Extending an Antiracism Lens to the Implementation of Precision Public Health Interventions.

Precision public health holds promise to improve disease prevention and health promotion strategies, allowing the right intervention to be delivered to the right population at the right time. Growing concerns underscore the potential for precision-based approaches to exacerbate health disparities by relying on biased data inputs and recapitulating existing access inequities. To achieve its full potential, precision public health must focus on addressing social and structural drivers of health and prominently incorporate equity-related concerns, particularly with respect to race and ethnicity. In this article, we discuss how an antiracism lens could be applied to reduce health disparities and health inequities through equity-informed research, implementation, and evaluation of precision public health interventions. (Am J Public Health. 2023;113(11):1210-1218. https://doi.org/10.2105/AJPH.2023.307386).

Identifying locally actionable strategies to increase participant acceptability and feasibility to participate in Phase I cancer clinical trials.

BACKGROUND: Recruitment of cancer clinical trial (CCT) participants, especially participants representing the diversity of the US population, is necessary to create successful medications and a continual challenge. These challenges are amplified in Phase I cancer trials that focus on evaluating the safety of new treatments and are the gateway to treatment development. In preparation for recruitment to a Phase I recurrent head and neck cancer (HNC) trial, we assessed perceived barriers to participation or referral and suggestions for recruitment among people with HNC and community physicians (oncologist, otolaryngologist or surgeon). METHODS: Between December 2020 and February 2022, we conducted a qualitative needs assessment via semistructured interviews with a race and ethnicity-stratified sample of people with HNC (n = 30: 12 non-Hispanic White, 9 non-Hispanic African American, 8 Hispanic and 1 non-Hispanic Pacific Islander) and community physicians (n = 16) within the University of Florida Health Cancer Center catchment area. Interviews were analyzed using a qualitative content analysis approach to describe perspectives and identify relevant themes. RESULTS: People with HNC reported thematic barriers included: concerns about side effects, safety and efficacy; lack of knowledge and systemic and environmental obstacles. Physicians identified thematic barriers of limited physician knowledge; clinic and physician barriers and structural barriers. People with HNC and physicians recommended themes included: improved patient education, dissemination of trial information and interpersonal communication between community physicians and CCT staff. CONCLUSIONS: The themes identified by people with HNC and community physicians are consistent with research efforts and recommendations on how to increase the participation of people from minoritized populations in CCTs. This community needs assessment provides direction on the selection of strategies to increase CCT participation and referral. PATIENT OR PUBLIC CONTRIBUTION: This study focused on people with HNC and community physicians' lived experience and their interpretations of how they would consider a future Phase I clinical trial. In addition to our qualitative data reflecting community voices, a community member reviewed the draft interview guide before data collection and both people with HNC and physicians aided interpretation of the findings.

A Pilot Test of a Workshop for Pediatric Clinicians About Communicating with Parents About the HPV Vaccine Using the C-LEAR Approach.

Low HPV vaccinations rates lead to missed opportunities to prevent cancer. Specifically, some parents (12-76%) report never receiving a recommendation for their child to receive the vaccine. Current models for talking about HPV vaccination fall short in that they focus primarily on how to introduce the vaccine with limited guidance on how to follow through with the conversation, particularly with those parents who may be hesitant. We developed the C-LEAR approach, an easy to remember, evidence-informed mnemonic to guide clinicians through the process of introducing and discussing the HPV vaccine with parents. We pilot tested this approach with a total of 20 pediatric clinicians (n = 13 residents; n = 7 attendings) in 60-min Zoom workshops that included a short didactic session, a demonstration of skills, and a small group, facilitator-led role play session. On an immediate post-training survey, all participants stated that the training was helpful and easy to understand. Ninety-four percent responded that they would implement what they had learned in their clinic. Participants reported appreciation for the small group sessions. While not specifically asked or required to incorporate the material into their practice, 1 year following the training, 8/9 (88%) participants reported using the C-LEAR approach in their clinics "most" or "all of the time." We are further testing this model through teaching our workshop in a large, randomized trial across the state of Florida.

Messaging preferences among Florida caregivers participating in focus groups who had not yet accepted the HPV vaccine for their 11- to 12-year-old child.

BACKGROUND: In the United States, human papillomavirus (HPV) vaccination rates remain low. The President's Cancer Panel suggests that effective messaging about the HPV vaccination focus on the vaccine's safety, efficacy, ability to prevent cancer, and recommendation at ages 11- to 12-years. We aimed to develop messages about HPV vaccine that include the President Cancer Panel's suggestions and were acceptable to caregivers of adolescents. METHODS: From August to October 2020, we conducted one-hour, Zoom videoconference focus groups with caregivers who lived in Florida, had an 11- to 12-year-old child, and had not had any of their children receive the HPV vaccine. Focus group moderators asked caregivers to react to three videos of clinician (i.e., MD, DO, APRN, PA) recommendations and three text message reminders. Thematic analysis was conducted using the constant comparative method and led by one author with qualitative analysis expertise. Two additional authors validated findings. RESULTS: Caregivers (n = 25 in six groups) were primarily non-Hispanic white (84%) and educated (64% had at least an Associate's degree). Approximately a third of caregivers had delayed (44%) or decided against a vaccine for their child (36%). Caregivers described six preferred message approaches: recognize caregivers' autonomy, balanced benefits and risks, trustworthy sources, increased feasibility of appointment scheduling, information prior to decision point, and preferred personalized information. Caregivers expressed a desire to have the follow-up doses mentioned in the introduction. CONCLUSIONS: HPV vaccine messages, whether delivered by a clinician or via text message, will be more acceptable to caregivers if they approach HPV vaccination as the caregivers' decision, and include information from trusted sources to help caregivers make an informed choice.

Primary Care Physician Perspectives on Recommending E-cigarettes to Smokers: a Best-Worst Discrete Choice Experiment.

BACKGROUND: Recent clinical trials suggest that e-cigarettes may be more effective for smoking cessation than traditional cessation aids, yet primary care physician (PCP) practices regarding e-cigarette recommendations for smokers have not been studied in-depth. OBJECTIVE: To identify factors influencing PCP recommendation of e-cigarettes for smoking cessation. DESIGN: Discrete choice experiment and survey. PARTICIPANTS: Florida PCPs. MEASURES: The survey included a discrete choice experiment in which PCPs indicated whether they would recommend e-cigarettes for each of 8 hypothetical patient profiles with the following contrasting characteristics: e-cigarette use, interest in approved cessation methods, smoking intensity, prior experience with approved cessation medications, quit intention, age, and comorbidity. Responses were summarized using descriptive statistics and standardized scores (SS). KEY RESULTS: The sample (n = 216) was predominately male (76%), white (66%), and non-Hispanic (78%), and most respondents had held their medical degree for 20+ years (77%). The response rate was 28.7%. Most PCPs thought e-cigarettes were at least somewhat effective for smoking cessation (66%) and lowering disease risk (65%); 31% perceived e-cigarettes to be equally/more effective than traditional cessation aids. PCPs were split regarding whether e-cigarettes were less (50%) or equally harmful (38%) as cigarettes. Yet, few were very confident in their ability to counsel patients on e-cigarettes risks (27%) or benefits (15%). PCPs recommended e-cigarettes in 27% of patient profiles they evaluated. The most important factors influencing the decision to recommend or not recommend e-cigarette were patients' prior use of nicotine replacement therapy with (SS = 0.22, 95% CI = 0.17-0.27) and without use of other medications for cessation (SS = 0.18, 95% CI = 0.13-0.23), and being middle age (50 years old) with chronic obstructive pulmonary disease (SS = 0.16, 95% CI = 0.10-0.23). CONCLUSIONS: Considering the increased patient use of e-cigarettes and increasing use for cessation, this study highlights the need for guidelines and education to aid PCPs' counseling of patients about e-cigarette use.

A feasibility trial of parent HPV vaccine reminders and phone-based motivational interviewing.

BACKGROUND: We assessed the feasibility and acceptability of a sequential approach of parent-targeted HPV vaccine reminders and phone-based Motivation Interviewing (MI). METHODS: In 2016, we selected all 11- to 12-year-old boys and girls seen in one clinic whose vaccine records did not include the HPV vaccine (n=286). By gender, we individually randomized parents of adolescents to an interactive text message (74 girls and 45 boys), postcard reminder (46 boys and no girls because of previously demonstrated efficacy), or standard care group (75 girls and 46 boys). Reminders were sent with medical director permission and a HIPAA waiver. Two months after reminders, among the adolescents whose vaccine records still did not include the HPV vaccine, we selected a gender-stratified random sample of 20 parents for phone-based MI. We assessed the percentage of deliverable messages, the percentage of parents' responding to the interactive text message, parent acceptability of receiving a text message, and MI parent responsiveness and interviewer competence (MI Treatment Integrity Coding system). RESULTS: Nearly all messages were deliverable (98% of postcards and 74% of text messages). Six of the 88 parents (7%) receiving text messages scheduled an appointment through our interactive system. The acceptability survey response rate was 37% (38/102). Respondents were favorable toward vaccine reminders for all parents (82%). Among 20 sampled parents, 17 were reached by phone of whom 7 completed MI, 4 had or were getting the HPV vaccine for their child, and 5 expressed disinterest. Across the 7 MI calls, the interviewer was rated 100% MI adherent and scored an average 4.19 rating for Global Spirit. CONCLUSION: Without providing explicit consent to receive vaccine-related messages, parents nonetheless found postcards and interactive text messages acceptable. Centralizing MI to phone calls with trained staff was acceptable to parents and resulted in highly MI-adherent interviews.

Perceptions and Knowledge About the MenB Vaccine Among Parents of High School Students.

Serogroup B meningococcal disease (MenB) causes almost 60% of meningitis cases among adolescents and young adults. Yet, MenB vaccine coverage among adolescents remains below 10%. Since parents are the primary medical decision makers for adolescents, we examined MenB vaccination rates and parent attitudes about meningitis and the MenB vaccine. In 2018, in conjunction with a county-wide, school-based immunization campaign, we conducted a mixed methods study among parents of 16- to 17-year-olds. We facilitated focus groups asking parents about their knowledge of meningitis and reactions to educational materials and sent behavioral surveys based on Health Belief Model constructs to parents through the county high school system. Parents in three focus groups (n = 8; participation rate = 13%) expressed confusion about their child's need to receive the MenB vaccine in addition to the meningococcal conjugate vaccine (MenACWY), but conveyed strong trust in their physicians' recommendation. Among survey participants (n = 170), 70 (41%) had heard of the MenB vaccine. Among those 70 parents, the most common barriers to vaccination were concerns about side effects (55%) and uncertainty of susceptibility due to receipt of the MenACWY vaccine (30%). The percentage of teens that received at least one dose of the MenB vaccine was 50% (n = 35) by parent report and 23% (n = 16) by state vaccination records. Parents demonstrated uncertainty and confusion about the MenB vaccine particularly due to the existence of another meningitis vaccine and limited health care provider recommendations. Confirmatory studies of parent confusion about the MenB vaccine are needed to develop interventions.

"I can be the Judge of What's Serious": A Qualitative Pilot Study of Parents' Responses to Messaging About Side Effects of the HPV Vaccine.

OBJECTIVE: Parents' concerns about vaccine safety and side effects likely contribute to low rates of human papillomavirus (HPV) vaccination among adolescents. To facilitate parent-provider discussions about the HPV vaccine, we developed and tested the content of a clinical decision support application for implementation in pediatric clinical settings. This study sought to elicit perspectives of parents and providers on the best way to communicate information on vaccine side effects. METHODS: To understand the acceptability of the application's content, we conducted focus groups with parents (n = 11) and providers (n = 9) at three primary care clinics. Focus groups transcriptions were analyzed using iterations of deductive and inductive coding, with independent coding by two trained reviewers to improve inter-rater reliability. RESULTS: Surprisingly, when parents reviewed screen shots of HPV vaccine safety and side effect messages, parents took exception to the expression "no evidence of serious side effects". Parents wanted side effects listed explicitly so they could decide for themselves which side effects were "serious". Parents also felt that the HPV vaccine did have serious side effects, and the wording undermined their trust in the vaccine messaging overall. Providers accepted the phrasing of side effects and did not express concerns that parents would object to the messaging. CONCLUSIONS: Further research is needed to confirm parents' concerns with the phrasing "no serious side effects" for the HPV vaccine and to assess the impact on HPV vaccination deferral or delay.

Increasing adolescent girls' ability to identify STI-risk characteristics of sexual partners: a pilot study within an alternative disciplinary school.

OBJECTIVES: We evaluated the feasibility of conducting a 9-week long sexually transmitted infection (STI) prevention intervention, Angels in Action, within an alternative disciplinary school for adolescent girls. METHODS: All girls who were 16-18 years old, enrolled in the school and did not have plans to transfer from the school were eligible to participate. We measured process feasibility with recruitment, retention and participant enjoyment. Using a pretest-post-test design with a double post-test, we used χ² tests to estimate the intervention effect on participants' sexual partner risk knowledge, intentions to reduce partner risk and sexual activities in the past 60 days with three behavioural surveys: prior to, immediately following and 3 months after the intervention. RESULTS: Among the 20 girls who were eligible, 95% (19/20) of parents consented and all girls (19/19) agreed to participate. Survey participation was 100% (19/19) prior to, 76% (13/17) immediately following and 53% (9/17) 3 months after the intervention. The intervention was administered twice and a total 17 girls participated. Session attendance was high (89%) and most participants (80%) reported enjoying the intervention. The intervention increased the percentage of girls who could identify partner characteristics associated with increased STI risk: 38% before, 92% immediately following and 100% 3 months after the intervention (p=0.01). Girls also increased their intentions to find out four of the most highly associated partner characteristics (partner's age, recent sexual activity and STI or jail history): 32% before to 75% immediately following (p=0.02) and 67% 3 months after the intervention (p=0.09). CONCLUSIONS: This pilot study suggests girls at alternative disciplinary schools participated in and enjoyed a 9-week STI preventive intervention. Within alternative disciplinary schools, it is potentially feasible to increase girls' consideration of partner risk characteristics as a means to enhance their STI prevention skills.

Human papillomavirus vaccine administration among Medicaid providers who consistently recommended vaccination.

We examined factors potentially related to providers' self-reported human papillomavirus vaccine administration to female Medicaid enrollees among providers who consistently recommended vaccination. Some pronounced variability was observed in characteristics among providers who consistently administered vaccination, including provider age, race, and Vaccines for Children enrollment; patient/parent vaccine refusal; patient race/ethnicity; and patient volume.

Usability of a Web-Based App for Increasing Adolescent Vaccination in Primary Care Settings: Think-Aloud and Survey Assessment.

BACKGROUND: In the United States, only 58% of teens receive the recommended 2 doses of the human papillomavirus vaccine by 15 years of age. Overcoming vaccine hesitancy often requires effective communication between clinicians and parents to address specific concerns. To support this, we developed ProtectMe4, a multilevel, theory-informed web-based intervention designed to address parents' vaccine-related questions and assist clinicians in discussing vaccine concerns for 4 adolescent vaccines. OBJECTIVE: This study aims to evaluate the usability of ProtectMe4 in routine care settings across 3 pediatric primary care clinics. Specifically, the study aims to (1) observe the proposed workflow in practice, (2) identify usability issues experienced by parents and clinicians, and (3) assess the perceptions of both parents and clinicians regarding the app's usability. METHODS: On designated days in 2020 and 2021, the study team recruited parents of 11- to 12-year-old patients attending appointments with participating clinicians. We conducted think-aloud assessments during routine care visits and administered a usability survey after participants used the app. For parents, we simultaneously video-recorded the app screens and audio-recorded their commentary. For clinicians, observational notes were taken regarding their actions and comments. Timings recorded within the app provided data on the length of use. We reviewed the recordings and notes to compile a list of identified issues and calculated the frequencies of survey responses. RESULTS: Out of 12 parents invited to use the app, 9 (75%) participated. Two parents who were invited outside of the planned workflow, after seeing the clinician, refused to participate. For the parents whose child's vaccination record was identified by the app, the median time spent using the app was 9 (range 6-28) minutes. Think-aloud assessment results for parents were categorized into 2 themes: (1) troubleshooting vaccine record identification and (2) clarifying the app content and purpose. Among the 8 parents who completed the survey, at least 75% (6/8) agreed with each acceptability measure related to user satisfaction, perceived usefulness, and acceptance. These parents' children were patients of 4 of the 7 participating clinicians. Consistent with the planned workflow, clinicians viewed the app before seeing the patient in 4 of 9 (44%) instances. The median time spent on the app per patient was 95 (range 5-240) seconds. Think-aloud assessment results for clinicians were grouped into 2 themes: (1) trust of app vaccine results and (2) clarifying the app content. On the survey, clinicians were unanimously positive about the app, with an average System Usability Scale score of 87.5 (SE 2.5). CONCLUSIONS: This mixed methods evaluation demonstrated that ProtectMe4 was usable and acceptable to both parents and clinicians in real-world pediatric primary care. Improved coordination among clinic staff is needed to ensure the app is consistently offered to patients and reviewed by clinicians before seeing the patient.

Promoting Rural-Residing Parents' Receptivity to HPV Vaccination: Targeting Messages and Mobile Clinic Implementation.

Interventions are needed to increase low HPV vaccination rates within rural areas in the United States, particularly in the state of Florida, which has the seventh highest number of HPV-related cancers. Florida also ranks low compared to other states in terms of HPV vaccination. Rural-residing parents may benefit from two evidence-based strategies to increase vaccination rates: reminder messages informing and prompting vaccination appointments and mobile clinics to reduce transportation barriers. We sought to identify parental attitudes towards (1) message features that promote rural-residing parents' receptivity to HPV vaccination; (2) parents' acceptability of three reminder message modalities (text, postcard, phone); and (3) implementation factors that promote parents' acceptability of using a mobile clinic for vaccination. We recruited 28 rural-residing parents of 9- to 12-year-old children (unvaccinated for HPV) for focus group and individual interviews and thematically analyzed transcripts. Three features promoted parents' receptivity to HPV vaccination messages: source credibility, specific information coverage, and personalization (name and birthday wishes). Parents most preferred text messages and identified three factors promoting parents' mobile clinic use: convenience and feasibility, trustworthiness, and detailed information. The findings indicate rural-residing parents' acceptability of reminder messages and mobile clinics as well as the importance of trust and feasibility when implementing these evidence-based strategies for rural-residing parents.

Educating Hematology-Oncology Fellows About How to Communicate with Patients About Clinical Trials: A Needs Assessment.

Objectives: Only 5-8% of adults with cancer participate in cancer clinical trials (CCTs), with even lower rates among underrepresented groups. Improving oncologists' communication skills may enhance the frequency and quality of their discussions with patients about CCTs, consequently increasing participation. However, little is known about interest in or presence of CCT-related communication training during Hematology-Oncology (Hem-Onc) fellowships. This study aimed to describe, from the perspective of Hem-Onc fellowship program directors (PDs): (1) the current landscape of CCT education for Hem-Onc fellows; (2) the acceptability and feasibility of implementing a CCT communication skills workshop for Hem-Onc fellows. Methods: We used an explanatory sequential mixed-methods approach. PDs were surveyed and interviewed about their graduate medical education (GME) programs' current CCT curriculum, training challenges, fellows' CCT knowledge and CCT communication skills, and preferences for a CCT communication workshop. Results: PDs were surveyed (n = 40) and interviewed (n = 12). PDs reported that their institutions prioritize CCT accrual (M = 4.58, SD = .78; 1-5 scale, 5 = "Strongly Agree") and clinical research training (M = 4.20, SD = .85). CCT skills that programs least often addressed were how to (1) discuss CCTs with newly diagnosed patients, (2) talk to patients about CCTs when none are available, and (3) help patients find CCTs at other institutions. PDs were interested in a CCT communication workshop for fellows ("yes" = 67.5%, "maybe" = 32.5%) and said training would be feasible (M = 4.28, SD = .78) and useful (M = 4.47, SD = .78). Qualitative results described programs' current approaches to CCT education and insights about developing and implementing CCT communication training. Conclusions: There is a clear need to improve CCT communication skills training in Hem-Onc fellowship programs and to implement and scale such training to increase CCT participation, especially among diverse patient populations. Furthermore, Hem-Onc GME PDs view such training as feasible and useful.

Design and development of a machine-learning-driven opioid overdose risk prediction tool integrated in electronic health records in primary care settings.

BACKGROUND: Integrating advanced machine-learning (ML) algorithms into clinical practice is challenging and requires interdisciplinary collaboration to develop transparent, interpretable, and ethically sound clinical decision support (CDS) tools. We aimed to design a ML-driven CDS tool to predict opioid overdose risk and gather feedback for its integration into the University of Florida Health (UFHealth) electronic health record (EHR) system. METHODS: We used user-centered design methods to integrate the ML algorithm into the EHR system. The backend and UI design sub-teams collaborated closely, both informed by user feedback sessions. We conducted seven user feedback sessions with five UF Health primary care physicians (PCPs) to explore aspects of CDS tools, including workflow, risk display, and risk mitigation strategies. After customizing the tool based on PCPs' feedback, we held two rounds of one-on-one usability testing sessions with 8 additional PCPs to gather feedback on prototype alerts. These sessions informed iterative UI design and backend processes, including alert frequency and reappearance circumstances. RESULTS: The backend process development identified needs and requirements from our team, information technology, UFHealth, and PCPs. Thirteen PCPs (male = 62%, White = 85%) participated across 7 user feedback sessions and 8 usability testing sessions. During the user feedback sessions, PCPs (n = 5) identified flaws such as the term "high risk" of overdose potentially leading to unintended consequences (e.g., immediate addiction services referrals), offered suggestions, and expressed trust in the tool. In the first usability testing session, PCPs (n = 4) emphasized the need for natural risk presentation (e.g., 1 in 200) and suggested displaying the alert multiple times yearly for at-risk patients. Another 4 PCPs in the second usability testing session valued the UFHealth-specific alert for managing new or unfamiliar patients, expressed concerns about PCPs' workload when prescribing to high-risk patients, and recommended incorporating the details page into training sessions to enhance usability. CONCLUSIONS: The final backend process for our CDS alert aligns with PCP needs and UFHealth standards. Integrating feedback from PCPs in the early development phase of our ML-driven CDS tool helped identify barriers and facilitators in the CDS integration process. This collaborative approach yielded a refined prototype aimed at minimizing unintended consequences and enhancing usability.

Provider factors associated with disparities in human papillomavirus vaccination among low-income 9- to 17-year-old girls.

BACKGROUND: Many women who develop cervical cancer are eligible for or are participants of Medicaid. Providing human papillomavirus (HPV) vaccination to girls enrolled in Medicaid may reduce cervical cancer disparities in low-income and minority women. This study evaluated provider characteristics associated with HPV vaccination among 9- to 17-year-old female Medicaid enrollees. METHODS: A random sample of 800 providers from the Florida Medicaid Master Provider File was mailed a survey in October 2009 that evaluated demographic and practice characteristics, HPV information and knowledge, barriers to HPV vaccination, vaccine practices, and vaccine recommendation practices. To measure HPV vaccination, Medicaid claims data were used to calculate the proportion of eligible patients who received at least 1 dose of the vaccine from participating providers within the study period. Provider factors associated with vaccination at the bivariate level were evaluated in a multiple linear regression model. RESULTS: The response rate was 68.3% (N = 485). After excluding ineligible respondents, the current analysis included 433 providers. HPV vaccination prevalence ranged from 0% to 61.9% (M = 20.4, standard deviation = 14.5). HPV vaccination rates were higher among providers who were pediatricians, had a private practice, practiced in a single specialty setting, were providers under the Vaccines for Children program, saw primarily non-Hispanic white patients, used 2 or more strategies for vaccine series completion, and did not refer out for HPV vaccination. CONCLUSIONS: Despite financial coverage for Medicaid-eligible girls, HPV vaccination rates are low. Study findings can be used to target health services interventions to providers least likely to administer HPV vaccine to female Medicaid enrollees.

Perceived racial/ethnic discrimination, problem behaviors, and mental health among minority urban youth.

OBJECTIVES: We examined perceived frequency and intensity of racial/ethnic discrimination and associations with high-risk behaviors/conditions among adolescents. DESIGN: With surveys from 2490 racial/ethnic minority adolescents primarily with low socioeconomic status, we used regression analysis to examine associations between racial/ethnic discrimination and behavioral health outcomes (alcohol use, marijuana use, physical aggression, delinquency, victimization, depression, suicidal ideation, and sexual behaviors). RESULTS: Most adolescents (73%) experienced racial/ethnic discrimination and 42% of experiences were 'somewhat-' or 'very disturbing.' Adolescents reporting frequent and disturbing racial/ethnic discrimination were at increased risk of all measured behaviors, except alcohol and marijuana use. Adolescents who experienced any racial/ethnic discrimination were at increased risk for victimization and depression. Regardless of intensity, adolescents who experienced racial/ethnic discrimination at least occasionally were more likely to report greater physical aggression, delinquency, suicidal ideation, younger age at first oral sex, unprotected sex during last intercourse, and more lifetime sexual partners. CONCLUSION: Most adolescents had experienced racial/ethnic discrimination due to their race/ethnicity. Even occasional experiences of racial/ethnic discrimination likely contribute to maladaptive behavioral and mental health outcomes among adolescents. Prevention and coping strategies are important targets for intervention.

Do Florida Medicaid providers' barriers to HPV vaccination vary based on VFC program participation?

This study aimed to determine if physicians' perceived barriers to human papillomavirus (HPV) vaccination were associated with participation in the federal Vaccines for Children (VFC) program. A sample of 800 Florida Medicaid providers was randomly selected from the Florida Medicaid Master Provider File. A cross-sectional study was conducted using a 27-item survey that included 13 potential barriers to immunizing Medicaid patients against HPV, including concerns about vaccine safety and efficacy, discussing sexuality, vaccinated teens practicing riskier sexual behaviors, cost and reimbursement, ensuring 3-dose series completion, and school attendance requirements associated with HPV vaccination. Pearson χ(2) tests were conducted to investigate differences between each barrier and VFC program participation. Data were analyzed for 449 physicians. Compared to non-VFC providers, VFC providers were significantly less likely to somewhat or strongly agree that the following were barriers to vaccination: the cost of stocking the HPV vaccine (p = 0.0011), lack of adequate reimbursement for HPV vaccination (p < 0.0001), and lack of timely reimbursement for HPV vaccination (p < 0.0001). After adjusting for provider specialty and number of years since completion of residency training, VFC status remained significantly associated with the barrier regarding lack of adequate reimbursement for vaccination such that non-VFC providers had a 2.6-fold (95% confidence interval, 1.1-5.8) greater odds of somewhat or strongly agreeing that this barrier applied to them. Increasing participation in the VFC program may decrease physicians' cost-related barriers, which may increase the number of children vaccinated on time according to the recommended schedule.

Patients' comfort with and receipt of health risk assessments during routine dental visits: Results from the South Atlantic region of the US National Dental Practice-Based Research Network.

OBJECTIVES: To understand patients' comfort with health risk assessments (HRAs) and patient and dentist factors associated with the provision of HRAs. METHODS: In this cross-sectional study, 857 patients seen by 30 dental practitioners in the United States National Dental Practice-Based Research Network reported their comfort receiving HRA for six risk factors (tobacco use, alcohol use, dietary sugar intake, human immunodeficiency virus risks, human papillomavirus risks and existing medical conditions) and whether they discussed any of the risk factors during their visits. Multi-level logistic models were used to examine the impacts of patient, practitioner, practice characteristics on the (1) number of risk factors patients were comfortable discussing and (2) number of risk factors assessed in the current dental visit. RESULTS: Only a small percentage (4%) of patients reported being uncomfortable receiving any HRA during their dental visits. However, over half of the patients (53%) reported that they did not receive any HRAs during the current visit. In the regression analyses, patients who were older, male and from the suburban were more likely to be comfortable with more HRAs. Dentists were more likely to provide HRA if they were younger, not non-Hispanic white, less likely to feel that providing HRAs was beyond their scope of practice, yet more likely to feel occasional discomfort in providing HRA. CONCLUSIONS: Interventions should focus on reducing dental practitioner perception that conducting HRAs is beyond their scope of practice and standardizing screening assessments for multiple risk factors.

Screening for cervical cancer among women with behavioral health conditions-A systematic review.

Cervical cancer screening is credited with dramatically reducing cervical cancer mortality in the United States. There is a lack of consensus on whether women with behavioral health conditions (mental health or substance use) receive cervical cancer screening at rates similar to women without the conditions. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we searched for articles and abstracts of conference proceedings in PubMed, EMBASE, Web of Science and the EBSCO databases: CINAHL, PsycINFO, Psychosocial and Behavioral Science Collection, Academic Search Premier Databases, and the ProQuest database Applied Social Sciences Index and Abstracts from January 1, 2000 to July 31, 2020. Eligibility criteria included studies conducted in the United States, published in English, and comparing cervical cancer screening rates of women with and without behavioral health conditions. Of 1,242 unique articles screened, 52 were included in the full text review. And after title/abstract/and full-text review, 14 articles met the eligibility criteria. Six studies examined both mental health and substance use conditions, two studies only examined substance use disorders, and six studies examined only mental health conditions. Substance use disorders were associated with a decreased likelihood of receiving screening. This study yeilded inconclusive findings on the relationship between mental health conditions and cervical cancer screening. More research is needed to better understand the relationship between behavioral health conditions and cervical cancer screening.

County-Level Factors Associated With HPV Vaccine Coverage Among 11-Year-Olds to 12-Year-Olds Living in Florida in 2019.

BACKGROUND: In the United States, human papillomavirus (HPV) vaccine initiation and up-to-date (UTD) status are associated with multiple factors at the individual level such as racial/cultural (e.g., race, immigration status), socioeconomic status (e.g., living below poverty level, education), and healthcare access (e.g., insurance status/type). HPV vaccination rates differ dramatically by US geographic areas and within states. To tailor interventions to local areas, it is important to understand county-level characteristics associated with HPV vaccination rates. METHODS: Using linear regression, we assessed the association between county-level HPV vaccination initiation and UTD rates for 11-year-olds to 12-year-olds in Florida (collected from the Florida SHOTS immunization registry) and county-level variables. Factors found significant in bivariate analysis and with a variance influence factors <4 were included in multivariable models. RESULTS: In 2019, county-level HPV vaccine coverage among Florida 11-year-olds to 12-year-olds ranged from 31% to 92% initiation and 3%-36% UTD. Counties with the lowest HPV vaccine coverage were concentrated in Florida's North-Central and Panhandle regions. In multivariable models, counties with primarily rural populations had lower vaccination initiation and UTD coverage. Above and beyond the association with rurality, UTD coverage was associated with family physicians per 100,000 residents and uninsured or Medicaid-enrolled populations. DISCUSSION: While Florida county-level HPV vaccine initiation rates among 11-year-olds to 12-year-olds varied by county in 2019, UTD rates remained universally low despite recommendations. Tailoring interventions toward healthcare access in rural communities may increase HPV vaccine coverage.