Development and validation of VaxConcerns: A taxonomy of vaccine concerns and misinformation with Crowdsource-Viability.

We present VaxConcerns, a taxonomy for vaccine concerns and misinformation. VaxConcerns is an easy-to-teach taxonomy of concerns and misinformation commonly found among online anti-vaccination media and is evaluated to produce high-quality data annotations among crowdsource workers, opening the potential adoption of the framework far beyond just academic or medical communities. The taxonomy shows high agreement among experts and outperforms existing taxonomies for vaccine concerns and misinformation when presented to non-expert users. Our proof-of-concept study on the changes in anti-vaccination content during the COVID-19 pandemic indicate impactful future use cases, such as longitudinal studies of the shift in vaccine concerns over time.

Vaccination patterns and up-to-date status of children 19-35 months, 2011-2021.

INTRODUCTION: Being up-to-date with all recommended vaccines is needed to protect children from vaccine preventable diseases. Understanding vaccination patterns is needed to develop messaging and strategies to increase vaccination uptake and confidence. METHODS: Data from the 2011 to 2021 National Immunization Surveys was used to assess trends and disparities in vaccination patterns, zero vaccination status, and up-to-date status of U.S. children by 19-35 months. RESULTS: From 2011 to 2021, adherence to the recommended schedule using the stringent definition increased from 35.7 % to 52.2 % (p < 0.01), adherence to the alternate schedule decreased from 28.2 % to 15.1 % (p < 0.01), and proportion of children who were not up-to-date decreased from 49.0 % to 33.3 % (p < 0.01). However, the proportion of children who had zero vaccinations did not change from 2011 (0.9 %) to 2021 (0.9 %; p = 0.08). In 2021, children 19-23 months were less likely to follow the recommended schedule than children 24-29 months (49.2 % compared to 56.4 %, p < 0.01). Adherence to the recommended schedule among children 19-23 months decreased in 2021 compared to 2020 overall and for some subpopulations (e.g. those with non-Hispanic (NH) Black parents (33.2 % compared to 44.9 %, p < 0.01). Furthermore, it was lowest among children of NH Black parents living at or below the federal poverty level (31.2 %) compared to their respective NH White counterparts (43.6 %, p < 0.01). CONCLUSIONS: While there were overall increases in adherence to the recommended schedule from 2011 to 2021, a sustained catch-up program is needed to prevent missed vaccinations and achieve equitable vaccination coverage for all children.

Interactive Narrative-Based Digital Health Interventions for Vaccine Communication: Protocol for a Scoping Review.

BACKGROUND: Interactive narrative-based digital health interventions hold promise for effectively addressing the complex determinants of vaccine hesitancy and promoting effective communication across a wide range of settings and vaccine types. Synthesizing evidence related to the implementation and evaluation of these interventions could offer valuable perspectives for shaping future strategies in vaccine communication. Prior systematic and scoping reviews have examined narrative-based vaccine communication interventions but not the inclusion of interactivity in such interventions. OBJECTIVE: The overall objective of the scoping review is to summarize the evidence on the use of interactive narrative-based digital health interventions for vaccine communication. Specific research questions focus on describing the use of interactive narrative-based digital health interventions (RQ1), describing evaluations of the impact of interactive narrative-based digital health interventions on promoting vaccine uptake (RQ2), and factors associated with their implementation (RQ3). METHODS: A detailed search string will be used to search the following databases for records that are relevant to the review questions: PubMed, Embase, Scopus, Web of Science, CINAHL, and PsycINFO. Two reviewers will independently screen the titles and abstracts of identified records against the predefined eligibility criteria. Subsequently, eligible records will undergo comprehensive full-text screening by 2 independent reviewers to assess their relevance to review questions. A data charting tool will be developed and used to extract relevant information from the included articles. The extracted information will be analyzed following the review questions and presented as a narrative summary. Tabular or graphical representations will be used to display review findings, as relevant. RESULTS: Public health informationists were consulted to develop the detailed search strategy. The final search string comprised terms related to narrative communication, digital health, and vaccines. The search string was customized to each proposed publication database and implemented on April 18, 2023. A total of 4474 unique records were identified using the search strategy and imported into the Covidence (Veritas Health Innovation Ltd) review management software for title and abstract screening. Title and abstract screening of identified records are ongoing as of December 29, 2023. CONCLUSIONS: To our knowledge, this will be the first scoping review to investigate the features of interactive narrative-based digital health interventions and their role in vaccine communication. The goal of this study is to provide a comprehensive overview of the current research landscape and identify prevailing gaps in knowledge. The findings will provide insights for future research and development of novel applications of interactive narrative-based digital health vaccine communication interventions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/51137.

COVID-19 Diagnosis, Severity, and Long COVID Among U.S. Adolescents, National Health Interview Survey, 2022.

PURPOSE: Understanding disparities in COVID-19 outcomes, overall and stratified by vaccination status, is important for developing targeted strategies to increase vaccination coverage and protect adolescents from COVID-19. DESIGN: The 2022 National Health Interview Survey (NHIS) is a cross-sectional nationally representative household survey of U.S. adults. SETTING: A probability sample of households in the U.S. SAMPLE: One child aged 12-17 years is randomly selected from each family in the household. A knowledgeable adult (eg, parent or guardian), responds on behalf of the child through an in-person interview (response rate = 49.9%). MEASURES: Input measures-sociodemographic characteristics and COVID-19 vaccination status; output measures-ever had COVID-19, moderate/severe COVID-19, long COVID. ANALYSIS: Prevalence of COVID-19 outcomes was assessed for adolescents aged 12-17 years. Factors associated with each COVID-19 outcome were assessed with multivariable logistic regression analyses. RESULTS: Among 2758 adolescents aged 12-17 years in 2022, 60.5% had received ≥1 dose of COVID-19 vaccine, 30.2% had ever been diagnosed by a doctor that they had COVID-19, 29.5% had moderate/severe COVID-19, and 6.2% had long COVID. Adolescents who were vaccinated with ≥1 dose were less likely to be diagnosed with COVID-19 (aOR = .79) and less likely to have long COVID (aOR = .30). CONCLUSION: Targeted messaging to highlight the importance of early treatment, the harms of long COVID-19, and the benefits of vaccination in protecting against long-term effects may be necessary to ensure that all adolescents and their families are adequately protected.

Leveraging Community Health Workers and a Responsive Digital Health System to Improve Vaccination Coverage and Timeliness in Resource-Limited Settings: Protocol for a Cluster Randomized Type 1 Effectiveness-Implementation Hybrid Study.

BACKGROUND: Tanzania is 1 of 20 countries where the majority of unvaccinated and undervaccinated children reside. Prior research identified substantial rural-urban disparities in the coverage and timeliness of childhood vaccinations in Tanzania, with children in rural settings being more likely to receive delayed or no vaccinations. Further research is necessary to identify effective and scalable interventions that can bridge rural-urban gaps in childhood vaccination while accounting for multifaceted barriers to vaccination. OBJECTIVE: This protocol describes a type 1 effectiveness-implementation hybrid study to evaluate Chanjo Kwa Wakati (timely vaccination in Kiswahili), a community-based digital health intervention to improve vaccination timeliness. The intervention combines human resources (community health workers), low-cost digital strategies (electronic communication, digital case management, and task automation), a vaccination knowledge intervention, and insights from behavioral economics (reminders and incentives) to promote timely childhood vaccinations. METHODS: The study will be conducted in 2 predominantly rural regions in Tanzania with large numbers of unvaccinated or undervaccinated children: Shinyanga and Mwanza. Forty rural health facilities and their catchment areas (clusters) will be randomized to an early or delayed onset study arm. From each cluster, 3 cohorts of mother-child dyads (1 retrospective cohort and 2 prospective cohorts) will be enrolled in the study. The timeliness and coverage of all vaccinations recommended during the first year of life will be observed for 1200 children (n=600, 50% intervention group children and n=600, 50% nonintervention group children). The primary effectiveness outcome will be the timeliness of the third dose of the pentavalent vaccine (Penta3). Quantitative surveys, vaccination records, study logs, fidelity checklists, and qualitative interviews with mothers and key informants will inform the 5 constructs of the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. The results will be used to develop an implementation blueprint to guide future adaptations and scale-up of Chanjo Kwa Wakati. RESULTS: The study was funded in August 2022. Data collection is expected to last from February 2024 to July 2027. CONCLUSIONS: This study will address the lack of rigorous evidence on the effectiveness of community-based digital health interventions for promoting vaccination coverage and timeliness among children from sub-Saharan Africa and identify potential implementation strategies to facilitate the deployment of vaccination promotion interventions in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT06024317; https://www.clinicaltrials.gov/study/NCT06024317. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52523.

Population Attributable Fraction of Nonvaccination of COVID-19 Due to Vaccine Hesitancy, United States, 2021.

Understanding the extent of coronavirus disease 2019 (COVID-19) nonvaccination attributable to vaccine hesitancy versus other barriers can help prioritize approaches for increasing vaccination uptake. Using data from the Centers for Disease Control and Prevention's Research and Development Survey, a nationally representative survey fielded from May 1 to June 30, 2021 (n = 5,458), we examined the adjusted population attribution fraction (PAF) of COVID-19 vaccine hesitancy attributed to nonvaccination according to sociodemographic characteristics and health-related variables. Overall, the adjusted PAF of nonvaccination attributed to vaccine hesitancy was 76.1%. The PAF was highest among adults who were ≥50 years of age (87.9%), were non-Hispanic White (83.7%), had a bachelor's degree or higher (82.7%), had an annual household income of at least $75,000 (85.5%), were insured (82.4%), and had a usual place for health care (80.7%). The PAF was lower for those who were current smokers (65.3%) compared with never smokers (77.9%), those who had anxiety or depression (65.2%) compared with those who did not (80.1%), and those who had a disability (64.5%) compared with those who did not (79.2%). Disparities in PAF suggest areas for prioritization of efforts for intervention and development of messaging campaigns that address all barriers to uptake, including hesitancy and access, to advance health equity and protect individuals from COVID-19.

Disparities in child and adolescent COVID-19 vaccination coverage and parental intent toward vaccinations for their children and adolescents.

INTRODUCTION: Despite recommendations for COVID-19 primary series completion and booster doses for children and adolescents, coverage has been less than optimal, particularly in some subpopulations. This study explored disparities in childhood/adolescent COVID-19 vaccination, parental intent to vaccinate their children and adolescents, and reasons for non-vaccination in the US. METHODS: Using the U.S. Census Bureau's Household Pulse Survey (HPS), we analyzed households with children aged <18 years using data collected from September 14 to November 14, 2022 (n = 44,929). Child and adolescent COVID-19 vaccination coverage (≥1 dose, completed primary series, and booster vaccination) and parental intentions toward vaccination were assessed by sociodemographic characteristics. Factors associated with child and adolescent vaccination coverage were examined using multivariable regression models. Reasons for non-vaccination were assessed overall, by the child's age group and respondent's age group. RESULTS: Overall, approximately half (50.1%) of children aged < 18 years were vaccinated against COVID-19 (≥1 dose). Completed primary series vaccination was 44.2% among all children aged <18 years. By age group, completed primary series was 13.2% among children <5 years, 43.9% among children 5-11 years, and 63.3% among adolescents 12-17 years. Booster vaccination among those who completed the primary series was 39.1% among children 5-11 years and 55.3% among adolescents 12-17 years. Vaccination coverage differed by race/ethnicity, educational attainment, household income, region, parental COVID-19 vaccination status, prior COVID-19 diagnosis, child's age group, and parental age group. Parental reluctance was highest for children aged <5 years (46.8%). Main reasons for non-vaccination among reluctant parents were concerns about side effects (53.3%), lack of trust in COVID-19 vaccines (48.7%), and the belief that children do not need a COVID-19 vaccine (38.8%). CONCLUSION: Disparities in COVID-19 vaccination coverage among children and adolescents continue to exist. Further efforts are needed to increase COVID-19 primary series and booster vaccination and parental confidence in vaccines.

Using survey data collected from September 14 to November 14, 2022, COVID-19 vaccination coverage was low among children and adolescents. Overall, approximately half (50.1%) of the children aged <18 years were vaccinated against COVID-19 (≥1 dose). Completed primary series vaccination was 44.2% among all children aged < 18 years. By age group, completed primary series was 13.2% among children <5 years, 43.9% among children 5­11 years, and 63.3% among adolescents 12­17 years. Booster vaccination, among those who completed the primary series, was 39.1% among children 5­11 years and 55.3% among adolescents 12­17 years.Vaccination coverage differed by race/ethnicity, educational attainment, household income, region, parental COVID-19 vaccination status, prior COVID-19 diagnosis, child's age group, and parental age group.Parental reluctance was the highest for children aged <5 years (46.8%), followed by children 5­11 years (35.8%) and adolescents 12­17 years (23.5%).Main reasons for non-vaccination among reluctant parents were concerns about side effects (53.3%), lack of trust in COVID-19 vaccines (48.7%), the belief that children do not need a COVID-19 vaccine (38.8%), lack of trust in the government (35.6%), and that children in the household were not members of a high-risk group (32.8%).Disparities in COVID-19 vaccination coverage among children and adolescents continue to exist. Further efforts are needed to increase COVID-19 primary series and booster vaccination and parental confidence in vaccines.

Is the intention to vaccinate enough? Systematic variation in the value of timely vaccinations and preferences for monetary vs non-monetary incentives among pregnant women in southern Tanzania.

Background: Globally, approximately 19.7 million children remain under-vaccinated; many more receive delayed vaccinations. Sustained progress towards global vaccination targets requires overcoming, or compensating for, incrementally greater barriers to vaccinating hard-to-reach and hard-to-vaccinate children. We prospectively assessed pregnant women's valuations of routine childhood vaccinations and preferences for alternative incentives to inform interventions aiming to increase vaccination coverage and timeliness in southern Tanzania. Methods: Between August and December 2017, 406 women in their last trimester of pregnancy were enrolled from health facilities and communities in the Mtwara region of Tanzania and asked contingent valuation questions about their willingness to vaccinate their child if they were (a) given an incentive, or (b) facing a cost for each vaccination. Interval censored regressions assessed correlates of women's willingness to pay (WTP) for timely vaccinations. Participants were asked to rank monetary and non-monetary incentive options for the timely vaccination of their children. Findings: All women expected to get their children vaccinated according to the recommended schedule, even without incentives. Nearly all women (393; 96.8 %) were willing to pay for vaccinations. The average WTP was Tanzania Shilling (Tsh) 3,066 (95 % confidence interval Tsh 2,523-3,610; 1 USD âˆ¼ Tsh 2,200) for each vaccination. Women's valuations of timely vaccinations varied significantly with vaccine-related knowledge and attitudes, economic status, and rural vs urban residence. Women tended to prefer non-monetary over monetary incentives for the timely vaccination of their children. Interpretation: Women placed a high value on timely childhood vaccinations, suggesting that unexpected system-level barriers rather than individual-level demand factors are likely to be the primary drivers of missed vaccinations. Systematic variation in the value of vaccinations across women reflects variation in perceived benefits and opportunity costs. In this setting, nonmonetary incentives and other interventions to increase demand and compensate for system-level barriers hold significant potential for improving vaccination coverage and timeliness. ClinicalTrialsgov Protocol: NCT03252288.

Pregnant individuals' information needs and intention to vaccinate their children with routine and COVID-19 vaccines: Findings from a cross-sectional survey.

OBJECTIVE: The current study assessed pregnant individuals' intention to accept routine and COVID-19 vaccines for their baby after birth, and to identify key demographic (e.g., age) and nondemographic characteristics (e.g., prior birth) associated with vaccination intention. METHODS: The authors conducted a cross-sectional survey with pregnant individuals attending prenatal practices affiliated with a large academic medical center and two rural county health departments in the southeastern United States. The survey included 11 questions and was self-administered by pregnant individuals in clinic settings. The final analysis included responses from 443 pregnant individuals. RESULTS: Only 67% of pregnant individuals planned to vaccinate their baby with all recommended routine vaccines; an additional 22% reported having questions about recommendations. Only 35% of pregnant individuals said they would vaccinate their baby as soon as possible with a COVID-19 vaccine. Younger pregnant individuals and those identifying as Black or African American had lower routine and COVID-19 vaccination intention. Routine vaccination, but not COVID-19 vaccination intention, was associated with familiarity with routine vaccination schedule, trimester of pregnancy, Hispanic ethnicity, history of prior birth, and having access to a computer. CONCLUSION: Study findings support differential tailoring of future interventions targeting pregnant individuals to promote routine and COVID-19 vaccines for children.

Prevalence of self-reported diabetes risk factors and integration of diabetes screening and referral at two urban HIV care and treatment clinics in Zambia.

People living with HIV (PLWH) on antiretroviral therapy (ART) are living longer and are at risk of HIV co-morbidities including non-communicable diseases (NCDs), particularly in low-resource settings. However, the evidence base for effectively integrating HIV and NCD care is limited. The Chronic Health Care (CHC) checklist, designed to screen for multiple NCDs including a 6-item diabetes self-report screener, was implemented at two PEPFAR-supported HIV clinics in Kabwe and Kitwe, Zambia. Study objectives were to describe the HIV care and treatment population and their self-reported diabetes-related symptoms, and to evaluate provider-initiated screening and referral post-training on the CHC checklist. This cross-sectional study enrolled 435 adults receiving combination ART services. Clinic exit interviews revealed 46% self-reported at least one potential symptom, and 6% self-reported three or more symptoms to the study team, indicating risk for diabetes and need for further diagnostic testing. In comparison, only 8% of all participants reported being appropriately screened for diabetes by their health provider, with less than 1% referred for further testing. This missed opportunity for screening and referral indicates that HIV-NCD integration efforts need more fully resourced and multi-pronged approaches in order to ensure that PLWH who are already accessing ART receive the comprehensive, holistic care they need.

Beyond coverage: Rural-urban disparities in the timeliness of childhood vaccinations in Tanzania.

BACKGROUND: Timely vaccination maximizes efficacy for preventing infectious diseases. In the absence of national vaccination registries, representative sample survey data hold vital information on vaccination coverage and timeliness. This study characterizes vaccination coverage and timeliness in Tanzania and provides an analytic template to inform contextually relevant interventions and evaluate immunization programs. METHODS: Cross-sectional data on 6,092 children under age 3 from the 2015-16 Tanzania Demographic and Health Survey were used to examine coverage and timeliness for 14 vaccine doses recommended in the first year of life. The Kaplan-Meier method was used to model time to vaccination. Cox proportional hazard models were used to examine factors associated with timely vaccination. RESULTS: Substantial rural-urban disparities in vaccination coverage and timeliness were observed for all vaccines. Across 14 recommended doses, documented coverage ranged from 52 % to 79 %. Median vaccination delays lasted up to 35 days; gaps were larger among rural than urban children and for later doses in vaccine series. Among rural children, median delays exceeded 35 days for the 3rd doses of the polio, pentavalent, and pneumococcal vaccines. Median delays among urban children were < 21 days for all doses. Among rural and urban children, lower maternal education and delivery at home were associated with increased risk of delayed vaccination. In rural settings, less household wealth and greater distance to a health facility were also associated with increased risk of delayed vaccination. DISCUSSION: This study highlights persistent gaps in uptake and timeliness of childhood vaccinations in Tanzania and substantial rural-urban disparities. While the results provide an informative situation assessment and outline strategies for identifying unvaccinated children, a national electronic registry is critical for comprehensive assessments of the performance of vaccination programs. The timeliness measure employed in this study-the amount of time children are un- or undervaccinated-may serve as a sensitive performance metric for these programs.

COVID-19 vaccination intention and activation among health care system employees: A mixed methods study.

BACKGROUND: Achieving high COVID-19 vaccination rates among employees is necessary to prevent outbreaks in health care settings. The goal of the study was to produce actionable and timely evidence about factors underlying the intention and decisions to obtain the COVID-19 vaccine by employees. METHODS: The study was conducted from December 2020 - May 2021 with employees from a VA health care system in Southeastern US. The study used a convergent mixed methods design comprising two main activities: a cross-sectional survey conducted prior to COVID-19 vaccine distribution, and semi-structured interviews conducted 4-6 months after vaccine distribution. Data were collected about participant characteristics, vaccination intention prior to distribution, vaccination decision post-distribution, determinants of vaccination intention and decision, activating factors, sources of information and intervention needs. Data from the survey and interviews were analyzed separately and integrated narratively in the discussion. RESULTS: Prior to vaccine distribution, 77% of employees wanted to be vaccinated. Post vaccine distribution, we identified 5 distinct decision-making groups: 1) vaccine believers who actively sought vaccination and included those sometimes described as "immunization advocates", 2) go along to get along (GATGA) individuals who got vaccinated but did not actively seek it, 3) cautious acceptors who got the COVID-19 vaccine after some delay, 4) fence sitters who remained uncertain about getting vaccinated, and 5) vaccine refusers who actively rejected the COVID-19 vaccine. Participants identifying with Black or multiple races were more likely to express hesitancy in their vaccination intention. CONCLUSION: The findings of our study highlight distinct decision-making profiles associated with COVID-19 vaccination among employees of a VA health care system, and provide tailored recommendations to reduce vaccine hesitancy in this population.

Association of caregiver attitudes with adolescent HPV vaccination in 13 southern US states.

Background and objectives:  HPV vaccination coverage is lower than that of other adolescent vaccines in the southern US. This study sought to characterize caregiver attitudes associated with adolescent HPV vaccination in the southern US and to inform interventions to promote HPV vaccination. Methods: From December 2019 - January 2020, caregivers of adolescents (ages 9-17 years) living in thirteen southern US states were recruited from a nationally-representative online survey panel. Caregivers (N = 1,105) completed a cross-sectional survey that assessed general adolescent vaccine attitudes as well as those associated with the HPV vaccine and HPV vaccination decision-making. The primary study outcome was adolescents' receipt of at least one dose of the HPV vaccine. Results: Caregivers with vaccinated adolescents had greater positive attitudes towards adolescent vaccines compared to caregivers of unvaccinated adolescents. Top three areas of concern among caregivers were related to vaccine ingredients, perceptions that adolescents receive too many vaccines, and worry about vaccine side effects. In multivariable regression models, positive attitudes towards the HPV vaccine and HPV vaccination decision-making strongly associated with HPV vaccination in addition to general adolescent vaccination attitudes. Caregivers' reported discomfort with discussing the topic of sex was predictive of lower vaccination uptake for older adolescents. Conclusions: Public health messaging in the southern US should be tailored to reduce concerns about vaccine safety and to communicate the importance of timely HPV vaccination. Campaigns that deliver information specific to the HPV vaccine and to support vaccination decision-making may be more effective than those delivering only general adolescent vaccination information at promoting on-time HPV vaccination.

Using the Consolidated Framework for Implementation Research to Inform the Design of the Mobile Inspección Visual con Ácido Acético System: Mixed Methods Case Study.

BACKGROUND: There is growing evidence supporting the use of mobile health (mHealth) interventions in low- and middle-income countries to address resource limitations in the delivery of health information and services to vulnerable populations. In parallel, there is an increasing emphasis on the use of implementation science tools and frameworks for the early identification of implementation barriers and to improve the acceptability, appropriateness, and adoption of mHealth interventions in resource-limited settings. However, there are limited examples of the application of implementation science tools and frameworks to the formative phase of mHealth design for resource-limited settings despite the potential benefits of this work for enhancing subsequent implementation, scale-up, and sustainability. OBJECTIVE: We presented a case study on the use of an implementation science framework in mHealth design. In particular, we illustrated the usability of the Consolidated Framework for Implementation Research (CFIR) for organizing and interpreting formative research findings during the design of the mobile Inspección Visual con Ácido Acético (mIVAA) system in Lima, Peru. METHODS: We collected formative data from prospective users of the mIVAA intervention using multiple research methodologies, including structured observations, surveys, group and individual interviews, and discussions with local stakeholders at the partnering organization in Peru. These activities enabled the documentation of clinical workflows, perceived barriers to and facilitators of mIVAA, overarching barriers to cervical cancer screening in community-based settings, and related local policies and guidelines in health care. Using a convergent mixed methods analytic approach and the CFIR as an organizing framework, we mapped formative research findings to identify key implementation barriers and inform iterations of the mIVAA system design. RESULTS: In the setting of our case study, most implementation barriers were identified in the CFIR domains of intervention characteristics and inner setting. All but one barrier were addressed before mIVAA deployment by modifying the system design and adding supportive resources. Solutions involved improvements to infrastructure, including cellular data plans to avoid disruption from internet failure; improved process and flow, including an updated software interface; and better user role definition for image capture to be consistent with local health care laws. CONCLUSIONS: The CFIR can serve as a comprehensive framework for organizing formative research data and identifying key implementation barriers during mHealth intervention design. In our case study of the mIVAA system in Peru, formative research contributing to the CFIR domains of intervention characteristics and inner setting elicited the most key barriers to implementation. The early identification of barriers enabled design iterations before system deployment. Future efforts to develop mHealth interventions for low- and middle-income countries may benefit from using the approach presented in this case study as well as prioritizing the CFIR domains of intervention characteristics and inner setting.

Key stakeholder perspectives on challenges and opportunities for rural HPV vaccination in North and South Carolina.

The objective of this study was to identify factors at the individual, provider, and systems levels that serve as challenges or opportunities for increasing adolescent vaccination-including Human Papillomavirus (HPV) vaccination-in rural communities in the southern United States (US). As part of a broader study to increase HPV vaccine uptake in the southern US, we conducted in-depth interviews with vaccination stakeholders representing public health and education agencies in North Carolina (NC) and South Carolina (SC). Fourteen key stakeholders were recruited using purposive sampling to obtain insights into challenges and solutions to rural-urban disparities in HPV vaccination coverage. Stakeholders were also queried about their experiences and attitudes toward school-based vaccination promotion programs and campaigns. We used a rapid qualitative approach to analyze the data. Stakeholders identified factors at the individual, provider, and systems levels that serve as challenges to vaccination in rural communities. Similar to previous studies, stakeholders mentioned challenges with healthcare access and vaccine-related misconceptions that pose barriers to HPV vaccination for rural residents. Systems-level challenges identified included limited access to high-speed internet in rural areas that may impact providers' ability to interface with state-level digital systems such as the vaccination registry. Stakeholders identified a number of opportunities to increase HPV vaccination coverage, including through school-based health promotion programs. Stakeholders strongly supported school-based programs and approaches to strengthen confidence and demand for HPV vaccination and to help address persistent social determinants and system level factors that pose challenges to HPV vaccination coverage in many rural areas.

Caregiver Acceptability of Mobile Phone Use for Pediatric Cancer Care in Tanzania: Cross-sectional Questionnaire Study.

BACKGROUND: There is a 60% survival gap between children diagnosed with cancer in low- and middle-income countries (LMICs) and those in high-income countries. Low caregiver knowledge about childhood cancer and its treatment results in presentation delays and subsequent treatment abandonment in LMICs. However, in-person education to improve caregiver knowledge can be challenging due to health worker shortages and inadequate training. Due to the rapid expansion of mobile phone use worldwide, mobile health (mHealth) technologies offer an alternative to delivering in-person education. OBJECTIVE: The aim of this study is to assess patterns of mobile phone ownership and use among Tanzanian caregivers of children diagnosed with cancer as well as their acceptability of an mHealth intervention for cancer education, patient communication, and care coordination. METHODS: In July 2017, caregivers of children <18 years diagnosed with cancer and receiving treatment at Bugando Medical Centre (BMC) were surveyed to determine mobile phone ownership, use patterns, technology literacy, and acceptability of mobile phone use for cancer education, patient communication, and care coordination. Descriptive statistics were generated from the survey data by using mean and SD values for continuous variables and percentages for binary or categorical variables. RESULTS: All eligible caregivers consented to participate and completed the survey. Of the 40 caregivers who enrolled in the study, most used a mobile phone (n=34, 85%) and expressed high acceptability in using these devices to communicate with a health care provider regarding treatment support (n=39, 98%), receiving laboratory results (n=37, 93%), receiving reminders for upcoming appointments (n=38, 95%), and receiving educational information on cancer (n=35, 88%). Although only 9% (3/34) of mobile phone owners owned phones with smartphone capabilities, about 74% (25/34) self-reported they could view and read SMS text messages. CONCLUSIONS: To our knowledge, this is the first study to assess patterns of mobile phone ownership and use among caregivers of children with cancer in Tanzania. The high rate of mobile phone ownership and caregiver acceptability for a mobile phone-based education and communication strategy suggests that a mobile phone-based intervention, particularly one that utilizes SMS technology, could be feasible in this setting.

Mucosa-adherent Pediococcus Pentosaceus I44 isolated from healthy human and effect of oleic acid on its probiotic properties.

With the aim of selectively isolating and understanding the cultivable lactic acid bacteria that are autochthonous to human gut, biopsy samples were collected from the terminal ileum and caecum of healthy volunteers who underwent routine colonoscopy procedure. The use of tissue samples (over stool samples) provides for a better expression of the autochthonous bacterial population of the human gut. The strains that were stable after many rounds of sub-culture were identified and studied further. One such ileal isolate, a Gram-positive, catalase-negative cocci was identified to be Pediococcus pentosaceus I44. It was studied for its gastric tolerance, bile tolerance and surface properties, and reported here. The effect of tween-80, oleic acid, extra virgin olive oil and sesame oil on the aforementioned properties of P. pentosaceus I44 was also analysed. The isolate was able to survive well in simulated gastric fluid of pH 3.0 followed by treatment in simulated intestinal fluid with a survival percentage of around 70%. It was, however, unable to withstand pH 2.0 even in the presence of supplements. It showed good tolerance to bile stress (1% w/v), and its cell surface was found to be hydrophilic. P. pentosaceus I44 showed good aggregation of 87% after 24 h, with oleic acid having a significant effect on the isolate's aggregation potential. P. pentosaceus I44 is one of the few mucosa-bound cultivable bacteria that are adapted for survival in human colon. Studying and analysing such isolates might provide useful insights into their role in metabolism and health.

Disparities in healthcare access and utilization and human papillomavirus (HPV) vaccine initiation in the United States.

Currently in the United States, Human Papillomavirus (HPV) vaccination coverage among eligible individuals is lower compared to coverage goals of 80% set by the HealthyPeople 2030 initiative. In this study, we used the National Health and Nutrition Examination Survey (NHANES) 2015-2016 and 2017-2018 datasets to determine the association between HPV vaccine initiation among individuals of ages 9 to 26 years and their patterns of healthcare access and utilization. In particular, we examined the following healthcare characteristics: 1) having a routine place of healthcare, 2) having health insurance coverage, 3) frequency of healthcare visits per year, and 4) type of routine place of healthcare (outpatient primary care vs. ED, etc.). We fit independent multivariable logistic regression models for each NHANES dataset and controlled for sociodemographic characteristics and interactions with healthcare access and utilization characteristics. Our findings suggest that HPV vaccine initiation is positively associated with having a routine place of healthcare (2015-2016: aOR 1.92, 95% CI 1.25-2.95; 2017-2018: aOR 1.99, 95% CI 1.07-3.68). Relatedly, HPV vaccine initiation is negatively associated with never having received healthcare in the past year (2015-2016: aOR 0.61, 95% CI 0.41-0.90; 2017-2018: aOR 0.45, 95% CI 0.27-0.75). The results of this study suggest that interventions to promote HPV vaccination should include strategies that promote access to and utilization of routine health care services. Our findings are particularly salient in light of the drop in HPV vaccine initiation and healthcare access and utilization among adolescents during the COVID-19 pandemic.

Predictors of HPV vaccination in the southern US: A survey of caregivers from 13 states.

BACKGROUND AND OBJECTIVES: Despite a high burden of human papillomavirus (HPV)-attributable cancers, the southern US lags other regions in HPV vaccination coverage. This study sought to characterize and contextualize predictors of HPV vaccination in the southern US. METHODS: From December 2019 - January 2020, parents of adolescents (ages 9-17 years) living in thirteen southern US states were recruited from a nationally-representative online survey panel and completed a cross-sectional survey. The primary study outcome was initiation of HPV vaccination. RESULTS: Of 1105 parents who responded to the survey, most were ≥35 years of age and of female gender. HPV vaccination initiation was reported only among 37.3% of adolescents and was highest at age 12. Cumulative HPV vaccination coverage was highest at age 15 (60%) but lower than coverage for tetanus-diphtheria-acellular pertussis (Tdap, 79.3%) and Meningococcal vaccines (MenACWY, 67.3%). Provider recommendation was strongly associated with higher odds of HPV vaccination (aOR: 49.9, 95 %CI: 23.1-107.5). In alternative predictive models, home/online (vs. public) schooling and parents' working status were associated with lower odds of vaccination; health care visits in the past 12 months and shorter travel times to adolescents' usual health care provider were associated with greater odds of vaccination. CONCLUSIONS: Our findings suggest missed opportunities for HPV vaccination in the southern US and support strengthening provider recommendation for on-time initiation of HPV vaccination among adolescents. Other strategies to increase HPV vaccinations may include encouraging co-administration with other adolescent vaccines, increasing vaccine access, and promoting vaccinations for home/online-school students.