Emily G. Marks

Stigma among patients with lung cancer: A patient-reported measurement model

Although stigma may have negative psychosocial and behavioral outcomes for patients with lung cancer, its measurement has been limited. A conceptual model of lung cancer stigma and a patient‐reported outcome measure are needed to mitigate these sequelae. This study identified key stigma‐related themes to provide a blueprint for item development through a thematic analysis of semi‐structured interviews and focus groups with lung cancer patients.

Characterizing safety-net providers’ HPV vaccine recommendations to undecided parents: A pilot study

OBJECTIVE Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations. METHODS We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination. RESULTS We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale. CONCLUSION Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction. PRACTICE IMPLICATIONS Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale.

Physical, Emotional, and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study.

Objective Back pain is the most common type of pain reported by older adults, yet current management strategies often do not address the multi-dimensional impacts on older adults who face unique challenges as compared with younger populations. The objective of this qualitative study was to assess the physical, psychological, and social impacts of back pain (severe enough to restrict activity, hereafter referred to as restricting back pain) on older adults. Design This was a qualitative study using semi-structured interviews and focus groups. Setting and Patients This study was comprised of a diverse sample of 93 community-living older adults (median age 83) with restricting back pain. Methods We used a semi-structured guide in 23 interviews and 16 focus groups to discuss the various ways that restricting back pain impacted participants. Transcripts were analyzed in an iterative process to develop thematic categories. Results Restricting back pain affected participants physically (inability to execute routine tasks, disruption of sleep and exercise), psychologically (feelings of sadness and irritability, fears about worsening health, loss of hope towards recovery or pain relief), and socially (experiences of isolation, inability to pursue hobbies). Conclusions These data inform which outcomes should be measured in studies evaluating treatments for older adults with restricting back pain.

Impact of Risk Assessment and Tailored versus Nontailored Risk Information on Colorectal Cancer Testing in Primary Care: A Randomized Controlled Trial

Background: Colorectal cancer screening is effective but underused. Guidelines for which tests are recommended and at what intervals depend on specific risks. We developed a tablet-based Cancer Risk Intake System (CRIS) that asks questions about risk prior to appointments and generates tailored printouts for patients and physicians summarizing and matching risk factors with guideline-based recommendations. Methods: Randomized controlled trial among patients who: (i) used CRIS and they and their physicians received tailored printouts; (ii) used CRIS to answer questions but received standard information about cancer screening while their physicians received a standard electronic chart prompt indicating they were age-eligible but not currently adherent for colorectal cancer screening; or (iii) comprised a no-contact group that neither used CRIS nor received any information while their physicians received the standard prompt. Participation in testing was assessed via electronic medical record at 12 months. Results: Participation in any colorectal cancer testing was three times higher for those who used the CRIS and received any printed materials, compared with no-contact controls (47% vs. 16%; P < 0.0001). Among CRIS users ages 50 and older, participation in any testing was higher in the tailored group (53% vs. 44%, P = 0.023). Conclusion: Use of CRIS and receipt of any information facilitated participation in testing. There was more testing participation in the CRIS-tailored than nontailored group. Impact: Asking patients questions about their specific risk factors and giving them and their providers information just prior to an appointment may increase participation in colorectal cancer testing. Tailoring the information has some added benefit. Cancer Epidemiol Biomarkers Prev; 24(10); 1523–30. ©2015 AACR.

Tailored information increases patient/physician discussion of colon cancer risk and testing: The Cancer Risk Intake System trial

Assess whether receipt of tailored printouts generated by the Cancer Risk Intake System (CRIS) – a touch-screen computer program that collects data from patients and generates printouts for patients and physicians – results in more reported patient-provider discussions about colorectal cancer (CRC) risk and screening than receipt of non-tailored information. Cluster-randomized trial, randomized by physician, with data collected via CRIS prior to visit and 2-week follow-up telephone survey among 623 patients. Patients aged 25–75 with upcoming primary-care visits and eligible for, but currently non-adherent to CRC screening guidelines. Patient-reported discussions with providers about CRC risk and testing. Tailored recipients were more likely to report patient-physician discussions about personal and familial risk, stool testing, and colonoscopy (all p < 0.05). Tailored recipients were more likely to report discussions of: chances of getting cancer (+ 10%); family history (+ 15%); stool testing (+ 9%); and colonoscopy (+ 8%) (all p < 0.05). CRIS is a promising strategy for facilitating discussions about testing in primary-care settings.

Parent-Provider Communication of HPV Vaccine Hesitancy

With our qualitative analysis of audio recordings, we suggest that engaging parents who express HPV vaccine hesitancy and addressing concerns may result in high rates of same-day vaccination. BrightcoveDefaultPlayer10.1542/6138653799001PEDS-VA_2017-2312 Video Abstract OBJECTIVES: To prevent human papillomavirus (HPV)–related cancers, providers must effectively communicate with HPV vaccine–hesitant parents. Here, we developed a typology characterizing parent-provider communication around HPV vaccine hesitancy. METHODS: We audio-recorded 43 visits with unvaccinated adolescents at 6 pediatric clinics in Dallas, Texas in which parents were undecided about HPV vaccination. We qualitatively coded how parents verbally expressed hesitancy (assertive response, asking a question, or expressing concern) and whether providers responded with acquiescence (agree to defer vaccination) and/or persistence (continue discussion). We described the frequency of parent and provider communication codes and same-day vaccination. RESULTS: Among the 43 visits, 37 parents expressed hesitancy ≥1 times in many ways. Assertive responses were most common (27 visits), followed by questions (16 visits), and concerns (12 visits). When the first expression of hesitancy was a question or concern, 71% and 75% of adolescents, respectively, received same-day vaccinations, whereas 33% of adolescents who received an initial assertive response were vaccinated. Providers responded with only persistence in 18 visits, a mix of acquiescence and persistence in 13 visits, and only acquiescence in 6 visits. When providers only used persistence, 17 of 18 adolescents were vaccinated; when providers responded with only acquiescence, no adolescents received the vaccine. CONCLUSIONS: Our exploratory analysis reveals that providers engaging hesitant parents and addressing their concerns can lead to same-day HPV vaccination. Data reveal that even parents making assertive statements are amenable to influence by providers. Our findings reveal an important missed opportunity when providers simply acquiesce to parental hesitation.

Abstract B87: Development of a tablet-based application to elicit self-persuasion about HPV vaccination among undecided parents

Introduction: The human papillomavirus (HPV) vaccine is highly efficacious and universally recommended, yet US adolescent vaccination rates remain suboptimal. Vaccination rates are lowest among racial/ethnic minorities and other medically underserved (uninsured, and low-income) populations. Many parents are ambivalent or hesitant about the HPV vaccine and delay making a decision. Self-persuasion – the process of generating one9s own arguments for changing behavior – has been an effective approach to influence motivation and behavior. But, self-persuasion9s effectiveness for HPV vaccination among safety-net populations is unknown. Also, evidence is unclear about the optimal method to elicit self-persuasion. We describe development of a tablet-based application with two different elicitation methods (verbalizing own arguments versus listening to peer-generated narratives) to encourage HPV vaccination among parents of adolescents attending safety-net clinics. Methods: We recruited participants from six clinics in Dallas, TX, the 9th largest US county— a diverse population of low-literacy Spanish- and English-speaking parents. In the first phase of the project, we developed application functions, interface, and language-specific (English and Spanish) scripts. Culturally-matched graphics and narrators were selected for an educational video and self-persuasion elicitation question prompts. In the second phase, we conducted cognitive interviews where parents used the tablet application and then were queried about the experience (e.g., feedback on comprehension of instructions and educational video as well as the time spent on each task). The goal of the interview was to identify prompts that were perceived as helpful and elicited detailed responses. Results: We dropped prompts that did not elicit new or relevant arguments and modified the language of other prompts to improve parents9 understanding (e.g. the item addressing anticipated regret was reworded as it was eliciting parental concerns about potential vaccine side effects rather than perceived future regret for not vaccinating). Parents reported they enjoyed using the application, found the self-persuasion prompts helpful in vaccine decision-making, and confirmed that tablet use did not raise concerns about the HPV vaccine. We used the audio-recorded responses of 45 parents to generate peer narratives with the vernacular of the target population. The final version of the application will be used in a randomized factorial design trial to examine basic psychological processes underlying why self-persuasion is effective. Conclusion: It is feasible for safety-net parents to use a tablet application and verbalize their self-generated arguments for HPV vaccination. Tablet-based interventions may be ideal to deliver educational messages in busy clinic settings because it is self-administered and addresses literacy limitations of safety-net parents. Citation Format: Jasmin A. Tiro, Simon Craddock Lee, David Farrell, Emily G. Marks, Austin S. Baldwin, Deanna C. Denman. Development of a tablet-based application to elicit self-persuasion about HPV vaccination among undecided parents. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B87.