Human papillomavirus vaccine beliefs and intentions Post-COVID-19 vaccine release among mothers in Alabama.

PURPOSE: The current study sought to determine if the release of COVID-19 vaccines influenced Alabama mothers' attitudes and behaviors regarding HPV vaccination of their adolescent children. METHODS: A social media survey was conducted August - September 2022 among mothers of adolescents ages 9-18, who self-identified as Alabama residents and their child(ren)'s primary medical decision maker. The survey assessed demographics, vaccine knowledge and opinions, vaccination history, influences on vaccination decisions, and how COVID-19 vaccine release affected vaccine opinions. Univariable and multivariable analyses were conducted. RESULTS: Of 241 responses, most participants were white (82.0 %, n = 196), non-Hispanic (96.6 %, n = 230), and privately insured (64.5 %, n = 151), with annual household incomes ≥$61,000 (45.4 %, n = 103). The majority (60.8 %) reported that their child either had or planned to receive the HPV vaccine. The release of COVID-19 vaccines did not change the majority of parental opinions towards HPV, with 78.5 % (n = 161) reporting no change. Among those who experienced a change, 25 % (n = 5) reported an increased likelihood of having their child vaccinated for HPV and 75 % (n = 15) reported a decrease in likelihood. Moderate and high HPV knowledge scores were associated in multivariable analysis with increased likelihood of having their child vaccinated for HPV ("moderate" knowledge AOR: 12.4, 95 % CI: 1.98-78.1; "high" knowledge AOR: 12.8, 95 % CI: 2.00-82.1). Positive HPV opinion scores in the univariable analysis similarly showed increased odds (AOR = 1.5). CONCLUSIONS: These findings indicate that, in this population, COVID-19 vaccine release did not significantly impact subsequent HPV vaccination decision making. Parental perceptions regarding vaccination are critical to informing future interventions.

Proximity to Hospital-Based Obstetric Care in a Maternity Desert in the Deep South.

Objectives. To examine the accessibility of hospital facilities with maternity care services in 1 rural county in Alabama in preparation for the initiation of prenatal care services at a federally qualified health center. Methods. We analyzed driving distance (in miles) from maternal city of residence in Conecuh County, Alabama to hospital of delivery, using 2019-2021 vital statistics data and geographic information system (GIS) software. Results. A total of 370 births to mothers who have home addresses in Conecuh County were reported, and 368 of those were in hospital facilities. The majority of deliveries were less than 30 miles (median = 23 miles) from the maternal city of residence. Some women traveled more than 70 miles for obstetrical care. Conclusions. Pregnant patients in Conecuh County experience significant geographic barriers related to perinatal care access. Using GIS for this analysis is a promising approach to better understand the unique challenges of pregnant individuals in this rural population. Public health policy efforts need to be geographically tailored to address these disparities. (Am J Public Health. 2024;114(S4):S330-S333. https://doi.org/10.2105/AJPH.2024.307692).

HPV Vaccination among College Students in the South: The Role of HPV Knowledge on Vaccine Initiation and Completion.

BACKGROUND: The purpose of this study was to examine factors related to HPV vaccination initiation and completion, especially the role of health knowledge, among college students in a southern state. METHODS: College students ages 17-45 (n=1,708) were analyzed in this study. Primary outcomes were HPV vaccine series initiation and completion; binary logistic regressions were performed to identify associated factors. RESULTS: Among total participants, students who were aware that HPV could be transmitted even without symptoms were less likely to initiate HPV vaccination. However, among students who have initiated the vaccine series, those who were aware that HPV could be transmitted without symptoms and that men should receive the HPV vaccine were more likely to complete the vaccine series. Other significant variables included age, gender, race, and international student status. CONCLUSION: Future studies are needed to investigate students' concerns regarding initiating HPV vaccination and how to effectively motivate students to initiate and complete the HPV vaccine series.

Advancing Survivors Knowledge (ASK Study) of Skin Cancer Surveillance After Childhood Cancer: A Randomized Controlled Trial in the Childhood Cancer Survivor Study.

PURPOSE: To improve skin cancer screening among survivors of childhood cancer treated with radiotherapy where skin cancers make up 58% of all subsequent neoplasms. Less than 30% of survivors currently complete recommended skin cancer screening. PATIENTS AND METHODS: This randomized controlled comparative effectiveness trial evaluated patient and provider activation (PAE + MD) and patient and provider activation with teledermoscopy (PAE + MD + TD) compared with patient activation alone (PAE), which included print materials, text messaging, and a website on skin cancer risk factors and screening behaviors. Seven hundred twenty-eight participants from the Childhood Cancer Survivor Study (median age at baseline 44 years), age > 18 years, treated with radiotherapy as children, and without previous history of skin cancer were randomly assigned (1:1:1). Primary outcomes included receiving a physician skin examination at 12 months and conducting a skin self-examination at 18 months after intervention. RESULTS: Rates of physician skin examinations increased significantly from baseline to 12 months in all three intervention groups: PAE, 24%-39%, relative risk [RR], 1.65, 95% CI, 1.32 to 2.08; PAE + MD, 24% to 39%, RR, 1.56, 95% CI, 1.25 to 1.97; PAE + MD + TD, 24% to 46%, RR, 1.89, 95% CI, 1.51 to 2.37. The increase in rates did not differ between groups (P = .49). Similarly, rates of skin self-examinations increased significantly from baseline to 18 months in all three groups: PAE, 29% to 50%, RR, 1.75, 95% CI, 1.42 to 2.16; PAE + MD, 31% to 58%, RR, 1.85, 95% CI, 1.52 to 2.26; PAE + MD + TD, 29% to 58%, RR, 1.95, 95% CI, 1.59 to 2.40, but the increase in rates did not differ between groups (P = .43). CONCLUSION: Although skin cancer screening rates increased more than 1.5-fold in each of the intervention groups, there were no differences between groups. Any of these interventions, if implemented, could improve skin cancer prevention behaviors among childhood cancer survivors.

Rural Americans' COVID-19 Vaccine Perceptions and Willingness to Vaccinate against COVID-19 with Their Community Pharmacists: An Exploratory Study.

In early 2022 in the U.S., rural adults were the least likely to vaccinate against COVID-19 due to vaccine hesitancy and reduced healthcare access. This study explored the factors influencing rural adults' COVID-19 vaccine perceptions and their acceptance of pharmacist-administered vaccination. We utilized phone-based semi-structured interviews with 30 adults living in rural regions of one southwestern state and analyzed the data using a team-based thematic analysis approach. Vaccine-willing participants described knowing other people affected by the virus and their desired protection from the virus. They reported trusting scientific institutions and the government to provide safe vaccines. Vaccine-hesitant populations, however, feared that the COVID-19 vaccine development process had been rushed, compromising the safety of these newer vaccines. Although they differed in the news sources they preferred for receiving COVID-19 vaccine information, both vaccine-willing and vaccine-hesitant participants described trusting local authorities, such as healthcare providers and county government officials, to provide accurate COVID-19 vaccine information. Regarding the acceptability of pharmacist-administered COVID-19 vaccinations, all but one participant described their acceptance of this healthcare delivery approach. Future outreach should leverage rural adults' trust in local sources, including community pharmacists, deemed more convenient access points to healthcare, when addressing vaccine hesitancy.

U.S. adults' reasons for changing their degree of willingness to vaccinate against COVID-19.

Introduction: COVID-19 vaccines significantly reduce the risk of complications and hospitalizations due to this virus. When COVID-19 vaccines first became commercially available, roughly 30% of U.S. adults reported being hesitant to receive these newly developed vaccines, and 15% said they would not receive the vaccine. However, by May 2021, 19% of adults were vaccine-hesitant, and 13% refused to vaccinate against COVID-19. It is critical to understand why adults' degree of willingness to vaccinate against COVID-19 changed over time to plan for future pandemics and vaccination campaigns. Methods: We conducted two waves of survey research over five months (January and May 2021) with a panel of 890 U.S. adults. One survey question assessed willingness to vaccinate against COVID-19. The response option included a slider scale ranging from 0 (signifying complete unwillingness) to 10 (complete willingness). We asked participants whose willingness score changed by more than one point to report their rationale for their change in perceptions. We conducted a conventional content analysis on all qualitative responses. Results: We analyzed qualitative responses for 289 participants, 54.7% of whom had not been vaccinated against COVID-19 by May 2021. Among those who remained unvaccinated, 36.1% reported increased willingness to vaccinate. The most commonly cited reasons for becoming more willing to receive the vaccine include believing that COVID-19 vaccines are safe and effective, protecting against the pandemic, and desiring to return to pre-pandemic life. Reasons for increased COVID-19 vaccine hesitancy include vaccine safety concerns, the low perceived need for the vaccine, distrust in how COVID-19 vaccines are made and of larger institutions such as the government and pharmaceutical companies, and concerns about vaccine effectiveness. Conclusion: Findings illuminate the rationale behind individuals' changes in their degree of willingness to vaccinate against COVID-19. It is critical to incorporate these considerations in future vaccine rollout initiatives to increase the public's vaccine confidence.

Adaptation of Remote Symptom Monitoring Using Electronic Patient-Reported Outcomes for Implementation in Real-World Settings.

PURPOSE: Despite evidence of clinical benefits, widespread implementation of remote symptom monitoring has been limited. We describe a process of adapting a remote symptom monitoring intervention developed in a research setting to a real-world clinical setting at two cancer centers. METHODS: This formative evaluation assessed core components and adaptations to improve acceptability and fit of remote symptom monitoring using Stirman's Framework for Modifications and Adaptations. Implementation outcomes were evaluated in pilot studies at the two cancer centers testing technology (phase I) and workflow (phase II and III) using electronic health data; qualitative evaluation with semistructured interviews of clinical team members; and capture of field notes from clinical teams and administrators regarding barriers and recommended adaptations for future implementation. RESULTS: Core components of remote symptom monitoring included electronic delivery of surveys with actionable symptoms, patient education on the intervention, a system to monitor survey compliance in real time, the capacity to generate alerts, training nurses to manage alerts, and identification of personnel responsible for managing symptoms. In the pilot studies, while most patients completed > 50% of expected surveys, adaptations were identified to address barriers related to workflow challenges, patient and clinician access to technology, digital health literacy, survey fatigue, alert fatigue, and data visibility. CONCLUSION: Using an implementation science approach, we facilitated adaptation of remote symptom monitoring interventions from the research setting to clinical practice and identified key areas to promote effective uptake and sustainability.

Evaluating the implementation and impact of navigator-supported remote symptom monitoring and management: a protocol for a hybrid type 2 clinical trial.

BACKGROUND: Symptoms in patients with advanced cancer are often inadequately captured during encounters with the healthcare team. Emerging evidence demonstrates that weekly electronic home-based patient-reported symptom monitoring with automated alerts to clinicians reduces healthcare utilization, improves health-related quality of life, and lengthens survival. However, oncology practices have lagged in adopting remote symptom monitoring into routine practice, where specific patient populations may have unique barriers. One approach to overcoming barriers is utilizing resources from value-based payment models, such as patient navigators who are ideally positioned to assume a leadership role in remote symptom monitoring implementation. This implementation approach has not been tested in standard of care, and thus optimal implementation strategies are needed for large-scale roll-out. METHODS: This hybrid type 2 study design evaluates the implementation and effectiveness of remote symptom monitoring for all patients and for diverse populations in two Southern academic medical centers from 2021 to 2026. This study will utilize a pragmatic approach, evaluating real-world data collected during routine care for quantitative implementation and patient outcomes. The Consolidated Framework for Implementation Research (CFIR) will be used to conduct a qualitative evaluation at key time points to assess barriers and facilitators, implementation strategies, fidelity to implementation strategies, and perceived utility of these strategies. We will use a mixed-methods approach for data interpretation to finalize a formal implementation blueprint. DISCUSSION: This pragmatic evaluation of real-world implementation of remote symptom monitoring will generate a blueprint for future efforts to scale interventions across health systems with diverse patient populations within value-based healthcare models. TRIAL REGISTRATION: NCT04809740 ; date of registration 3/22/2021.

Factors associated with COVID-19 vaccination intentions among adults in the deep South.

The recent approval of several COVID-19 vaccines signals progress toward controlling the pandemic. Although social distancing and masking have been effective, vaccines are an important additional measure of protection to reduce COVID-19 spread. Adequate uptake is essential to reach herd immunity, estimated to be approximately 67%. However, vaccine hesitancy, the fast-tracked nature of the COVID-19 vaccines, and misinformation circulating through various forms of media have contributed to lower vaccination intention than desired. The current research study developed an online survey conducted via Facebook to explore the attitudes and perceptions of adult Alabama residents about COVID-19 and the COVID-19 vaccines. Of the 3,781 respondents, only 44.3% reported intent to receive a vaccine, with a large proportion reporting they were unsure (28.1%). Lack of intention to vaccinate was associated with low educational attainment, low COVID-19 knowledge levels, low income, and African American race. The current survey also explored participants' influenza vaccine behavior as this information can also be used to inform successful COVID-19 vaccine distribution. Of the respondents, 56% report receiving the yearly influenza vaccine and the majority receive it at a pharmacy or healthcare provider office. This informs likely successful locations for COVID-19 vaccine distribution. Appropriate education targeted to populations most likely to refuse COVID-19 vaccination is essential to promote uptake. The information collected from the current study should be utilized to inform effective and efficient vaccine distribution strategies.

Enrolling a rural community pharmacy as a Vaccines for Children provider to increase HPV vaccination: a feasibility study.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. with over 80 million infected individuals. High-risk strains are associated with 6 different cancers. Although infection is preventable, U.S. vaccination rates remain suboptimal and there are noted disparities between urban and rural communities due to economic barriers, lack of access, and low awareness and education. METHODS: The current pilot study sought to overcome these barriers through an interprofessional collaborative enrolling a community pharmacy in a rural, medically underserved Alabama county as a Vaccines for Children (VFC) provider to provide free vaccines to eligible adolescents. Program evaluation was conducted to determine the intervention's feasibility. Potential efficacy was assessed by analyzing county-level HPV vaccination uptake and completion rates using state immunization registry data. RESULTS: Over the 8-month study, 166 total vaccines were administered to 89 adolescents ages 10-18, including 55 doses of HPV vaccine, 53 doses of Tdap vaccine, 45 doses of meningococcal vaccine, and 13 doses of influenza vaccine. Among these adolescents, mean age was 12.6 years old, and 64 (71.9%) were VFC patients. The pharmacy recorded an increase in total vaccine administration of 158.8%, an increase in prescription revenue of 34.8%, and an increase in total revenue by 24.4% during the course of the study, compared to the previous year. CONCLUSIONS: Findings from the current work demonstrate the potential of this strategy and can serve as a blueprint for statewide and national dissemination and implementation to ultimately increase access to vaccination services, increase vaccination rates, and reduce urban-rural vaccine disparities.

Cancer-related Beliefs and Preventive Health Practices among Residents of Rural versus Urban Counties in Alabama.

Higher prevalence of cancer-related risk factors, for example, tobacco use, obesity, poor diet, and physical inactivity, is observed in the U.S. Deep South and likely contributes to its increased cancer burden. While this region is largely rural, it is unknown whether cancer-related beliefs and lifestyle practices differ by rural-urban status or are more influenced by other factors. We contacted 5,633 Alabamians to complete a cross-sectional survey to discern cancer-related beliefs and lifestyle practices, and compared data from respondents residing in rural- versus urban-designated counties. Findings were summarized using descriptive statistics; rural-urban subgroups were compared using two-tailed, χ 2 and t tests. Multivariable logistic regression models were used to explore associations by rural-urban status and other sociodemographic factors. Surveys were completed by 671 rural- and 183 urban-county respondents (15.2% response rate). Overall, the prevalence for overweight and obesity (77.8%) and sugar-sweetened beverage intake (273-364 calories/day) was higher than national levels. Most respondents (58%) endorsed raising the state tobacco tax. Respondents from rural- versus urban-designated counties were significantly more likely to be racial/ethnic minority, have lower education, employment, income, food security, and internet access, and endorse fatalistic cancer-related beliefs (<0.05; although regression models suggested that cancer belief differences are more strongly associated with education than counties of residence). Lifestyle practices were similar among rural-urban subgroups. Few rural-urban differences in cancer-related beliefs and lifestyle practices were found among survey respondents, although the high overall prevalence of fatalistic health beliefs and suboptimal lifestyle behaviors suggests a need for statewide cancer prevention campaigns and policies, including increased tobacco taxation.Prevention Relevance: Cancer incidence and mortality are higher in the U.S. Deep South, likely due to increased tobacco-use, obesity, poor diet, and physical inactivity. This study explores whether cancer-related beliefs and lifestyle practices differ by rural-urban status or other sociodemographic factors in a random sample of 855 residents across Alabama.

Factors associated with HPV vaccination initiation among United States college students.

Human papillomavirus (HPV) remains the most common sexually transmitted infection (STI) in the U.S. despite widespread availability of a safe, effective vaccine. Although young adults are at greatest risk of HPV infection, extensive vaccine promotion and intervention efforts has been directed toward 11-12-year-olds. College students represent an ideal audience for HPV vaccine "catch-up;" however, research indicates inconsistent HPV vaccination rates within this demographic. An online survey assessing HPV and HPV vaccine knowledge and behaviors was distributed to all undergraduate college students at a large, public university in the Deep South region of the U.S. The primary outcome was receipt of HPV vaccination (binary response options of Yes/No). Logistic regression analyses were performed to determine predictors of HPV vaccination. Of the 1,725 who completed the survey, 47.0% reported having received at least one dose of HPV vaccine; overall series completion (series = 3 doses for this population) was 17.4%. The primary outcome was HPV initiation among college students, defined as having received at least one dose of the HPV vaccine. Results indicated substantial gaps in participants' knowledge of their vaccination status. Provider and parental recommendations as well as social influences were shown to significantly impact student vaccination status, emphasizing the importance of incorporating these elements in future interventions, potentially as multi-level strategies. Future college interventions should address HPV and vaccination knowledge and the importance of provider and parental recommendations.

HPV and HPV Vaccination Knowledge and Attitudes Among Medical Students in Alabama.

In addition to being the most common sexually transmitted infection, the human papillomavirus (HPV) is associated with six types of cancer in men and women. The HPV vaccine provides long-lasting, effective protection from high-risk HPV infection, thus serving as a means of cancer prevention. An effective healthcare provider recommendation is well-established as the most significant influence on HPV vaccine uptake, and, as emerging providers, it is critical that medical students receive comprehensive training in this area. However, the type and extent of such training for current medical students in the USA is unclear. An online survey assessing HPV and HPV vaccine knowledge, attitudes, and vaccine status was distributed to all medical students at an Alabama university. Scales were developed to assess composite HPV and HPV knowledge scores and HPV vaccination intentions. Of those age-eligible, 32.1% reported completion of the HPV vaccine series while 15.2% reported partial completion. Knowledge of both HPV and HPV vaccination significantly increased with program year (p < 0.0001 and p = 0.0069, respectively); however, there were knowledge gaps across all years regarding HPV-associated cancers. Attitudes and intentions showed a similar association, with more advanced students demonstrating more positive attitudes toward HPV vaccination (p = 0.0003). There is a need within the current curriculum to include more education and training on HPV, HPV vaccination, and counseling-particularly for students in the first 2 years of their program. Implementation of a classroom module or interactive workshop would likely improve knowledge and attitudes, better preparing students for their future role as potential immunizers.

Quantifying treatment preferences and their association with financial toxicity in women with breast cancer.

BACKGROUND: The objective of the current study was to understand treatment preferences and their association with financial toxicity in Patient Advocate Foundation clients with breast cancer. METHODS: This choice-based conjoint analysis used data from a nationwide sample of women with breast cancer who received assistance from the Patient Advocate Foundation. Choice sets created from 13 attributes of 3 levels each elicited patient preferences and trade-offs. Latent class analysis segmented respondents into distinct preference archetypes. The Comprehensive Score for Financial Toxicity (COST) tool captured financial toxicity. Adjusted generalized linear models estimated COST score differences by preference archetype. RESULTS: Of 220 respondents (for a response rate of 10%), the median age was 58 years (interquartile range, 49-66 years); 28% of respondents were Black, indigenous, or people of color; and approximately 60% had household incomes <$40,000. The majority of respondents were diagnosed with early-stage cancer (91%), 38% had recurrent disease, and 61% were receiving treatment. Treatment choice was most affected by preferences related to affordability and impact on activities of daily living. Two distinct treatment preference archetypes emerged. The "cost-prioritizing group" (75% of respondents) was most concerned about affordability, impact on activities of daily living, and burdening care partners. The "functional independence-prioritizing group" (25% of respondents) was most concerned about their ability to work, physical side effects, and interference with life events. COST scores were found to be similar between the archetypes in adjusted models (cost-prioritizing group COST score, 12 [95% confidence interval, 9-14]; and functional independence-prioritizing COST score, 11 [95% confidence interval, 9-13]). CONCLUSIONS: Patients with breast cancer prioritized affordability or maintaining functional independence when making treatment decisions. Because of this variability, preference evaluation during treatment decision making could optimize patients' treatment experiences.

Factors Associated with HPV Vaccination Uptake and HPV-Associated Cancers: A County-Level Analysis in the State of Alabama.

Despite availability of a safe, effective vaccination, uptake and completion rates of human papillomavirus (HPV) vaccination remain low in the United States. This is particularly true in the southeast, which also sees some of the highest rates of HPV-associated (HPVa) cancers. We aimed to identify areas in Alabama in need of intervention with respect to HPVa cancers and HPV vaccination, and factors potentially associated with these rates by performing county-level secondary data analysis using state and national data sources. Alabama ranks 15th nationally in HPVa cancer rates, with 66.7% and 80.8% of counties having higher HPVa cancer rates than the national incidences of males and females, respectively. Regarding HPV vaccination, 95.5% and 98.5% of Alabama's counties have uptake rates less than the national averages for males and females, respectively. The seven counties with the highest HPV vaccination uptake ranged in rates from 60.2 to 73.6%. Counties with the highest HPV vaccination rates for adolescents were majority African American with low adult educational attainment rates and high rates of poverty and publicly-insured children/adolescents. These counties were also located in Alabama's Black Belt region, traditionally known for low socioeconomics, reduced access to social services, and negative health outcomes. Some counties with the highest rates of HPVa cancers also had among the highest rates of HPV vaccination, indicating a potential association between perceived susceptibility and desire to get HPV vaccine in these communities, warranting further investigation. Future work is needed to translate these findings into actionable intervention practices to increase HPV vaccination.

Skin Cancer Early Detection Practices among Adult Survivors of Childhood Cancer Treated with Radiation.

Because rates of skin cancer are greater among adult survivors of childhood cancer who received radiation therapy than among the general population, the National Cancer Institute recommends skin self-examinations and annual physician examination. There has been no comprehensive assessment of survivors' adherence to the skin cancer screening guidelines associated with skin self-examination (SSE) and physician whole-body skin examination (PSE). We conducted a cross-sectional survey of radiation-treated, adult 5-year survivors of childhood cancer, diagnosed between 1970 and 1986, in the Childhood Cancer Survivor Study cohort. Multivariate multinomial logit regression investigated the association between demographic, cancer diagnosis, patient activation, cancer treatment characteristics, and skin cancer screening practice. Among 728 survivors, 13.1% reported performing SSE in the prior 2 months plus receiving PSE in the prior 12 months, and 16.4% and 11.0% reported performing only an SSE or a PSE, respectively; 59.5% of survivors reported having had neither. Participants at the highest patient activation score were most likely to report SSE plus PSE compared with neither (adjusted relative risk ratio = 4.16, 95% confidence interval = 1.34-12.85). Most adult survivors of childhood cancer who had radiation therapy do not practice strategies that promote early detection of skin cancer. Interventions designed to activate survivors to increase their participation in screening are needed.