address treatment-related fatigue to limit the negative impacts of fatigue on ovarian cancer patients' well-being.


Asunto(s)
Fatiga/inducido químicamente , Neoplasias Ováricas/tratamiento farmacológico , Inhibidores de Poli(ADP-Ribosa) Polimerasas/efectos adversos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Persona de Mediana Edad , Investigación Cualitativa , Calidad de Vida
13.
Demography ; 57(5): 1833-1851, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32833176

RESUMEN

Scholars have increasingly drawn attention to rising levels of income inequality in the United States. However, prior studies have provided an incomplete account of how changes to specific transfer programs have contributed to changes in income growth across the distribution. Our study decomposes the direct effects of tax and transfer programs on changes in the household income distribution from 1967 to 2015. We show that despite a rising Gini coefficient, lower-tail inequality (the ratio of the 50th to 10th percentile) declined in the United States during this period due to the rise of in-kind and tax-based transfers. Food assistance and refundable tax credits account for nearly all the income growth between 1967 and 2015 at the 5th percentile and roughly one-half the growth at the 10th percentile. Moreover, income gains near the bottom of the distribution are concentrated among households with children. Changes in the income distribution were far less progressive among households without children.


Asunto(s)
Renta/estadística & datos numéricos , Asistencia Pública/estadística & datos numéricos , Impuestos/estadística & datos numéricos , Composición Familiar , Humanos , Renta/tendencias , Asistencia Pública/tendencias , Factores Socioeconómicos , Impuestos/tendencias , Estados Unidos
14.
Pediatrics ; 146(1)2020 07.
Artículo en Inglés | MEDLINE | ID: mdl-32540986

RESUMEN

OBJECTIVES: To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention. METHODS: DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months. RESULTS: In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention). CONCLUSIONS: Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.


Asunto(s)
Infecciones por Papillomavirus/prevención & control , Vacunas contra Papillomavirus , Cobertura de Vacunación/estadística & datos numéricos , Adolescente , Niño , Femenino , Educación en Salud , Humanos , Masculino
15.
Hum Vaccin Immunother ; 16(11): 2736-2743, 2020 11 01.
Artículo en Inglés | MEDLINE | ID: mdl-32401592

RESUMEN

Objective: To evaluate the effect of a multi-component intervention including communication training on provider beliefs and recommendation practices around the human papillomavirus (HPV) vaccine using both self-reports and audio-recordings of clinical interactions. Methods: We conducted a mixed method study at five family medicine and pediatric practices. Providers self-reported beliefs and practices about HPV vaccination via surveys and qualitative interviews conducted pre- and post-intervention. We also assessed provider recommendation style using audio-recordings of clinical interactions pre- and post-intervention. Content analysis was used to identify themes in qualitative interviews. Matched pre- and post-intervention surveys were analyzed for changes in provider beliefs and attitudes. Pre- and post-intervention audio recordings of clinical interactions were analyzed for observed differences in recommendation styles. Bivariate analyses of quantitative data used Chi-square and Fisher's exact tests; t-tests were used for continuous variables. Results: Providers reported in interviews that the intervention led to communication changes by increasing their knowledge, reframing the HPV vaccine as a routine vaccination, and providing tools for engaging with parents. Surveys indicated that the proportion of providers reporting that the HPV vaccine is one of the most important adolescent vaccines increased from 71% pre-intervention to 100% post-intervention (p = .03). Audio-recording analysis demonstrated that use of an indicated (presumptive) recommendation style increased from 62.5% pre-intervention to 79.6% post-intervention (p = .047). Conclusions: Educating providers about HPV vaccination and giving them tools to facilitate communication with parents can reframe HPV as a routine adolescent vaccination and motivate providers to routinely use effective recommendation styles in practice.


Asunto(s)
Infecciones por Papillomavirus , Vacunas contra Papillomavirus , Adolescente , Niño , Comunicación , Conocimientos, Actitudes y Práctica en Salud , Personal de Salud , Humanos , Infecciones por Papillomavirus/prevención & control , Padres , Vacunación
16.
J Adolesc Health ; 66(4): 447-454, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-31974012

RESUMEN

PURPOSE: The aim of the study was to examine adolescents' influence on human papillomavirus (HPV) vaccine decision-making and receipt during clinical visits. METHODS: We recruited English- and/or Spanish-speaking parents and their adolescent children aged 9-17 years who were eligible for the first HPV vaccine dose and seeking routine care at pediatric and family medicine clinics in the Greater Boston area enrolled in a multilevel intervention to improve HPV vaccination coverage. Parents completed previsit surveys that included parental intention to vaccinate. We coded transcripts of adolescents' clinical encounters to define adolescents' participation in vaccine discussions and cooperation with immunization. Adolescents' influence on vaccine decision-making was determined based on analyses of their participation in discussions and parents' previsit vaccine intentions. RESULTS: A total of 113 adolescents and their parents participated. Eighty-seven percent of adolescents received their first HPV vaccine dose during the visit. Most reactions were negative (23% mild, 23% moderate, and 10% extreme); nearly all objections were concerns related to the pain of injection rather than specific to HPV vaccination. A minority of reactions were positive (12%), 33% were neutral, and 12% did not participate in vaccine discussions. All adolescents with positive or neutral reactions received vaccination, as did 91% of those with negative reactions. After accounting for parents' previsit vaccine intentions and analyzing discussions during clinical encounters, only 5% of adolescents appeared to influence vaccination either positively (n = 3) or negatively (n = 3). CONCLUSIONS: In this study, adolescents rarely influenced parents' vaccine decision-making, although many exhibited distress over the pain of injections. This suggests that increasing adolescents' involvement in vaccine discussions may have limited effects on vaccination rates.


Asunto(s)
Toma de Decisiones , Conocimientos, Actitudes y Práctica en Salud , Infecciones por Papillomavirus/prevención & control , Vacunas contra Papillomavirus/administración & dosificación , Padres/psicología , Aceptación de la Atención de Salud/estadística & datos numéricos , Participación del Paciente , Adolescente , Boston , Niño , Femenino , Humanos , Intención , Masculino , Relaciones Médico-Paciente , Vacunación
17.
J Health Soc Behav ; 60(2): 240-256, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-31113247

RESUMEN

Despite authority's centrality to the medical profession, providers routinely forgo their medical authority during clinical encounters. Research focuses on patients challenging medical authority but indicates these confrontations are uncommon and providers seldom relinquish their authority in response. Using rare data of 75 audio recordings of adolescent vaccine discussions during clinical encounters and interviews with and observations of medical staff, I examine how staff leverage or abandon their medical authority to convince parents to vaccinate. I find medical professionals use less authority when at risk of stigmatizing patients: Medical professionals are less authoritative when recommending human papillomavirus (HPV) vaccination versus other adolescent vaccines, particularly when addressing the need to vaccinate before sexual onset due to concerns of labeling the child as sexually active. Medical staff defer to parents in ways that potentially discourage HPV vaccine uptake: They encourage HPV vaccination less than other vaccines and infrequently challenge parents' sex-related reasons for vaccine refusal.


Asunto(s)
Atención a la Salud , Infecciones por Papillomavirus/prevención & control , Vacunas contra Papillomavirus , Relaciones Médico-Paciente , Estereotipo , Adolescente , Anciano , Niño , Toma de Decisiones , Humanos , Persona de Mediana Edad , New England , Grabación en Cinta
18.
Hum Vaccin Immunother ; 15(10): 2460-2465, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30862301

RESUMEN

We described the relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt. Parent-child dyads that were eligible for both meningococcal and HPV vaccines participated in pre-visit surveys and consented to audio recording of their clinical interactions with healthcare providers related to vaccination. Surveys were analyzed for parent and child demographics and parental intention to vaccinate children with HPV and/or meningococcal vaccines. Audio recordings were analyzed for provider recommendation style, defined as indicated (provider stated vaccine was due at that visit) or not, and for child receipt of vaccines. Linear and logistic regression models were used to determine the relative contributions of parental intention and provider recommendation style to vaccine receipt. 56 parents/child dyads participated. 79% of children received HPV vaccines, and 93% received meningococcal vaccines. After controlling for demographic variables, parental intention did not differ by vaccine type. However, providers were less likely to use an indicated recommendation for HPV than for meningococcal vaccine. After controlling for demographic factors, parental intention, and provider recommendation style, vaccine type (HPV or meningococcal) was no longer associated with vaccine receipt Differences that were previously attributed to vaccine-specific factors may be explained by parents' and providers' roles in vaccine receipt. These findings suggest that interventions and policy recommendations regarding adolescent vaccination should focus on increasing parental demand for vaccines and ensuring that providers present all vaccines as the medical standard of care.


Asunto(s)
Personal de Salud/psicología , Vacunas Meningococicas/administración & dosificación , Vacunas contra Papillomavirus/administración & dosificación , Padres/psicología , Vacunación/psicología , Adolescente , Adulto , Niño , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Intención , Masculino , Infecciones Meningocócicas/prevención & control , Persona de Mediana Edad , Infecciones por Papillomavirus/prevención & control , Análisis de Regresión , Encuestas y Cuestionarios , Vacunación/estadística & datos numéricos
19.
Health Serv Res ; 54 Suppl 1: 275-286, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30467831

RESUMEN

OBJECTIVE: To examine whether black-white patient experience disparities vary by geography and within-county contextual factors. DATA SOURCES: 321 300 Medicare beneficiaries responding to the 2015-2016 Medicare Consumer Assessment of Health care Providers and Systems (MCAHPS) Surveys; 2010 Census data for several within-county contextual factors. STUDY DESIGN: Mixed-effects regression models predicted three MCAHPS patient experience measures for black and white beneficiaries from geographic random effects, contextual fixed effects, and beneficiary-level case-mix adjustors. PRINCIPAL FINDINGS: Black-white disparities in patient experiences were smaller in counties with higher average patient experiences. Black-white disparities in patient experiences were not associated with county-level poverty or racial segregation. However, county racial segregation and some measures of poverty were significantly associated with all beneficiaries' level of health care access. Getting Needed Care scores were higher with greater racial segregation, while Getting Care Quickly scores were lower with higher poverty and racial segregation. CONCLUSIONS: Efforts to reduce black-white disparities in patient experiences should focus on areas with low average patient experiences. Attempts to reduce disparities in timely access to health care should target primarily black, low-income, and racially and economically segregated areas. Positive associations of racial segregation with accessing needed care were unexpected.


Asunto(s)
Negro o Afroamericano/estadística & datos numéricos , Etnicidad/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Disparidades en Atención de Salud/etnología , Medicare , Población Blanca/estadística & datos numéricos , Anciano , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Áreas de Pobreza , Calidad de la Atención de Salud , Grupos Raciales/estadística & datos numéricos , Estados Unidos
20.
Hum Vaccin Immunother ; 14(10): 2503-2509, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29847201

RESUMEN

BACKGROUND: Appropriate provider recommendation is crucial to raising HPV vaccination uptake, yet scant research has explored actual conversations between providers and parents, the effect of parental pre-visit vaccine intention on vaccination, or the effect of conversation style on parental satisfaction with that conversation. METHODS: We analyzed 146 audio-recorded clinical encounters between providers, parents/guardians, and HPV vaccine-eligible adolescents, from May 2015 to March 2017, at eight practices in Northeastern U.S. Parents completed pre-visit measures of intent to vaccinate and post-visit assessments of satisfaction with vaccine conversations. We qualitatively analyzed transcribed audio recordings and evaluated associations between providers' vaccine introductions and vaccine receipt. RESULTS: Provider recommendations were empirically defined as "indicated" (clear recommendation that the child receive HPV vaccination at that visit), "elective" (vaccination presented as optional), or "contraindicated" (delay recommended). The vaccination rates were 87%, 68%, and 0% following "indicated," "elective," and "contraindicated" presentations respectively. Providers' statements attesting to the vaccine's value to the child did not affect receipt. Parental pre-visit intent to vaccinate was associated with vaccine receipt: 100% for likely/very likely compared to 28% for very unlikely. The association between vaccine recommendation style and vaccine receipt was most pronounced with undecided parents, with 92% accepting vaccination after an "indicated" recommendation vs. 68% after an "elective" recommendation. Satisfaction with vaccine conversations was high regardless of recommendation style. CONCLUSIONS: The results suggest that the words used to introduce HPV vaccination have the potential to inform parents' HPV vaccination decisions. Providers should be encouraged to simply state, "Your child is due for the HPV vaccine today."


Asunto(s)
Comunicación en Salud/métodos , Infecciones por Papillomavirus/prevención & control , Vacunas contra Papillomavirus/administración & dosificación , Cobertura de Vacunación , Vacunación/psicología , Adolescente , Adulto , Anciano , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Estados Unidos
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