High-Risk Human Papillomavirus Messenger RNA Testing Using Urine, Cervicovaginal Self-Collected and Provider-Collected Cervical Samples Among Women in Mombasa, Kenya.

ABSTRACT: We compared human papillomavirus messenger RNA testing using urine, self-, and provider-collected samples for the detection of high-grade cervical cytology and assessed acceptability of urine self-collection among females who engage in sex work in Kenya. Participants found urine sampling comfortable, but high-risk human papillomavirus messenger RNA detection in urine samples was less likely to detect high-grade lesions than self- and provider-collected cervical samples.

Testing for Sexually Transmitted Infection Using Wet and Dry Self-Collected Brush Samples Among Women in Mombasa, Kenya.

ABSTRACT: We compared detection of Chlamydia trachomatis , Neisseria gonorrhoeae , and Trichomonas vaginalis using dry and wet self-collected samples using brushes among females who engage in sex work in Mombasa, Kenya. Detection of T. vaginalis and N. gonorrhoeae in dry and wet samples was similar, but C. trachomatis detection in dry samples appeared lower.

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.

Quality Improvement Coaching for Human Papillomavirus Vaccination Coverage: A Process Evaluation in 3 States, 2018-2019.

PURPOSE AND OBJECTIVES: Quality improvement (QI) coaching improves human papillomavirus (HPV) vaccination coverage, but effects of coaching have been small, and little is known about how and when QI coaching works. To assess implementation outcomes and explore factors that might explain variation in outcomes, we conducted a process evaluation of a QI coaching intervention for HPV vaccination. INTERVENTION APPROACH: QI coaches received tools and training to support 4 core coaching competencies: 1) expertise in using clinic-level adolescent vaccination data to drive change, 2) knowledge of the evidence base to support change in HPV vaccination practice, 3) familiarity with improvement strategies and action planning, and 4) skill in building relationships. EVALUATION METHODS: Our mixed methods evaluation involved collecting quantitative data through effort-tracking logs and gathering qualitative data through in-depth interviews with QI coaches (N = 11) who worked with 89 clinics in 3 US states. Data were collected on implementation outcomes and on contextual factors that might explain variations in those outcomes. Implementation outcomes included adoption by clinics, reach to providers and staff (ie, participation in the coaching visit), and implementation fidelity. RESULTS: States achieved either high adoption or high reach, but not both. For example, state A had high adoption with 94% of clinics accepting a coaching visit, but low reach with a median of 1 participant per clinic. In contrast, state C had lower adoption (29%, P < .01) than state A but higher reach (median of 4 participants per clinic, P < .01). Generally, states had high coaching protocol fidelity with the exception of advising on strategies and action planning. QI coaches described factors that might explain these variations, including strength of relationships with clinic staff and whether they recruited clinics directly or through large clinic networks. IMPLICATIONS FOR PUBLIC HEALTH: Our findings have implications for the design of future QI coaching initiatives, including how coaches recruit clinics to ensure full clinic engagement, refinements to coaching visits, and how QI coaches can effectively engage with clinic networks. Findings could inform future QI coaching interventions to strengthen their impact on public health.

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.

Feasibility of using an app-based coaching intervention to improve provider communication about HPV vaccination.

Provider communication training is effective for increasing HPV vaccination rates among U.S. adolescents. However, such trainings often rely on in-person meetings, which can be burdensome for providers and costly to implement. To evaluate the feasibility of Checkup Coach, an app-based coaching intervention, to improve provider communication about HPV vaccination. In 2021, we offered Checkup Coach to providers in 7 primary care clinics in a large integrated delivery system. Participating providers (n = 19) attended a 1-h interactive virtual workshop that taught 5 high-quality practices for recommending HPV vaccination. Providers then had 3 months of access to our mobile app, which offered ongoing communication assessments, tailored tips for addressing parents' concerns, and a dashboard of their clinic's HPV vaccination coverage. Online surveys assessed pre-/post-intervention changes in providers' perceptions and communication behaviors. Compared to baseline, more providers reported high-quality HPV vaccine recommendation practices at 3-month follow-up (47% vs. 74%, p < .05). Providers' knowledge, self-efficacy, and shared commitment to improving HPV vaccination also improved (all p < .05). Although we found improvements in several other cognitions after the workshop, these changes did not retain statistical significance at 3 months. About three-quarters (78%) of providers used the mobile app, logging 2.3 sessions on average. Most providers agreed the app was easy to use (mean = 4.7/5.0), a convenient way to get vaccination data (mean = 4.6/5.0), and a tool they would recommend (mean = 4.3/5.0). Our app-based coaching intervention demonstrated feasibility and warrants additional evaluation as a novel mode for training providers to improve their HPV vaccine communication.

The aim of this study was to evaluate the feasibility of Checkup Coach, an app-based coaching intervention to improve provider communication about HPV vaccination, by offering the app to providers in 7 primary care clinics in a large integrated delivery system. Participating providers attended a 1-h interactive virtual workshop that taught high-quality HPV vaccine recommendation practices. For the following 3 months, providers used the app for ongoing communication assessments, tailored tips for addressing parents' concerns, and a dashboard of their clinic's HPV vaccination rates. Online surveys assessed pre- and post-intervention changes in providers' perceptions and communication practices. The percentage of providers reporting high-quality HPV vaccine recommendation practices increased from baseline to follow-up. Providers also reported higher HPV vaccine-related knowledge, self-efficacy, and shared commitment at 3 months. Providers agreed that the app was easy to use, a convenient way to get vaccination data, and a tool they would recommend. Our app-based coaching intervention demonstrated feasibility and warrants additional evaluation as a novel mode for training providers to improve their HPV vaccine communication.

Primary care professionals' support for Covid-19 vaccination mandates: Findings from a US national survey.

Healthcare organizations have been early adopters of Covid-19 vaccine mandates as a strategy to end the pandemic. We sought to evaluate support for such mandates among pediatric primary care professionals (PCPs) in the United States. In February-March 2021, we conducted a national online survey of 1,047 PCPs (71% physicians). We used multivariable logistic regression to assess correlates of PCPs' support for Covid-19 vaccine mandates for health care workers. Most PCPs supported Covid-19 vaccine mandates for health care workers (83%). PCPs were more likely to support mandates if they perceived health care workers to be at highest risk of getting Covid-19 compared to other worker types (8 percentage points, p < 0.01). PCPs were also more likely to support mandates if their clinic recommended or required vaccination (11 percentage points and 20 percentage points respectively, both p < 0.01). However, PCPs were less likely to support mandates if their clinic offered incentives to vaccinate (10 percentage points, p < 0.05). Clinic recommendations and requirements for Covid-19 vaccination may increase support for mandates. Incentives may decrease support, perhaps by creating the perception that viable alternatives to mandates exist.

Explaining higher Covid-19 vaccination among some US primary care professionals.

BACKGROUND AND OBJECTIVE: Research in several countries shows higher Covid-19 vaccination willingness and uptake among physicians than nurses. Our paper aims to characterize and explain this difference. METHODS: In early 2021, we surveyed 1047 U.S. primary care professionals who served adolescents, ages 11-17. The national sample included physicians (71%) as well as nurses and advanced practice providers. The survey assessed the three domains of the Increasing Vaccination Model: thinking and feeling, social processes, and direct behavior change. RESULTS: Covid-19 vaccine uptake was higher among physicians than among nurses and advanced practice providers (91% vs. 76%, p < .05). Overall, in the thinking and feeling domain, higher confidence in Covid-19 vaccination, higher perceived susceptibility to the disease, and stronger anticipated regret were associated with higher vaccine uptake (all p < .05). In the social processes domain, perceiving more positive social norms for Covid-19 vaccination, receiving recommendations to get the vaccine, and wanting to help others were associated with higher vaccine uptake (all p < .05). In the direct behavior change domain, receiving an invitation to get the vaccine and better access to vaccination were associated with higher uptake (both p < .05). Of these variables, most of the thinking and feeling and social processes variables mediated the association of training with vaccine uptake. CONCLUSIONS: Physicians had higher Covid-19 vaccine uptake than nurses and advanced practice providers, corresponding with their more supportive vaccine beliefs and social experiences. Efforts to reach the remaining unvaccinated cohort can build on these findings.

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.

Feasibility and sustainability of a nurse-led intervention to integrate HPV vaccination into medical processing for active-duty Soldiers.

To increase Soldiers' access to HPV vaccination, we evaluated the feasibility and sustainability of a nurse-led intervention to integrate HPV vaccination into medical processing procedures for Soldiers. We partnered with nursing staff to introduce HPV vaccine into existing vaccination services at a nurse-led clinic that serves Soldiers at Fort Bragg, North Carolina. In addition to stocking the vaccine, the intervention included training nursing staff (n = 11) strategies for recommending HPV vaccination for Soldiers ages 18-26. We conducted surveys of nursing staff to assess their perspectives on feasibility. Nursing staff tracked HPV vaccine uptake among Soldiers for 4 weeks post-training to assess adoption and again for 2 weeks at 4-month follow-up to assess sustainability. We assessed delivery cost as the cost of personnel time, vaccine doses, and other materials during the initial 4-week intervention period. Nursing staff agreed that recommending HPV vaccination fit in with medical processing procedures (mean = 4.6 of 5.0). Of the 516 Soldiers offered HPV vaccine in the 4 weeks following the training, 198 (38%) accepted and received the vaccine. Soldier ages 18-20 more often accepted HPV vaccination than older Soldier ages 21-26 (46% versus 32%, p < .01). Vaccine uptake was similar at follow-up, with 98 of 230 eligible Soldiers (43%) receiving HPV vaccine. The total delivery cost was $12,737, with an average cost per vaccine dose delivered of $64. Our findings suggest that training nursing staff to recommend and administer HPV vaccinations to Soldiers is feasible and warrants wider-scale testing as a strategy to protect soldiers from HPV-attributable cancers.

HPV vaccination is not required for US military service, and Soldiers' uptake is low. We trained nursing staff at a large military clinic to recommend HPV vaccine to Soldiers using a nursing education intervention to integrate HPV vaccination into routine care for active duty Soldiers. Our findings suggest that training nursing staff to recommend and administer HPV vaccines to Soldiers is feasible and low cost, and may warrant wider-scale testing as a strategy for increasing military readiness and protecting Soldiers from HPV-attributable cancers. Until guideline and policy changes are implemented and HPV vaccine is required for military service, use of education strategies is one path to increasing HPV vaccine coverage among Soldiers to ensure protection from HPV-related diseases.

Implementation of quality improvement coaching versus physician communication training for improving human papillomavirus vaccination in primary care: a randomized implementation trial.

Many US health departments (HDs) conduct in-person quality improvement (QI) coaching to help primary care clinics improve their HPV vaccine delivery systems and communication. Some HDs additionally conduct remote communication training to help vaccine prescribers recommend HPV vaccination more effectively. Our aim was to compare QI coaching and communication training on key implementation outcomes. In a cluster randomized trial, we offered 855 primary care clinics: 1) QI coaching; 2) communication training; or 3) both interventions combined. In each trial arm, we assessed adoption (proportion of clinics receiving the intervention), contacts per clinic (mean number of contacts needed for one clinic to adopt intervention), reach (median number of participants per clinic), and delivery cost (mean cost per clinic) from the HD perspective. More clinics adopted QI coaching than communication training or the combined intervention (63% vs 16% and 12%, both p < .05). QI coaching required fewer contacts per clinic than communication training or the combined intervention (mean = 4.7 vs 29.0 and 40.4, both p < .05). Communication training and the combined intervention reached more total staff per clinic than QI coaching (median= 5 and 5 vs 2, both p < .05), including more prescribers (2 and 2 vs 0, both p < .05). QI coaching cost $439 per adopting clinic on average, including follow up ($129/clinic), preparation ($73/clinic), and travel ($69/clinic). Communication training cost $1,287 per adopting clinic, with most cost incurred from recruitment ($653/clinic). QI coaching was lower cost and had higher adoption, but communication training achieved higher reach, including to influential vaccine prescribers.

Our cluster randomized trial compared two interventions that health departments commonly use to increase HPV vaccination coverage: quality improvement (QI) coaching and physician communication training. We found that QI coaching cost less and was more often adopted by primary care clinics, but communication training reached more staff members per clinic, including vaccine prescribers. Findings provide health departments with data needed to weigh the implementation strengths and challenges of QI coaching and physician communication training for increasing HPV vaccination coverage.

Coaching and Communication Training for HPV Vaccination: A Cluster Randomized Trial.

BACKGROUND AND OBJECTIVES: US health departments routinely conduct in-person quality improvement (QI) coaching to strengthen primary care clinics' vaccine delivery systems, but this intervention achieves only small, inconsistent improvements in human papillomavirus (HPV) vaccination. Thus, we sought to evaluate the effectiveness of combining QI coaching with remote provider communication training to improve impact. METHODS: With health departments in 3 states, we conducted a pragmatic 4-arm cluster randomized clinical trial with 267 primary care clinics (76% pediatrics). Clinics received in-person QI coaching, remote provider communication training, both interventions combined, or control. Using data from states' immunization information systems, we assessed HPV vaccination among 176 189 patients, ages 11 to 17, who were unvaccinated at baseline. Our primary outcome was the proportion of those, ages 11 to 12, who had initiated HPV vaccination at 12-month follow-up. RESULTS: HPV vaccine initiation was 1.5% points higher in the QI coaching arm and 3.8% points higher in the combined intervention arm than in the control arm, among patients ages 11 to 12, at 12-month follow-up (both P < .001). Improvements persisted at 18-month follow-up. The combined intervention also achieved improvements for other age groups (ages 13-17) and vaccination outcomes (series completion). Remote communication training alone did not outperform the control on any outcome. CONCLUSIONS: Combining QI coaching with remote provider communication training yielded more consistent improvements in HPV vaccination uptake than QI coaching alone. Health departments and other organizations that seek to support HPV vaccine delivery may benefit from a higher intensity, multilevel intervention approach.

Couple communication and contraception use in urban Senegal.

OBJECTIVES: Couple communication about family planning has been shown to increase uptake of contraception. However, couple communication is often measured based solely on one partner's report of communication. This research investigates the influence of couple-reported communication about family planning on current and future use of contraception using couple-level data. METHODS: We used baseline data from the Measurement, Learning, and Evaluation (MLE) project collected through household surveys in 2011 from a cross-sectional representative sample of women and men in urban Senegal to conduct secondary data analysis. We used multivariable logit models to estimate the average marginal effects of couple communication about family planning on current contraception use and future intention to use contraception. RESULTS: Couple communication about family planning reported by both partners was significantly associated with an increased likelihood of current use of contraception and with future intention to use contraception among non-contracepting couples. Couples where one partner reported discussing family planning had a 25% point greater likelihood of current contraception use than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 56% point greater likelihood of current contraception use, representing more than twice the effect size. Among couples not using contraception, couples where one partner reported discussing family planning had a 15% point greater likelihood of future intention to use contraception than couples where neither partner reported discussing, while couples where both partners reported discussing family planning had a 38% point greater likelihood of future intention to use contraception. CONCLUSION: These findings underscore the importance of the inclusion of both partners in family planning programs to increase communication about contraception and highlight the need for future research using couple-level data, measures, and analysis.

Partnering with healthcare systems to improve HPV vaccination:The perspective of immunization program managers.

The US's 64 CDC-funded immunization programs are at the forefront of efforts to improve the quality of adolescent vaccination services. We sought to understand immunization program managers' perspectives on partnering with healthcare systems to improve HPV vaccine uptake. Managers of 44 state and local immunization programs completed our online survey in 2019. Immunization managers strongly endorsed the importance of partnering with systems to improve HPV vaccine uptake (mean = 3.8/4.0), and most wanted to do so in the next year (mean = 3.5). Immunization managers reported that common barriers included difficulty contacting systems' leadership (57%), differing organizational cultures (52%), and time (52%). Many perceived systems as not prioritizing HPV vaccination (77%). Immunization managers expressed strong interest in participating in a training on partnering with systems (mean = 3.5). Overall, immunization managers are highly interested in partnering with systems to improve HPV vaccine uptake. Training and other support are needed to expand programs' capacity for such partnerships.

PLAIN LANGUAGE SUMMARYImmunization managers are interested in partnering with healthcare systems to improve HPV vaccination. However, support may be needed to facilitate partnerships between immunization programs and healthcare systems.

Prioritizing and implementing HPV vaccination quality improvement programs in healthcare systems: the perspective of quality improvement leaders.

Human papillomavirus (HPV) vaccination could prevent most of the ~34,000 HPV-attributable cancers diagnosed annually in the US, but uptake remains suboptimal. Healthcare systems are key partners in implementing HPV vaccination quality improvement (QI) programs. To inform future system-level HPV vaccine initiatives, we sought to understand HPV vaccine QI from the perspective of QI program leaders in healthcare systems. We conducted telephone interviews with a multi-state sample of 17 QI leaders in 15 systems. We analyzed data qualitatively via thematic analysis to describe QI leaders' perspectives on prioritizing and implementing HPV vaccine QI. All QI leaders endorsed HPV vaccination as beneficial, and some had already prioritized increasing uptake to improve adolescent health and meet payor reimbursement standards. Those not prioritizing HPV vaccination cited concerns including the relatively small size of adolescent patient populations, lack of buy-in among providers, and the need to focus on health services perceived as more profitable or urgent. When implementing HPV vaccine QI programs, QI leaders reported key barriers to be the lack of robust data systems and acceptable QI metrics, limited time, and pressures of a fee-for-service clinical environment. Facilitators included automation and standardization in QI efforts and passionate vaccine champions. Almost all QI leaders reported future plans to implement HPV vaccine QI projects. Findings suggest that many healthcare systems are motivated to improve HPV vaccination. However, resistance to guideline-consistent quality metrics, the narrow target of one vaccine in the adolescent patient population, payment structures, and constrained time of providers are key barriers to practice improvements.

Investigator Experiences Using Mobile Technologies in Clinical Research: Qualitative Descriptive Study.

BACKGROUND: The successful adoption of mobile technology for use in clinical trials relies on positive reception from key stakeholders, including clinical investigators; however, little information is known about the perspectives of investigators using mobile technologies in clinical trials. OBJECTIVE: The aim of this study was to seek investigators' insights on the advantages and challenges of mobile clinical trials (MCTs); site-level budgetary, training, and other support needs necessary to adequately prepare for and implement MCTs; and the advantages and disadvantages for trial participants using mobile technologies in clinical trials. METHODS: Using a qualitative descriptive study design, we conducted in-depth interviews with investigators involved in the conduct of MCTs. Data were analyzed using applied thematic analysis. RESULTS: We interviewed 12 investigators who represented a wide variety of clinical specialties and reported using a wide range of mobile technologies. Investigators most commonly cited 3 advantages of MCTs over traditional clinical trials: more streamlined study operations, remote data capture, and improvement in the quality of studies and data collected. Investigators also reported that MCTs can be designed around the convenience of trial participants, and individuals may be more willing to participate in MCTs because they can take part from their homes. In addition, investigators recognized that MCTs can also involve additional burden for participants and described that operational challenges, technology adoption barriers, uncertainties about data quality, and time burden made MCTs more challenging than traditional clinical trials. Investigators stressed that additional training and dedicated staff effort may be needed to select a particular technology for use in a trial, helping trial participants learn and use the technology, and for staff troubleshooting the technology. Investigators also expressed that sharing data collected in real time with investigators and trial participants is an important aspect of MCTs that warrants consideration and potentially additional training and education. CONCLUSIONS: Investigator perspectives can inform the use of mobile technologies in future clinical trials by proactively identifying and addressing potential challenges.

Physicians' rhetorical strategies for motivating HPV vaccination.

RATIONALE: Receiving a healthcare provider's recommendation is a well-documented predictor of human papillomavirus (HPV) vaccination, and yet recommendations remain understudied and undertheorized. OBJECTIVE: To qualitatively describe strategies providers use to motivate HPV vaccination. METHOD: We surveyed a national sample of 771 U.S. primary care physicians. Data came from an open-ended item that assessed physicians' perspectives on the most effective thing they could say to persuade parents to get HPV vaccine for their 11- to 12-year-old children. Using a standardized codebook and two independent coders, we conducted a thematic analysis to identify rhetorical strategies underlying physicians' responses. RESULTS: We identified two sets of strategies for motivating HPV vaccination. One set drew parents' attention to specific actors or vaccine characteristics. Physicians using these strategies asked parents to consider their children's individual risk in the short-term, named specific diseases that could be prevented, emphasized the novelty of HPV vaccine as a cancer prevention tool, and gave their personal endorsement for HPV vaccination. In contrast, the second set of strategies was more distancing and impersonal. Physicians using these strategies referenced future risk, described cancer prevention in general terms, framed HPV vaccine as similar to other vaccines, and shared organizational endorsements for HPV vaccination. Across these two sets of strategies, a tension emerged between the goals of engaging parents' perceptions of HPV as a threat to their children versus framing HPV vaccination as a normative standard of care. CONCLUSIONS: Our findings suggest that theoretical frameworks, such as Construal Level Theory, may be helpful for positioning provider recommendations in the broader literature on persuasive communication. By identifying competing approaches to motivating HPV vaccination, this study lays the groundwork for future research to test the acceptability and impact of strategies for recommending routine preventive care.

Expedited Medicaid Enrollment, Service Use, and Recidivism at 36 Months Among Released Prisoners With Severe Mental Illness.

OBJECTIVE: This study examined long-term outcomes (at 36 months) from Washington State's policy of expediting Medicaid enrollment for prison releasees with severe mental illness and compares them with previously reported short-term outcomes (at 12 months). METHODS: Linked administrative data on prison releasees (2006-2007) were analyzed by using a quasi-experimental design comparing those referred to expedited Medicaid (N=895) with a control group of those not referred (N=2,189). Aggregate outcomes were analyzed with inverse probability of treatment-weighted logit models. RESULTS: Expedited Medicaid had a sustained effect on both increased months of enrollment (p<.01) and increased use of community mental health and general medical services (p<.01) 36 months after prison release. However, expedited Medicaid did not reduce criminal recidivism, consistent with 12-month findings, Conclusions: Outcome results at 12 months were sustained at 36 months-namely, expedited Medicaid for released prisoners with severe mental illness improved enrollment and service use with no effects on criminal recidivism.