Adaptation and Formative Evaluation of Online Decision Support to Implement Evidence-Based Strategies to Increase HPV Vaccination Rates in Pediatric Clinics.

Human papilloma virus (HPV) vaccination rates remain below national goals in the United States despite the availability of evidence-based strategies to increase rates. The Adolescent Vaccination Program (AVP) is a multi-component intervention demonstrated to increase HPV vaccination rates in pediatric clinics through the implementation of six evidence-based strategies. The purpose of this study, conducted in Houston, Texas, from 2019-2021, was to adapt the AVP into an online decision support implementation tool for standalone use and to evaluate its feasibility for use in community clinics. Phase 1 (Adaptation) comprised clinic interviews (n = 23), literature review, Adolescent Vaccination Program Implementation Tool (AVP-IT) design documentation, and AVP-IT development. Phase 2 (Evaluation) comprised usability testing with healthcare providers (HCPs) (n = 5) and feasibility testing in community-based clinics (n = 2). AVP-IT decision support provides an Action Plan with tailored guidance on implementing six evidence-based strategies (immunization champions, assessment and feedback, continuing education, provider prompts, parent reminders, and parent education). HCPs rated the AVP-IT as acceptable, credible, easy, helpful, impactful, and appealing (≥80% agreement). They rated AVP-IT supported implementation as easier and more effective compared to usual practice (p ≤ 0.05). The clinic-based AVP-IT uses facilitated strategy implementation by 3-month follow-up. The AVP-IT promises accessible, utilitarian, and scalable decision support on strategies to increase HPV vaccination rates in pediatric clinic settings. Further feasibility and efficacy testing is indicated.

Parents' stigmatizing beliefs about the HPV vaccine and their association with information seeking behavior and vaccination communication behaviors.

Parents' stigmatizing beliefs about the HPV vaccine, such as beliefs that it promotes adolescent sexual activity, constitute a notable barrier to vaccine uptake. The purpose of this study is to describe the associations between parents' stigmatizing beliefs about the HPV vaccine, psychosocial antecedents to vaccination, and parents' intentions to vaccinate their children. Parents of vaccine-eligible children (n = 512) were surveyed in a large urban clinical network. Results indicate that two stigmatizing beliefs were significantly associated with self-efficacy in talking with a doctor about the HPV vaccine. Believing that the vaccine would make a child more likely to have sex was associated with citing social media as a source of information about the vaccine. Other stigmatizing beliefs were either associated with citing healthcare professionals as sources of information about the vaccine, or they were not significantly associated with any information source. This finding suggests that stigmatizing beliefs might discourage parents from seeking out information about the vaccine. This study is significant because it further highlights the importance of doctor recommendations to all patients at recommended ages; doctor visits may represent one of the few opportunities to normalize HPV vaccination and address parents' stigmatizing beliefs about the HPV vaccine.

Improving Student Perceptions of Simulation Effectiveness With Co-Facilitation From Prebriefing Through Debriefing.

ABSTRACT: Co-facilitation (combining presence and expertise of clinical faculty and simulationists during all stages of simulation) presents an opportunity to improve student perceptions of effectiveness. Using a retrospective before and after comparison, data on students' perceptions were collected from baccalaureate nursing students in clinical courses after each simulation experience. Mean differences in Simulation Effectiveness Tool-Modified scores for pre- and post-implementation were compared, as well as scores between levels of students. Statistically significant improvements in student-rated simulation effectiveness were found with co-facilitation. The authors recommend future studies expanding this methodology and considering co-facilitation where feasible.

AVPCancerFree: Impact of a digital behavior change intervention on parental HPV vaccine -related perceptions and behaviors.

Parent hesitancy contributes to reduced HPV vaccination rates. The HPVcancerfree app (HPVCF) was designed to assist parents in making evidence-based decisions regarding HPV vaccination. This study examined if parents of vaccine-eligible youth (11-12 yrs.) who use HPVCF in addition to usual care demonstrate significantly more positive intentions and attitudes toward HPV vaccination and greater HPV vaccination rates compared to those not using HPVCF. Clinics (n = 51) within a large urban pediatric network were randomly assigned to treatment (HPVCF + usual care) or comparison (usual care only) conditions in a RCT conducted between September 2017 and February 2019. Parents completed baseline and 5-month follow-up surveys. Participant-level analysis determined 1) change in HPV vaccination initiation behavior and related psychosocial determinants and 2) predictors of HPV vaccine initiation. Parents (n = 375) who completed baseline and 5-month follow-up surveys were female (95.2%), 40.8 (±5.8) yrs. married (83.7%), employed (68.3%), college educated (61.9%), and privately insured (76.5%). Between-group analysis of HPVCF efficacy demonstrated that parents assigned to receive HPVCF significantly increased knowledge about HPV and HPV vaccination (p < .05). Parents who accessed content within HPVCF significantly increased knowledge about HPV & HPV vaccine (p < .01) and perceived effectiveness of HPV vaccine (p < .05). Change in HPV vaccine initiation was not significant. A multivariate model to describe predictors of HPV vaccine initiation demonstrated an association with Tdap and MCV vaccination adoption, positive change in perceived effectiveness of the HPV vaccine, and reduction in perceived barriers against HPV vaccination. HPVCF appears to be a feasible adjunct to the education received in usual care visits and reinforces the value of apps to support the important persuasive voice of the health-care provider in overcoming parent HPV vaccine hesitancy.

Parent Engagement with a Self-Tailored Cancer Prevention Digital Behavior Change Intervention: Exploratory Application of Affiliation Network Analysis.

Evaluating digital behavior change intervention engagement is complex and requires multidimensional and novel approaches that are emerging. The relationship and interdependence between engagement with the technology and engagement with the psychosocial or behavior change process often presents conceptual and evaluative challenges. Large objective data sets detailing technology use are plentiful but meaningful interpretation can be challenging at granular levels. Affiliation network analysis which describes two-mode network data may provide a novel approach to evaluate engagement of digital behavior change interventions. The purpose of this paper is to use affiliation network analysis as an exploratory method to describe, assess and visualize content-specific patterns underlying psychosocial characteristics related to HPV vaccine safety concerns of parents using the HPVcancerFree intervention. Results indicate that affiliation network analysis shows promise in supplementing existing methods to assess engagement of digital interventions.

Parents' Experience With a Mobile Health Intervention to Influence Human Papillomavirus Vaccination Decision Making: Mixed Methods Study.

BACKGROUND: Human papillomavirus (HPV)-attributed cancers are preventable, yet HPV vaccination rates severely lag behind other adolescent vaccinations. HPVcancerFree (HPVCF) is a mobile health (mHealth) intervention developed to influence parental HPV vaccination decision making by raising awareness of HPV, reducing HPV vaccination barriers, and enabling HPV vaccination scheduling and reminders through a smartphone app. Evaluating the user experience of mHealth interventions is a vital component in assessing their quality and success but tends to be underreported in mHealth intervention evaluation. OBJECTIVE: We aimed to evaluate the user experience of HPVCF, an HPV cancer prevention app designed for a pediatric clinic network, using mixed methods data collected from log files, survey measures, and qualitative feedback. METHODS: Study data were evaluated from parents in a large US pediatric clinic network using HPVCF in the treatment study condition of a group randomized controlled trial. Log data captured HPVCF retention and use. Postintervention rating scales and items assessed HPVCF utility, usefulness, understandability, appeal, credibility, and perceived impact. Overall quality was evaluated using the user version of the Mobile Application Rating Scale (uMars). Open-ended responses assessed parent recommendations for HPVCF enhancement. RESULTS: The 98 parents were mainly female (n=94, 96%), 41 (5.67) years of age, college educated (n=55, 56%), and White and non-Hispanic (n=55, 56%) and had private health insurance for their children (n=75, 77%). Parents used HPVCF 197 times, with the average visit duration approximating 3.5 minutes. The uMARS app quality score was positively skewed (4.2/5.0). Mean ratings were highest for information (4.46 [SD 0.53]) and lowest for engagement (3.74 [SD 0.69]). In addition, of 95 parents, 45 (47%) rated HPVCF as helpful in HPV vaccination decision making and 16 (17%) attributed HPV vaccine initiation to HPVCF. Parents reported that HPVCF increased their awareness (84/95, 88%), knowledge (84/95, 88%), and HPV vaccination intentions (64/95, 67%). Most of the 98 parents rated the 4 HPVCF components as useful (72-92 [73%-94%]). Parents also agreed that HPVCF is clear (86/95, 91%), accurate (86/95, 91%), and more helpful than other HPV vaccine information they had received (89/95, 94%) and that they would recommend it to others (81/95, 85%). In addition, parents suggested ways to increase awareness and engagement with the app, along with opportunities to enhance the content and functionality. CONCLUSIONS: HPVCF was well received by parents and performed well on indicators of quality, usefulness, utility, credibility, and perceived impact. This study contributes a multimethod and multimeasure evaluation to the growing body of literature focused on assessing the user experience of patient-focused technology-mediated applications for HPV education.

Informing Content and Feature Design of a Parent-Focused Human Papillomavirus Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Group Study.

BACKGROUND: Human papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making. OBJECTIVE: This study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI. METHODS: We conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network. RESULTS: The 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience. CONCLUSIONS: Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child's pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents.

Baseline Cardiopulmonary Resuscitation Skill Performance of Nursing Students Is Improved After One Resuscitation Quality Improvement Skill Refresher.

This article reports the results of baseline cardiopulmonary resuscitation (CPR) skills performance measurements from 467 nursing students. All participants had completed a CPR course. Baseline measurements were compared to performance after one 10-minute refresher training session on the Resuscitation Quality Improvement system. Significant improvements were made after the computer- and practice-based refresher. Findings suggest that staff developers should evaluate the use of audio and visual feedback devices to improve the quality of CPR provided by clinical staff.

Planning and managing a complex multisite study in the age of technology.

A 2-year long, multisite research study that evaluated cardiopulmonary resuscitation skill decay among nursing students was conducted at 10 schools of nursing across the United States. The study was conducted in two phases and required carefully timed sessions for skill performance. Multisite studies in nursing education need to be carefully planned. Time delays should be anticipated with processes and Institutional Review Board protocols across sites. All team members were trained and consistently supported during the entire study. While challenges and obstacles were identified, innovative solutions were implemented that assisted the research team to successfully complete the study. The use of new and existing technology allowed the team to surmount many of the challenges encountered in this study. The purpose of this article is to describe the logistics, processes, challenges, and lessons learned related to conducting a complex multisite study.

Validity and reliability of measures to assess constructs from the inner setting domain of the consolidated framework for implementation research in a pediatric clinic network implementing HPV programs.

BACKGROUND: Accurate and valid measures for implementation constructs are critical to advance research and guide implementation efforts. However, there is a continued need for valid and reliable measures for implementation research. The purpose of this study was to assess the psychometric properties of measures for the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR) in a network of pediatric clinics. METHODS: This study used cross-sectional survey data collected from physicians, advanced practice providers, clinic managers, and clinical staff (n = 546) working in a pediatric clinic network (n = 51). Surveys included measures assessing Inner Setting constructs from CFIR (culture, learning climate, leadership engagement, and available resources). We used a series multilevel confirmatory factor analysis (CFA) models to assess factorial validity. We also examined measure correlations to test discriminant validity and intraclass correlation coefficients, ICC(1) and ICC(2), to assess inter-rater reliability. RESULTS: Factor loadings were high (≥0.60) for all but one of the measurement items. Most CFA models for respective constructs demonstrated adequate or good model fit (CFI > 0.90, TLI > 0.90, RMSEA< 0.08, and SRMR< 0.08). The measures also demonstrated good discriminant validity (correlations< 0.90) aside from some evidence of overlap between leadership engagement and learning climate at the clinic level (0.91). The ICC(1) values ranged from 0.05-0.16 while the ICC(2) values ranged from 0.34-0.67. CONCLUSIONS: The measures demonstrated good validity and adequate reliability with the exception of available resources, which had some evidence of lower than desired reliability and validity at the clinic level. Our findings extend previous work by providing additional psychometric evidence to support the use of these Inner Setting measures in pediatric clinics implementing human papillomavirus programs.