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Background: Health departments in the United States routinely conduct quality improvement (QI) coaching to help primary care providers optimize vaccine delivery. In a prior trial focusing on multiple adolescent vaccines, this light-touch intervention yielded only short-term improvements in HPV vaccination. We sought to evaluate the impact of an enhanced, HPV vaccine-specific QI coaching intervention when delivered in person or virtually. Methods: We partnered with health departments in three states to conduct a pragmatic cluster randomized trial in 2015 to 2016. We randomized 224 primary care clinics to receive no intervention (control), in-person coaching, or virtual coaching. Health department staff delivered the brief (45–60 minute) coaching interventions, including HPV vaccine-specific training with assessment and feedback on clinics’ vaccination coverage (i.e., proportion of patients vaccinated). States’ immunization information systems provided data to assess coverage change for HPV vaccine initiation (≥1 doses) at 12-month follow-up, among patients ages 11 to 12 (primary outcome) and 13 to 17 (secondary outcome) at baseline. Results: Clinics served 312,227 patients ages 11 to 17. For ages 11 to 12, coverage change for HPV vaccine initiation was higher in the in-person and virtual coaching arms than in the control arm at 12-month follow-up (1.2% and 0.7% point difference, both P < 0.05). For ages 13 to 17, coverage change was higher for virtual coaching than control (1.4% point difference, P < 0.001), but in-person coaching did not yield an intervention effect. Conclusions: Our brief QI coaching intervention produced small long-term improvements in HPV vaccination. Impact: Health departments may benefit from targeting QI coaching to specific vaccines, like HPV vaccine, that need them most.

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

Background COVID-19 vaccines are available for adolescents in the United States, but many parents are hesitant to have their children vaccinated. The advice of primary care professionals strongly influences vaccine uptake. Objective We examined the willingness of primary care professionals (PCPs) to recommend COVID-19 vaccination for adolescents. Methods Participants were a national sample of 1,047 US adolescent primary care professionals. They participated in an online survey in early 2021, after a COVID-19 vaccine had been approved for adults but before approval for adolescents. Respondents included physicians (71%), advanced practice providers (17%), and nurses (12%). We identified correlates of willingness to recommend COVID-19 vaccination for adolescents using logistic regression. Results The majority (89%) of respondents were willing to recommend COVID-19 vaccination for adolescents, with advanced practice providers and nurses being less likely than paediatricians to recommend vaccination (84% vs. 94%, aOR 0.47, 95% CI 0.23–0.92). Respondents who had received at least one dose of a COVID-19 vaccine were more likely to recommend adolescent vaccination (92% vs. 69%, aOR 4.20, 95% CI 2.56–6.87) as were those with more years in practice (94% vs. 88%, aOR 2.93, 95% CI 1.79–4.99). Most respondents (96%) said they would need some measure of support in order to provide COVID-19 vaccination to adolescents, with vaccine safety and efficacy information being the most commonly cited need (80%). Conclusion Adolescent primary care professionals were generally willing to recommend COVID-19 vaccination. However, most indicated a need for additional resources to be able to administer COVID-19 vaccines at their clinic.

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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.

Background: Few studies have assessed relationships between job loss due to breast cancer and well-being. These relationships may vary by race, work type, and functional difficulties.Methods: In the Carolina Breast Cancer Study, 1,646 women with primary breast cancer who worked prior to diagnosis were longitudinally evaluated for post-diagnosis job loss and well-being using the Functional Assessment of Cancer Therapy General (FACT-G) measure. Women were classified as having ‘sustained work’ (working at baseline and 25 months); ‘returned to work’ (not working at baseline, working at 25 months); ‘consequent job loss’ (working at baseline, not working at 25 months); or ‘persistent non-employment’ (not working at either timepoint). Analysis of covariance was used to evaluate associations between work status and well-being (physical, functional, social, emotional).Results: Women who had sustained work or returned to work had higher FACT-G scores than women with consequent job loss and persistent non-employment in all well-being domains (p Citation Format: Marc A Emerson, Bryce B Reeve, Melissa B. Gilkey, Shekinah N Elmore, Cathy J Bradley, Melissa A Troester. Consequent job loss, return to work and multidimensional well-being after breast cancer treatment in working-age black and white women [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD5-10.

Families affected by asthma report difficulty adhering to care regimens because of high medication costs, coupled with increased cost sharing required by some insurance plans. To inform efforts to support adherence, we conducted a qualitative study to explore how families manage asthma care costs.We conducted phone interviews with commercially-insured, US adults (Our analysis identified four overarching strategies for managing asthma care costs. First, participants used prevention strategies to avoid costly acute care by minimizing exposure to asthma triggers and adhering strictly to preventive medication regimens. Second, participants used shopping strategies to reduce costs, including by comparing medication prices across pharmacies, using medication coupons or free samples, and switching to lower-cost medications. Third, budgeting strategies involved putting aside funds, including in tax-exempt health savings accounts, or taking on debt to pay for care. Finally, some participants sought to reduce costs by forgoing recommended care, including by skipping medication doses or replacing prescribed medications with alternative therapies.Commercially-insured families use a wide range of strategies to manage asthma care costs, with both positive and negative implications for adherence. Our typology of asthma cost management strategies can inform insurance redesign and other interventions to help families safely reduce costs and maximize adherence to recommended care.

OBJECTIVE. Parents often decline HPV vaccination, but little is known about how healthcare providers should promote vaccination at a later visit for secondary acceptance. We examined the associations of two factors, providers’ response to declination during the visit and follow-up after the visit, with secondary acceptance. METHODS. We conducted a cross-sectional survey of US parents whose 9- to 17-year-old child had not yet completed the HPV vaccination series. Parents who declined HPV vaccination during an initial discussion with a provider (n=447) reported whether their provider engaged in any active response during the visit (e.g., giving information, trying to change their mind) or any follow-up after the visit (e.g., scheduling another visit). We conducted multivariable logistic regression to determine whether an active response or follow-up was associated with secondary acceptance of HPV vaccination. RESULTS. Only about one-third of parents reported an active response during the visit (35%) or follow-up after the visit (39%) following HPV vaccination declination. Parents had higher odds of secondary acceptance of HPV vaccine if they received any provider follow-up after the visit (43% vs. 20%, aOR:3.19; 95% CI:2.00:5.07). Receipt of an active provider response was not associated with secondary acceptance. More parents thought a provider should actively respond and follow-up (61% and 68% respectively), compared with those who received such a response (both p

BACKGROUND Social media has the potential to provide social support for rare disease communities, but little is known about the use of social media for the expression of medical uncertainty, a common feature of rare diseases. OBJECTIVE We evaluated the expression of medical uncertainty on social media in the context of dyskeratosis congenita (DC), a rare cancer-prone inherited bone marrow failure and telomere biology disorder (TBD). METHODS We content analyzed uncertainty-related posts among patients with DC/TBDs and caregivers on Facebook (FB) and Twitter managed by Team Telomere, a patient-advocacy group for this rare disease. We assessed the frequency of uncertainty-related posts, uncertainty sources, issues, and management strategies using the Han Taxonomy, and associations between uncertainty and social support. RESULTS Across all DC/TBD social media platforms, 46% of posts were uncertainty-related. Most uncertainty-related posts were authored by Team Telomere on Twitter or appeared in conversations within the FB Community Group. While uncertainty-related posts reflected multiple sources, issues, and management strategies, they primarily focused on information exchange related to diagnostic and prognostic uncertainty. All platforms had high frequency of emotional support, but only in the FB Community Group was emotional support significantly more frequent in uncertainty vs. non-uncertainty related posts (X²=7.76, DF=1, p=0.005). In all platforms, offers or requests for informational support were significantly more frequent in uncertainty-related compared to non-uncertainty-related posts (X²=468.0, DF=1, p CONCLUSIONS While uncertainty is a pervasive and multifactorial issue in DC/TBDs, our findings suggest the discussion of medical uncertainty on DC/TBD social media is largely limited to brief exchanges about scientific or practical issues, rather than ongoing supportive conversation about the impact of uncertainty on personal life. The higher involvement of female parents on DC/TBD social media suggests a potentially greater burden of uncertainty management among mothers compared to other groups. More research is needed to understand the dynamics of social media engagement to manage medical uncertainty in the DC/TBD community.

The Announcement Approach using presumptive announcements increases human papillomavirus vaccine uptake. This study seeks to understand the impact of the final Announcement Approach steps-easing parents' vaccine concerns and then encouraging them to get human papillomavirus vaccine for their children-on parents' human papillomavirus vaccine hesitancy and confidence in the vaccine's benefits.In 2017-2018, investigators recruited an online national sample of 1,196 U.S. parents of children aged 9-17 years who had not yet completed the human papillomavirus vaccine series. Following the steps of the Announcement Approach, participants viewed brief videos of a pediatrician announcing that a child was due for human papillomavirus vaccine (shown to all the parents). In the 2 × 2 experiment, parents saw (1) a video of the pediatrician attempting to ease a concern that the parent had raised earlier in the survey (Ease video), (2) a video of the pediatrician encouraging the parent to get their child vaccinated (Encourage video), (3) both videos, or (4) neither of the videos. Data analysis was conducted in spring 2020.Seeing the Ease video message led to lower human papillomavirus vaccine hesitancy than not seeing it (mean=2.71, SD=1.29 vs mean=2.97, SD=1.33; p0.001). The beneficial impact of easing concerns on lower vaccine hesitancy was explained by higher confidence (p0.05). By contrast, the Encourage video had no impact on human papillomavirus vaccine hesitancy or confidence.Addressing parents' concerns can decrease human papillomavirus vaccine hesitancy and increase confidence. On the basis of these findings, the Announcement Approach retained its emphasis on announcing that children are due for vaccination and easing parent concerns.

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.

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

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 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.

OBJECTIVES Preventive drug lists (PDLs) are a value-based insurance design intended to help high-deductible health plan (HDHP) members by covering preventive medications at lower or no cost before deductibles are met. Because little is known about members' experiences using this new tool, we sought to evaluate benefits and challenges of using PDLs to manage asthma costs. STUDY DESIGN Qualitative interview study. METHODS In 2018, we conducted telephone interviews with US adults (n = 22) who (1) were in HDHPs with PDLs and (2) had asthma and/or a child with asthma. We analyzed data using thematic content analysis. RESULTS Some members reported that PDLs provided financial benefit and facilitated adherence to preventive medications. Others experienced barriers to using PDLs. Notably, some PDLs did not include members' asthma medications or provided only modest cost coverage due to restrictions in underlying formulary structures. Members who were aware of having a PDL sometimes worked with their providers to switch to listed medications. However, many members were not aware of having a PDL. Finally, because PDLs did not cover nonmedication costs, some members still struggled to afford asthma care. CONCLUSIONS PDLs are a promising tool for helping families in HDHPs manage their medication costs and, in turn, their asthma. However, given current limitations in coverage, members must be aware of the benefit to seek out listed medications, and they may still struggle with the remaining cost sharing. Attention to implementation, including member outreach and education, is likely needed to realize the full potential of PDLs.

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.

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 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.

In the article by Sonawane et al,1 the important question of parental hesitancy regarding adolescent human papillomavirus (HPV) vaccination is examined. The authors reported an increase in hesitancy over a 6-year period (from 50% to 64%) among US parents asked about it. This apparent increase is due to progressively restricting the denominator in later years. Most importantly, the analytic choice masks a more general truth: HPV vaccine hesitancy actually fell among parents overall. To make sense of this seeming paradox, let us start by observing that … E-mail: ntb{at}unc.edu

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.

Our study examined how misinformation and other elements of social media messages affect antecedents to human papillomavirus (HPV) vaccination of adolescents. In 2017–2018, we randomly assigned a national sample of 1206 U.S. parents of adolescents to view one tweet using a 2 × 2 × 2 × 2 between-subjects factorial experiment. The 16 experimental tweets varied four messaging elements: misinformation (misinformation or not), source (person or organization), narrative style (storytelling or scientific data), and topic (effectiveness or safety). Parents reported their motivation to vaccinate (primary outcome), trust in social media content, and perceived risk about HPV-related diseases. Tweets without misinformation elicited higher HPV vaccine motivation than tweets with misinformation (25% vs. 5%, OR = 6.60, 95% CI:4.05, 10.75). Motivation was higher for tweets from organizations versus persons (20% vs. 10%, OR = 2.47, 95% CI:1.52, 4.03) and about effectiveness versus safety (20% vs. 10%, OR = 2.03, 95% CI:1.24, 3.30). Tweets with misinformation produced lower trust and higher perceived risk (both p

How stories from media and social interactions shape parents' HPV vaccination decisions is poorly understood. We sought to characterize parents' exposure to such stories, as well as associations between story exposure and vaccination behavior. Study participants were 1263 parents of U.S. adolescents who had not yet completed the HPV vaccine series. In 2017, these parents completed an online survey about whether they had heard stories of people who were harmed by HPV vaccine or who got diseases HPV vaccine could have prevented. Almost half of parents had heard HPV vaccine stories, which were about vaccine harms only (19%), vaccine preventable diseases only (11%), or both (15%). Stories of harms more often came from social and traditional media; stories of preventable diseases more often came from conversations (all p 0.01). Parents who heard only stories about harms were less likely than those who heard no stories to have initiated HPV vaccination (23% vs. 33%, aOR:0.48; 95% CI:0.33:0.69). They were more likely to have delayed (79% vs. 66%, aOR:2.00; 95% CI:1.09:3.71) or refused (72% vs. 24%, aOR:8.87; 95% CI:4.09:19.25) HPV vaccination. Exposure to both stories about harms and preventable diseases was similarly associated with initiation, delay and refusal. Exposure to only stories about preventable diseases was not associated with initiation, delay or refusal. In conclusion, stories of HPV vaccine harms may be associated more strongly with vaccination behavior than stories of HPV vaccine preventable diseases. Communication campaigns should consider strategies to elevate stories of preventable diseases in social and traditional media.

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.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.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.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.

Parents have varied HPV vaccine communication needs, which presents a challenge for healthcare providers. To improve communication resources for providers, we sought to characterize HPV vaccination messages available in existing educational materials. In fall 2016, we searched PubMed, educational material clearinghouses, and Google for English language HPV vaccination messages. We extracted messages that a provider might use when raising the topic of HPV vaccination, answering common questions, and motivating vaccination. Two reviewers independently coded each message. The search identified 267 unique messages about HPV vaccination. Messages generally were long (mean no. of words = 44, standard deviation [SD] = 33) and required a high level of education to read (mean reading grade level = 10, SD = 3). Only 32% of messages were shorter than 25 words, and 12% had a readability at or below grade 6. Most frequent were messages to address common parent questions or concerns (62%); the most common topics were diseases prevented by HPV vaccine (18%) and safety and side effects (16%). Many messages included information about cancer prevention (26%) and same-day vaccination (13%). Few messages (6%) used a presumptive style to recommend HPV vaccination. In conclusion, available messages about HPV vaccination were markedly varied. We identified few messages that were both brief (to facilitate providers memorizing them) and accessible (to facilitate parents understanding them). Future research should identify which messages lead to HPV vaccine uptake.

Background: Human papillomavirus (HPV) vaccination could prevent most HPV-associated cancers, but few U.S. adolescents are vaccinated according to guidelines. To inform efforts to counsel parents more effectively, we sought to quantify their views on the best and worst reasons for guideline-consistent HPV vaccination. We hypothesized that parents' views would differ according to their vaccination confidence. Methods: We developed a best–worst scaling experiment to evaluate 11 reasons healthcare providers commonly give for HPV vaccination. The instrument was administered in 2016 via a national online survey to 1,177 parents of adolescents. Parents completed 11 choice tasks of 5 reasons each, indicating the best and worst reason in each task. We used conditional logistic regression to rank reasons for the sample overall and by vaccination confidence (low/high). Results: Parents viewed cancer prevention as the best reason for HPV vaccination (P < 0.001). Other commonly endorsed reasons were preventing a common infection, having lasting benefits, or being a safe vaccine (all P < 0.001). Reasons viewed as worst were: It is a scientific breakthrough; I got it for my own child; and your child is due (all P < 0.001). Stratified analyses indicated small differences in how often parents with low versus high vaccination confidence endorsed messages (P < 0.001), but the two groups ranked reasons similarly overall. Conclusions: Parents prioritized cancer prevention as the best reason for guideline-consistent HPV vaccination. Several other common reasons, including having vaccinated one's own child, may warrant additional testing. Impact: Providers should emphasize cancer prevention when discussing HPV vaccination, as recommended by the Centers for Disease Control and Prevention, the President's Cancer Panel, and others. Cancer Epidemiol Biomarkers Prev; 27(7); 762–7. ©2018 AACR.

Background Despite increasing awareness of the importance of a provider recommendation for HPV vaccine, the U.S. has yet to achieve the Healthy people 2020 goal of 80% series completion among adolescents. This failure indicates a need for further examination of the modifiable influences on parents’ decision-making. Healthcare providers can influence parents’ HPV vaccination decision-making, but little is known about parents’ perspectives on the counseling they receive. We sought to assess U.S. parents’ satisfaction with provider communication about HPV vaccine and associations with vaccination behaviors. Methods Parents of 11-to-17-year-old adolescents who discussed HPV vaccination with a healthcare provider at least once (n = 795) completed our online survey in Fall 2016. We assessed their satisfaction with the discussion using the HPV Vaccine Communication Satisfaction Scale (α = 0.94). We examined associations between satisfaction (categorized as low, moderate, or high), and three vaccination behaviors: refusal/delay, series initiation (≥1 dose), and continuation (≥2 doses among initiators) using multivariable logistic regression. Results Most parents reported high (36%) or moderate (38%) satisfaction with provider communication about HPV vaccination; fewer reported low (26%) satisfaction. Moderately satisfied parents (vs. low) had lower odds of refusal/delay (aOR = 0.59, 95% CI: 0.38–0.89), and higher odds of initiation (aOR = 1.71, 95% CI:1.15–2.55) and continuation (aOR = 2.05, 95% CI: 1.24–3.40). The associations were stronger for highly satisfied parents (refusal/delay aOR = 0.45, 95% CI: 0.29–0.70, initiation aOR = 3.59, 95% CI: 2.23–5.78, and continuation aOR = 4.08, 95% CI: 2.38–7.01). Conclusions Our study suggests that parent satisfaction with provider communication may play an important role in HPV vaccination decision-making. Yet, communication satisfaction has been largely unexamined in the HPV-vaccine literature to date. We introduce a brief, 7-item HPV Vaccine Communication Scale that can be used to assess parents’ level of satisfaction with their provider’s communication specific to HPV vaccine. We identify communication areas for providers to prioritize when discussing HPV vaccine with parents.

Purpose Adolescence is a high-risk period for ultraviolet radiation exposure, a primary cause of skin cancer later in life. We sought to characterize receipt of health care provider-delivered counseling about skin cancer prevention (SCP) among parents of adolescents. Methods In 2016, we conducted an online survey with a national sample of parents of adolescents aged 11–17 years (n = 1,253). Multivariable logistic regression assessed correlates of receiving counseling from a health care provider about any of the six skin cancer prevention (SCP) topics. Results Only half (49%) of parents recalled discussing any SCP topic with their child's provider; the prevalence was highest for sunscreen (39%) and lowest for indoor tanning (3%). Parents had greater odds of receiving counseling if they had a child with more sun-reactive skin (odds ratio [OR] = 1.53); a family history of skin cancer (OR = 1.38); or a higher quality relationship with the provider (OR = 1.47; all p Conclusions Greater attention to SCP counseling is needed, especially for exposures such as indoor tanning that remain prevalent among adolescents but are rarely addressed in clinical encounters.

Background Addressing low HPV vaccination coverage will require U.S. health care providers to improve their recommendation practices and vaccine delivery systems. Because readily available continuing medical education (CME) could be an important tool for supporting providers in this process, we sought to assess the content of web-based CME activities related to HPV vaccination. Methods We conducted a content analysis of web-based CME activities about HPV vaccination available to U.S. primary care providers in May-September 2016. Using search engines, educational clearinghouses, and our professional networks, we identified 15 activities eligible for study inclusion. Through a process of open coding, we identified 45 commonly occurring messages in the CME activities, which we organized into five topic areas: delivering recommendations for HPV vaccination, addressing common parent concerns, implementing office-based strategies to increase HPV vaccination coverage, HPV epidemiology, and guidelines for HPV vaccine administration and safety. Using a standardized abstraction form, two coders then independently assessed which of the 45 messages each CME activity included. Results CME activities varied in the amount of content they delivered, with inclusion of the 45 messages ranging from 17% to 86%. Across activities, the most commonly included messages were related to guidelines for HPV vaccine administration and safety. For example, all activities (100%) specified that routine administration is recommended for ages 11 and 12. Most activities (73%) also noted that provider recommendations are highly influential. Fewer activities modeled examples of effective recommendations (47%), gave specific approaches to addressing common parent concerns (47%), or included guidance on office-based strategies to increase coverage (40%). Conclusions Given that many existing CME activities lack substantive content on how to change provider practice, future activities should focus on the practical application of interpersonal and organizational approaches for improving HPV vaccine delivery in the clinical setting.

Three vaccines are recommended by the Advisory Committee on Immunization Practices (ACIP) for routine vaccination of adolescents aged 11-12 years to protect against 1) pertussis; 2) meningococcal disease caused by types A, C, W, and Y; and 3) human papillomavirus (HPV)-associated cancers (1). At age 16 years, a booster dose of quadrivalent meningococcal conjugate vaccine (MenACWY) is recommended. Persons aged 16-23 years can receive serogroup B meningococcal vaccine (MenB), if determined to be appropriate through shared clinical decision-making. CDC analyzed data from the 2019 National Immunization Survey-Teen (NIS-Teen) to estimate vaccination coverage among adolescents aged 13-17 years in the United States.* Coverage with ≥1 dose of HPV vaccine increased from 68.1% in 2018 to 71.5% in 2019, and the percentage of adolescents who were up to date