Policy Approaches for Increasing Adolescent HPV Vaccination Coverage: A Systematic Review.

CONTEXT: US jurisdictions have enacted a wide range of policies to address low human papillomavirus (HPV) vaccination coverage among adolescents, but it is unclear which policies are effective. OBJECTIVE: To systematically review the impact of governmental policies on adolescent HPV vaccination coverage. DATA SOURCES: PubMed, Embase, and Scopus databases. STUDY SELECTION: Eligible studies, published from 2009 to 2022, evaluated the impact of governmental policies on HPV vaccination coverage among adolescents ages 9 to 18. DATA EXTRACTION: Two investigators independently extracted data on study sample, study design and quality, policy characteristics, and HPV vaccination outcomes. We summarized findings by policy type: school-entry requirements (SERs), federally-funded policies related to the Vaccines for Children program and Medicaid, educational requirements, and others. RESULTS: Our search yielded 36 eligible studies. A majority of studies evaluating HPV vaccine SERs found positive associations between SERs and HPV vaccination coverage (8 of 14), particularly for SERs in Rhode Island and Washington, DC. All studies evaluating SERs for other adolescent vaccines observed positive spillover effects for HPV vaccination (7 of 7). Federally-funded policies related to Vaccines for Children and Medicaid were consistently associated with higher HPV vaccination coverage (7 of 9). Relatively few studies found associations between educational requirements and HPV vaccination coverage (2 of 8). LIMITATIONS: Studies used limited vaccination data sources and non- or quasi-experimental designs. Some studies had no or poorly matched comparison groups. CONCLUSIONS: Our findings suggest promise for SERs and federally-funded policies, but not educational requirements, for increasing HPV vaccination coverage among adolescents.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals.

BACKGROUND: Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care. METHODS: In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates." RESULTS: Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001). CONCLUSIONS: Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Identifying Healthcare Professionals With Lower Human Papillomavirus (HPV) Vaccine Recommendation Quality: A Systematic Review.

PURPOSE: Strengthening healthcare professionals' (HCPs) communication is an evidence-based approach to increasing human papillomavirus (HPV) vaccine uptake among adolescents. To better target future interventions, we sought to synthesize evidence on HCP subgroups who most need to improve their HPV vaccine recommendation quality. METHODS: We searched five databases for quantitative studies published from 2012 to 2022 on HPV vaccine recommendation quality, including recommendation consistency and strength, for United States adolescents. Two coders independently abstracted data from each eligible study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We summarized variation in recommendation quality by clinical and HCP characteristics. RESULTS: The 28 eligible studies indicated that relatively low proportions of HCPs used higher-quality recommendation practices (median: 61% across 30 measures) and that recommendation quality varied across HCP subgroups. The most consistent findings were that more pediatric HCPs used higher-quality recommendations than family medicine HCPs (8 of 11 studies, 2-60 percentage point difference) and that HPV-related knowledge was associated with higher recommendation quality (four of seven studies). Most studies observed no differences in recommendation quality by clinical role (e.g., provider vs. nurse) or HCP demographics (e.g., gender, age, race/ethnicity). DISCUSSION: Studies suggest a substantial need to improve HCPs' recommendation quality, with opportunities for targeting future interventions.

Impact of visit characteristics on intention to recommend HPV vaccine: An experiment with US health care professionals.

OBJECTIVE: Presumptive recommendations that assume parents want to vaccinate can increase human papillomavirus (HPV) vaccine uptake. We sought to examine how visit characteristics affect health care professionals' (HCPs) intention to use this evidence-based recommendation style. METHODS: In 2022, we conducted an online experiment with 2527 HCPs who had a role in adolescent vaccination in the United States. Participants read 1 of 8 randomly assigned vignettes about a well-child visit. Using a 2 × 2 × 2 between-subjects factorial design, the vignettes varied the following visit characteristics: patient age (9 vs. 12-year-old), prior parental vaccine refusal (yes vs. no), and time pressure on the HCP (low vs. high). HCPs reported on their intention to use a presumptive HPV vaccine recommendation, as well as on related attitudes, subjective norms, and self-efficacy. Analyses used 3-way analysis of variance and parallel mediation. RESULTS: Participants were pediatricians (26%), family/general medicine physicians (22%), advanced practitioners (24%), and nursing staff (28%). Overall, about two-thirds of HCPs (64%) intended to use a presumptive recommendation. Intentions were higher for older children (b = 0.23) and parents without prior vaccine refusal (b = 0.39, both p < 0.001). Time pressure had no main effect or interactions. HCPs' attitudes and self-efficacy partially mediated effects of patient age and prior vaccine refusal (range of b = 0.04-0.28, all p < 0.05). CONCLUSION: To better support visits with younger children and parents who have refused vaccines, HCPs may need more training for making presumptive recommendations for HPV vaccine. Reinforcing positive attitudes and self-efficacy can help HCPs adopt this evidence-based recommendation style.

Using Cost Conversations to Address Financial Toxicity in Pediatric Asthma Care: Findings From a Survey of Caregivers.

INTRODUCTION: Asthma care teams are well-positioned to help caregivers address financial toxicity in pediatric asthma care, although discussing cost can be challenging. We sought to characterize cost conversations in pediatric asthma specialty care. METHOD: We surveyed 45 caregivers of children aged 4-17 with asthma. Eligible caregivers reported costs concerns and had accompanied their child to a multisite asthma specialty practice in North Carolina. RESULTS: About one-third of caregivers reported a cost conversation (36%). Cost conversations were less common among caregivers whose child had public versus private health insurance (16% vs. 56%), who attended a telehealth versus in-person visit (6% vs. 52%), or who did not versus did want a conversation (19% vs. 77%, all p < .05). Common cost conversation topics were medications and equipment like spacers. DISCUSSION: Our findings suggest cost conversations may be relatively uncommon in pediatric asthma care, particularly for publicly insured patients and telehealth visits.

An appropriate ammonium: nitrate ratio promotes the growth of centipedegrass: insight from physiological and micromorphological analyses.

Reasonable nitrogen fertilizer application is an important strategy to maintain optimal growth of grasslands, thereby enabling them to better fulfil their ecological functions while reducing environmental pollution caused by high nitrogen fertilizer production and application. Optimizing the ammonium (NH4 +):nitrate (NO3 -) ratio is a common approach for growth promotion in crops and vegetables, but research on this topic in grass plants has not received sufficient attention. Centipedegrass, which is widely used in landscaping and ecological protection, was used as the experimental material. Different NH4 +:NO3 - ratios (0: 100, 25:75, 50:50, 75:25, 100:0) were used as the experimental treatments under hydroponic conditions. By monitoring the physiological and morphological changes under each treatment, the appropriate NH4 +:NO3 - ratio for growth and its underlying mechanism were determined. As the proportion of ammonium increased, the growth showed a "bell-shaped" response, with the maximum biomass and total carbon and nitrogen accumulation achieved with the NH4 +:NO3 - ratio of 50:50 treatment. Compared with the situation where nitrate was supplied alone, increasing the ammonium proportion increased the whole plant biomass by 93.2%, 139.7%, 59.0%, and 30.5%, the whole plant nitrogen accumulation by 44.9%, 94.6%, 32.8%, and 54.8%, and the whole plant carbon accumulation by 90.4%, 139.9%, 58.7%, and 26.6% in order. As a gateway for nitrogen input, the roots treated with an NH4 +:NO3 - ratio of 50:50 exhibited the highest ammonium and nitrate uptake rate, which may be related to the maximum total root length, root surface area, average root diameter, root volume, and largest root xylem vessel. As a gateway for carbon input, leaves treated with an NH4 +:NO3 - ratio of 50:50 exhibited the highest stomatal aperture, stomatal conductance, photosynthetic rate, transpiration rate, and photosynthetic products. The NH4 +:NO3 - ratio of 50:50 treatment had the largest stem xylem vessel area. This structure and force caused by transpiration may synergistically facilitate root-to-shoot nutrient translocation. Notably, the change in stomatal opening occurred in the early stage (4 hours) of the NH4 +:NO3 - ratio treatments, indicating that stomates are structures that are involved in the response to changes in the root NH4 +:NO3 - ratio. In summary, we recommend 50:50 as the appropriate NH4 +:NO3 - ratio for the growth of centipedegrass, which not only improves the nitrogen use efficiency but also enhances the carbon sequestration capacity.

Using an ultra-compact optical system to improve lateral flow immunoassay results quantitatively.

The lateral flow immunoassay (LFIA) is a paper-based platform with extensive application in point-of-care (POC) testing and many fields. However, its clinical application is severely limited due to the lack of quantitative ability of standard LFIA tests; this augmentation provides the system with quantifying the signal from magenta-colored AuNPs. To address this issue, we proposed an ultra-compact optical system that allowed LFIAs to be performed more accurately and objectively. The experimental setup consisted of multiple optical accessories manufactured by 3D printing (STEP files were included). A high-resolution printer was used to print out a magenta card model for the LFIA, whose color code, ranging from 255, 255, 255 to 255, 0, 255 in the RGB (red, green, blue) format, represents different levels of magenta color intensity (from 0% to 100%) and thus the results of LFIA test strips. A mathematical model was built using a calibration curve to describe the relationship between magenta color value and reflectance spectrum. In addition, a spectrum module was integrated into the proposed system to identify and quantify LFIA results. This integration represents a pioneering step in developing portable detection techniques that facilitate quantifying LFIA results. Finally, we expect this ultra-compact optical spectroscopy system to have great potential for novel clinical applications.

Leveraging Telemedicine to Reduce the Financial Burden of Asthma Care.

One of the most compelling arguments for telemedicine is its potential to increase health care access by making care more affordable for patients and families, including those affected by asthma. This goal is critically important in the United States, where the high cost of asthma care is associated with nonadherence to preventive care regimens and suboptimal health outcomes. In this clinical commentary review, we draw from the literature and our own research to identify opportunities for and challenges to leveraging telemedicine to reduce the financial burden of asthma care. Our interviews with 42 families affected by asthma during the COVID-19 pandemic suggest that under favorable circumstances, telemedicine can meaningfully reduce costs, including those related to transportation and missed work, while offering high-quality care. However, families also identified ways in which telemedicine can increase costs. For example, some reported reduced access to support services and material resources such as medication samples, which they relied on to manage costs. In this way, our findings underscore the need for careful care coordination and communication in telemedicine. We conclude by discussing the 4Rs, a structured communication approach designed to support cost conversations, increase care coordination, and help families reduce asthma care cost burden.

A Faster, Novel Technique to Detect COVID-19 Neutralizing Antibodies.

BACKGROUND The COVID-19 pandemic has spread globally in a short period of time. It is known that antibody (nAb) level can effectively predict vaccine efficacy, which leads to the exploration of vaccine trials for efficacy assessment. Thus, the current study aimed to develop a platform to quantify nAb levels faster, at lower cost, and with better efficiency. MATERIAL AND METHODS A total of 69 sera samples were collected for the research, 28 of which were from unvaccinated participants. The other 27 samples and the remaining 14 samples were from the participants who had received the first and second dose, respectively, of AZ vaccine 1 month before. With cPass assays (Genscript cPass nAb ELISA assay) used as a criterion standard and lateral flow immunoassay kit (Healgen Scientific - LFIA test kit) coupled with a spectrometer (LFIA+S) for checking each specimen, we aimed to detect the presence of neutralizing antibodies in sera and to confirm the relationship between the inhibition rate from cPass assays and the nAb index from the LFIA+S. RESULTS Data analysis of the research were taken from the certified ELISA and LFIA+S, which indicated a high consistency (Pearson's r =0.864; ICC=0.90138) between the 2 methods. CONCLUSIONS The dataset demonstrated that LFIA+S was affordable, had a strong correlation with results of the cPass nAbs detection kit, and has potential clinical applications, with an exclusive feature that allows non-experts to use it with ease. It is believed that the proposed platform can be promoted in the near future.

Recommending Human Papillomavirus Vaccination at Age 9: A National Survey of Primary Care Professionals.

OBJECTIVE: Several US health organizations, including the American Academy of Pediatrics, now encourage primary care professionals to recommend human papillomavirus (HPV) vaccination before the traditionally targeted ages of 11 to 12 years as a strategy to increase vaccination timeliness. To understand the feasibility of this approach, we sought to evaluate primary care professionals' current recommendation timing and willingness to recommend HPV vaccination at age 9. METHODS: A national sample of 1047 primary care professionals completed our online survey in 2021. Respondents were physicians (71%), advanced practitioners (17%), and nurses (12%). RESULTS: About one-fifth (21%) of primary care professionals reported that they already routinely recommend HPV vaccination at ages 9 to 10. Among the remaining 822 respondents, over half (61%) reported being somewhat or more willing to start recommending at age 9. Willingness was higher among those working in family medicine versus pediatrics (adjusted odds ratio [aOR]: 1.40, 95% confidence interval [CI] 1.03, 1.92), but lower among those with ≥20 years of practice experience versus ≤9 years (aOR: 0.65, 95% CI 0.44, 0.96). Many primary care professionals believed age 9 recommendations would have the advantage of protecting adolescents before HPV exposure (67%) or increasing vaccination timeliness (55%). The most commonly perceived disadvantage was that parents are not ready to talk about HPV vaccination at age 9 (73%). CONCLUSION: Over two-thirds of primary care professionals in our national sample reported they recommend HPV vaccination at ages 9 to 10 or are somewhat or more willing to do so. Training may be needed to help primary care professionals address perceived parental hesitancy toward age 9 recommendations.

Disparities in Healthcare Providers' Recommendation of HPV Vaccination for U.S. Adolescents: A Systematic Review.

Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future interventions, we sought to characterize disparities in health care providers' HPV vaccine recommendation for U.S. adolescents. We systematically reviewed studies published in 2012-2019 that assessed provider HPV vaccine recommendations for adolescents aged 9-17. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 52 eligible studies and used a standardized abstraction form to assess recommendation prevalence by adolescent demographic characteristics. Studies consistently found that fewer parents of boys than girls reported receiving HPV vaccine recommendations (14 studies, range of difference: -11 to -35 percentage points). Studies also found fewer recommendations for adolescents who were younger (2 studies, -3% to -12% points), non-White (3 studies, -5% to -7% points, females only), lower income (3 studies, -1% to -8% points), or uninsured (1 study, -21% points, males only). Studies identified geographic disparities in southern and rural areas. In conclusion, findings from this systematic review identify disparities in HPV vaccine recommendation that may contribute to suboptimal vaccine uptake. Efforts to improve providers' HPV vaccine communication should focus on increasing recommendation consistency, especially for lower-income, non-White, and rural adolescents.

Using Telehealth to Deliver Primary Care to Adolescents During and After the COVID-19 Pandemic: National Survey Study of US Primary Care Professionals.

BACKGROUND: The COVID-19 pandemic has led to unprecedented use of telehealth, including by primary care professionals (PCPs) who serve adolescents. OBJECTIVE: To inform future practice and policies, we sought to characterize PCPs' recent experience using adolescent telehealth as well as their support for it after the COVID-19 pandemic is over. METHODS: From February to March 2021, we conducted a web-based survey of 1047 PCPs in the United States. Our national sample included physicians (747/1047, 71%), advanced practice providers (177/1047, 17%), and nurses (123/1047, 12%) who provided primary care to adolescents aged 11-17 years. RESULTS: Most PCPs reported using telehealth for a low, moderate, or high proportion of their adolescent patients in the three months prior to the survey (424/1047, 40%, 286/1047, 27%, and 219/1047, 21%, respectively); only 11% (118/1047) reported no use. A majority of respondents agreed that adolescent telehealth increases access to care (720/1047, 69%) and enables them to provide high-quality care (560/1047, 53%). Few believed that adolescent telehealth takes too much time (142/1047, 14%) or encourages health care overuse (157/1047, 15%). Most supported giving families the option of adolescent telehealth for primary care after the pandemic is over (683/1047, 65%) and believed that health insurance plans should continue to reimburse for telehealth visits (863/1047, 82%). Approximately two-thirds (702/1047, 67%) wanted to offer adolescent telehealth visits after the pandemic, with intentions being higher among those with recent telehealth experience (P<.001). CONCLUSIONS: PCPs in our national sample reported widespread use of and predominantly positive attitudes toward adolescent telehealth. Our findings also suggest broad support among PCPs for continuing to offer adolescent telehealth after the COVID-19 pandemic ends.

Secondary Risk Theory: Validation of a Novel Model of Protection Motivation.

Protection motivation theory states individuals conduct threat and coping appraisals when deciding how to respond to perceived risks. However, that model does not adequately explain today's risk culture, where engaging in recommended behaviors may create a separate set of real or perceived secondary risks. We argue for and then demonstrate the need for a new model accounting for a secondary threat appraisal, which we call secondary risk theory. In an online experiment, 1,246 participants indicated their intention to take a vaccine after reading about the likelihood and severity of side effects. We manipulated likelihood and severity in a 2 × 2 between-subjects design and examined how well secondary risk theory predicts vaccination intention compared to protection motivation theory. Protection motivation theory performed better when the likelihood and severity of side effects were both low (R2 = 0.30) versus high (R2 = 0.15). In contrast, secondary risk theory performed similarly when the likelihood and severity of side effects were both low (R2 = 0.42) or high (R2 = 0.45). But the latter figure is a large improvement over protection motivation theory, suggesting the usefulness of secondary risk theory when individuals perceive a high secondary threat.

A typology of beliefs and misperceptions about the influenza disease and vaccine among older adults in Singapore.

Access to the influenza vaccine pose little barriers in developed countries such as Singapore and vaccination against influenza is highly recommended for at-risk populations including older adults. However, vaccination rates are much lower than recommended despite the significant morbidity and mortality associated with the disease among this vulnerable population. Given timely goals to increase vaccine acceptance and uptake, we explored Singaporean older adults' misperceptions about influenza disease and vaccine. Qualitative semi-structured interviews were conducted among 76 Singaporean adults aged 65 and above with no focus on a specific area in Singapore. Data were analyzed with grounded theory methods to understand participants' attitudes, perceptions, and knowledge. We developed in vivo codes that reflect the verbiage used by participants and exhaustively catalogued themes through a constant comparison coding method. Focusing specifically on older adults' misperceptions, seven main themes about influenza disease or vaccine emerged from our data analysis: familiarity with influenza, misperceptions about influenza, personal susceptibility to influenza, familiarity with the influenza vaccine, misperceptions about the influenza vaccine, misperceptions about influenza vaccine usage, and opinions about and barriers to influenza vaccine uptake. Notably, there is a lack of adequate knowledge and motivation in vaccinating against influenza among older adults in Singapore. Health communication needs to be more tailored toward older adults' message processing systems and engage health professionals' involvement in addressing the influenza disease and vaccine misperceptions identified in this study.

The Interplay between Framing and Regulatory Focus in Processing Narratives about HPV Vaccination in Singapore.

This study examined whether regulatory focus changes the effects of gain- and loss-framed narratives on promoting Human Papillomavirus (HPV) vaccination among young females in Singapore. We conducted a quasi-experiment in which participants reported their regulatory focus and then read either a gain- or loss-framed narrative about HPV vaccination. The results showed an overall advantage of a loss frame over a gain frame in producing transportation and self-referent emotions, which in turn led to increased vaccination intentions. This pattern was more pronounced among those high in prevention or promotion focus, with self-referent emotions being the primary mediator transferring the interactive effects onto vaccination intentions. This study contributes to the extant literature on narrative persuasion by addressing the specific mechanisms of the effect of framing employed in narratives.

"Influenza" versus "Flu": Do Different Medical Terms Affect Vaccination Intention?

Confusion about disease terminology contributes to lower risk perceptions that may lead to lesser engagement in protective measures. Communication campaigns promoting influenza vaccination have become commonplace around the world. Such campaigns vary widely in their terminology used from depicting the disease and response formally as an "influenza vaccination" to more colloquial terms like "flu shot." This study gathered responses from 896 Singapore residents through an online experiment and employed a Chi-square test to assess if different medical terms describing the same preventive measure ("influenza vaccine" and "flu shot") influence vaccination intentions. Results indicate that the formal term "influenza vaccine" prompts significantly greater vaccination intention than the abbreviated colloquial term "flu shot," even when no further information about the disease or vaccine is provided. This finding suggests that the proclivity to use the less formal term "flu shot" in widespread campaigns is less advantageous in prompting intentions to vaccinate against the disease. This may be the result of an activated availability bias brought on by the distinct semantic frames. We conclude that in this instance the medical terms should not be used interchangeably and that "influenza vaccine" may be more advantageous in future communication to encourage adoption of advised health behavior.