Jane R. Montealegre

The Role of Media and the Internet on Vaccine Adverse Event Reporting: A Case Study of Human Papillomavirus Vaccination

PURPOSE This study aimed to determine the temporal association of print media coverage and Internet search activity with adverse events reports associated with the human papillomavirus vaccine Gardasil (HPV4) and the meningitis vaccine Menactra (MNQ) among United States adolescents. METHODS We used moderated linear regression to test the relationships between print media reports in top circulating newspapers, Internet search activity, and reports to the Vaccine Adverse Event Reporting System (VAERS) for HPV4 and MNQ during the first 2.5 years after Food and Drug Administration approval. RESULTS Compared with MNQ, HPV4 had more coverage in the print media and Internet search activity, which corresponded with the frequency of VAERS reports. In February 2007, we observed a spike in print media for HPV4. Although media coverage waned, Internet search activity remained stable and predicted the rise in HPV4-associated VAERS reports. CONCLUSIONS We demonstrate that media coverage and Internet search activity, in particular, may promote increased adverse event reporting. Public health officials who have long recognized the importance of proactive engagement with news media must now consider strategies for meaningful participation in Internet discussions.

Avoidable tragedies: Disparities in healthcare access among medically underserved women diagnosed with cervical cancer☆

BACKGROUND The purpose was to identify barriers including logistical and health belief correlates of late stage presentation of cervical cancer (CxCa) among medically underserved women presenting to a safety net health care system. METHODS Women presenting with newly diagnosed CxCa were asked to complete a detailed health belief survey that included questions about barriers to care and their knowledge of CxCa. All information was collected prior to initiating cancer treatment. Comparisons were made among women diagnosed at early stages of disease amendable to surgical treatment (≤IB1) and those diagnosed at a stage requiring local-regional or systemic/palliative treatment (≥IB2). RESULTS Among the 138 women, 21.7% were diagnosed with ≤lB1 disease, while 78.3% were diagnosed with ≥IB2 disease. Late-stage diagnosis was associated with a greater number of emergency room (ER) visits (p<.001) and blood transfusions (p<.001) prior to diagnosis. Compared to 88% with ≤lB1 disease, only 53% of patients with ≥IB2 disease had a car (p=.003). Women with ≥IB2 disease were more likely to be without a primary care provider (75.0% vs. 42.3%, p=.001). CONCLUSION Access to transportation and lack of a regular primary care provider or a medical home are associated with late-stage of CxCa at diagnosis. Many medically underserved women continue to use the ER as their primary source of health care, and as a result their CxCa is diagnosed in advanced stages, with higher medical costs and lower chances of cure. The lack of Medicaid expansion in Texas may result in a worsening of this situation.

Acceptability of self-sample human papillomavirus testing among medically underserved women visiting the emergency department

OBJECTIVE Self-sample human papillomavirus (HPV) testing in public emergency departments (EDs) may be a viable strategy to opportunistically screen women who otherwise do not attend for regular Papanicolaou test-based cervical cancer screening. We describe the acceptability of self-sample HPV testing among women presenting to two high-volume, urban EDs that primarily care for the medically underserved. METHODS In 2014, a total of 210 women 21 years of age and older were recruited from two public ED waiting areas following a two-stage cluster sampling design. Questionnaire items inquired about demographics, healthcare access and utilization, history of cervical cancer screening, and acceptability of self-sample HPV testing. Descriptive analyses were performed. RESULTS Overall, 34.8% of participants were considered screening non-attendees based on their adherence to the current guidelines for Pap testing every three years. Acceptability of self-sample HPV testing was high, with over 85% of participants reporting that they would be willing to use the test if available. A smaller proportion (58%) was deemed likely to accept self-sample HPV testing in a public ED restroom setting. Primary concerns expressed by women were that the sampling may not be done correctly (64%) and that they may not know how to perform the sampling (39%). CONCLUSIONS Opportunistic self-sample HPV testing is acceptable to women seeking care at a high-volume, urban emergency care center. The use of this intervention potentially offers a unique strategy to improve cervical cancer screening among high-risk women who otherwise do not attend for regular screening.

Implementing targeted cervical cancer screening videos at the point of care

OBJECTIVE To develop and implement educational videos to improve cervical cancer health literacy for patients within a safety net healthcare system. METHODS Testimonial-style videos were developed with the goal of describing the Pap test to low literacy patients and motivating them to participate in regular cervical cancer screening. Nurses were trained to use the electronic medical record to identify patients due or past due for a Pap test according to the current screening guidelines. They played the video for all eligible patients as they waited to be seen by their physician in clinical examination rooms. RESULTS Four 2-minute videos were developed in English, Spanish, and Vietnamese. Videos were made available on desktop computers in 458 exam rooms at 13 community health centers. CONCLUSION Integration of educational videos into the workflow of high-volume community health centers is feasible. Future work will focus on optimizing uptake of the videos as well as assessing their efficacy for improving cervical cancer health literacy. PRACTICE IMPLICATIONS Integrating targeted videos into patient flow may be a feasible way to address health literacy barriers to cervical cancer screening within a busy workflow environment.

Assessment of factors impacting cervical cancer screening among low-income women living with HIV-AIDS

ABSTRACT Very little is currently known about factors impacting the prevalence of cervical cancer screening among women living with HIV-AIDS (WLHA). To better understand this issue, we surveyed low-income, medically underserved women receiving subsidized gynecologic care through an integrated HIV clinic. A self-administered questionnaire was completed by 209 women who self-identified as HIV positive. A total of 179 subjects (85.7%) reported having had a Pap test in the last three years. The majority of WLHA (95%) knew that the Pap test screens for cervical cancer. However, overall knowledge of cervical cancer risk factors, such as multiple sexual partners or sex with a man with multiple partners, was low (43% and 35%, respectively). Unscreened women were younger and more likely to be single with multiple current sexual partners. In multivariable analyses, the only factors associated with Pap testing were a womans perception that her partner wants her to receive regular screening (aOR 4.64; 95% CI: 1.15–23.76; p = .04), number of clinic visits during the past year (aOR 1.36, 95% CI: 1.05–1.94; p = .04) and knowledge that the need for a Pap test does not depend on whether or not a woman is experiencing vaginal bleeding (aOR 6.52, 95% CI: 1.04–49.71; p = .05). We conclude that support from male partners in addition to effective contact with the health system and knowledge of cervical cancer risk factors influence Pap utilization among low-income WLHA. Future measures to improve the care for this population should increase knowledge of cervical cancer risk factors and encourage social support for cervical cancer screening among WLHA.

Incorporating Cultural Sensitivity into Interactive Entertainment-Education for Diabetes Self-Management Designed for Hispanic Audiences

Diabetes self-management education can improve outcomes in adults with Type 2 diabetes mellitus (T2DM). However, Hispanics, a group that carries a large burden of disease, may not participate in diabetes education programs. Audience engagement with entertainment-education has been associated with improved health education outcomes and may engage and empower Hispanic users to active self-care. Successful use of entertainment-education relies on the use of characters and situations with whom the viewers can feel some sense of involvement and for Hispanic audiences is encouraged when storylines and characters are culturally sensitive. In this study, we used a mixed methods approach that included descriptive statistics of closed-ended and content analysis of open-ended questions to measure the cultural sensitivity of the telenovela portion of a novel technology-based application called Sugar, Heart, and Life (SHL). Specifically, we analyzed the responses of 123 male and female patients diagnosed with uncontrolled T2DM to determine viewer involvement with characters and situations in the telenovela, viewer perceived self-efficacy in following recommendations, as well as viewer satisfaction with the program. Our findings indicate that the SHL application achieved its goal of creating a user-friendly program that depicted realistic, culturally sensitive characters and storylines that resonated with Hispanic audiences and ultimately fostered perceived self-efficacy related to following recommendations given about healthy lifestyle changes for diabetes self-management. These findings suggest that the SHL application is a culturally sensitive health education intervention for use by Hispanic male and female individuals that may empower them in self-management of T2DM.

Racial/ethnic differences in HPV 16/18 genotypes and integration status among women with a history of cytological abnormalities

OBJECTIVE HPV genotype distribution varies by race/ethnicity, but is unclear whether there are racial/ethnic variations in HPV 16/18 integration in the host genome. We describe HPV16/18 infection and integration status in a racially/ethnically diverse sample of women with a recent abnormal Pap test. METHODS Patients (n=640) represent a subset of women participating in a clinical trial. Cervical swabs were tested for HPV16/18 DNA using type-specific polymerase chain reaction assays. Viral integration status was assessed using type-specific integration assays and categorized as fully integrated, fully non-integrated, or mixed. Unconditional logistic regression was used to generate unadjusted (OR) and adjusted odds ratios (aOR) to assess the association between self-reported race/ethnicity and risk of these outcomes. RESULTS Hispanic and non-Hispanic black women had half the odds of prevalent HPV16 compared to non-Hispanic white women (aORs: 0.43 and 0.45, respectively). The prevalence odds of HPV18 was less than half among Hispanic women (aOR: 0.48), but not significantly different between black and white women (aOR: 0.72). Among women with prevalent HPV16, the odds of fully integrated viral DNA were significantly higher among black women (aORs: 2.78) and marginally higher among Hispanic women (aOR: 1.93). No racial/ethnic differences were observed for HPV18 DNA integration. CONCLUSIONS While HPV16 and 18 infections were less prevalent among Hispanic and black women compared to whites, their HPV16 DNA was more likely to be present in a fully integrated state. This could potentially contribute to the higher rates of abnormal cytology and cervical dysplasia observed among Hispanic and black women.

Racial/ethnic variation in the prevalence of vaccine-related human papillomavirus genotypes

ABSTRACT Objective: There are currently three licensed human papillomavirus (HPV) vaccines that protect against cervical cancer. Here we compare the prevalence of bi-, quadri-, and nonavalent vaccine-related HPV genotypes in a multi-ethnic sample of non-Hispanic white, non-Hispanic black, Hispanic, and Asian women. Design: Patients in this analysis (n = 419) represent a subset of women with a previous abnormal Pap test participating in a clinical trial. HPV genotyping was conducted using the Roche Linear Array. Prevalent HPV genotypes were grouped according to their inclusion in each of the vaccines: bivalent (16, 18), quadrivalent (16, 18, 6, 11), and nonavalent (16, 18, 31, 33, 45, 52, 58, 6, 11). Results: The prevalence of HPV genotypes covered by the bi-/quadrivalent vaccines was lowest among non-Hispanic black (15%) and Hispanic women (20%), compared to non-Hispanic white (38%) and Asian women (38%). Across all racial/ethnic groups, a large proportion of infections (38%–49%) were with genotypes included in the nonavalent vaccine. However, the prevalence of HPV genotypes not covered by any vaccine was significantly higher among non-Hispanic black (36%) and Hispanic women (42%), compared to non-Hispanic white (24%) and Asian women (16%) (p < 0.001). Racial/ethnic differences in HPV genotype prevalence were observed when controlling for demographic and sexual behavior characteristics, as well as when restricting the analysis to women with CIN 2+. Conclusion: Our data suggest racial/ethnic differences in the prevalence of vaccine-related HPV genotypes. In particular, non-Hispanic black and Hispanic women had the lowest prevalence of HPV genotypes covered by the bi-/quadrivalent vaccines. While a large proportion of their infections were covered by the nonavalent vaccine, non-Hispanic black and Hispanic women also had the highest prevalence of HPV genotypes not covered by any vaccine.

Abstract C17: Community theater outreach to increase HPV vaccine intention among parents of Latino adolescents: A pilot test

Introduction: Although Latinos have higher HPV vaccination rates than non-Hispanic whites, coverage is far below the 80% Healthy People 2020 goal. Significant gaps in knowledge and awareness about HPV and the HPV vaccine persist. Community theater performances are an effective tool to communicate health messages to medically underserved minority populations. Here we describe the pilot test of a community theater-based intervention to increase HPV vaccination intention among Spanish-speaking parents of underserved Latino adolescents. Methods: The monologue script was written by a professional playwright and then modified in an iterative process based on recommendations from clinical and community advisory boards. The monologue performance was pilot tested in two groups, one at a charter school and another at a church in Harris County, TX. Audiences viewed a performance of the monologue and then participated in a question-and-answer session. After the intervention, they were asked questions about the performance and their comprehension of health messages. Additionally, participants answered a self-administered questionnaire. Feedback from the pilot audiences was compiled and incorporated into a revised monologue script. Results: The monologue pilot performances were attended by 36 people. They were mostly female around the average age of 41. 36% were very likely to get their children vaccinated for HPV before viewing the monologue, and 97% were very likely to get their children vaccinated for HPV after the viewing the monologue. This difference was statistically significant (p Discussion: Responses to the pre- and post-performance intention-to-vaccinate item suggest that the monologue may increase Latino parents9 intentions to vaccinate their adolescent children against the HPV vaccine. This suggests that community theater performances targeted to Latino parents may be an effective approach to communicate health messages and improve parents9 knowledge and intentions to vaccinate their adolescent children for HPV. For the most part, audiences understood the main health messages of the monologue and were entertained by and identified with the character and scenarios depicted in the script. However, there were several key messages that audience members felt were not strongly conveyed in the original script: specifically, that the vaccine is about cancer prevention not sexual activity, why the recommended age for vaccination is 11 and 12 years, and the importance of vaccinating against HPV and other adolescent vaccines (Tdap and meningococcal). Changes made to the monologue script will be made based on the feedback from the pilot audiences. Community theater performances targeted to Latino parents may be an effective approach to communicate health messages and improve parents9 knowledge and intentions to vaccinate their adolescent children for HPV. Citation Format: Veronica Landa, Jane Montealegre, Maria Jibaja-Weiss. Community theater outreach to increase HPV vaccine intention among parents of Latino adolescents: A pilot test [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C17.

Abstract A46: Understanding the influential factors to human papillomavirus vaccination among youth in Harris County, Texas: A qualitative study

Introduction: Harris County, Texas is the 3rd largest county in the United States, and home to a large ratio of racial/ethnic minorities and immigrants. It has one of the highest rates of cervical cancer, where nearly all cases are caused by human papillomavirus (HPV), with the incidence rate highest among African Americans and Hispanics/Latinos. A wealth of medical resources exist, yet HPV-related cancers have failed to improve over the past 10 years. Youth are particularly at risk for HPV infection and are more likely to not receive the HPV vaccine. The aim of this research was to better understand the factors influencing HPV vaccination among youth in Harris County and to develop an evidence-based approach to improve vaccine uptake. Methods: A socio-ecological framework was used to identify key stakeholders. Data was collected using a mixed methods approach between October 2014 and October 2015 in Harris County, Texas. One focus group and 31 focused interviews were conducted with parents of 5-18 year old children. Seven key informant interviews were conducted with school nurses; a political leader; and health professionals from adolescent health clinics, pediatric hospitals, health centers, community-based organizations (CBOs), and medical institutions. Three community advisory board (CAB) meetings were held with school nurses and board members; physicians; and health professionals from health departments, CBOs, and educational and advocacy organizations. Results: Parents Most parents lacked knowledge of HPV and the vaccine. Many felt the best way to receive education was from their providers. Others expressed interest in receiving education from schools, the media, seminars, and community involvement. Spanish-speaking parents emphasized the need for more linguistically appropriate literature. Some parents voiced discomfort with vaccinating 9-12 year olds, mainly due to safety concerns and vaccine efficacy. Physicians9 recommendations were an influential factor in some parents9 decision making regarding vaccination. Other key stakeholders Lack of education about HPV infection and the vaccine was cited as a major barrier to vaccination. CAB participants often felt misinformed by their providers, and stated some physicians lack time to hold discussions and fail to provide confident recommendations. Perceived negative side effects; cultural and religious beliefs; lack of reminders for the 2nd and 3rd doses; and labeling the vaccine as a cervical cancer and sexual vaccine were noted as other barriers. Health clinics felt some providers9 recommendation approaches were a barrier. Mistrust of the healthcare system was reported as common in Hispanic/Latino communities, and lack of engagement in preventable activities was described as common in African American and immigrant communities. It was stressed that education targeting parents, use of the opt-out approach for provider recommendations, and promoting the vaccine as a cancer-prevention vaccine are essential to increasing HPV vaccine uptake. Conclusions: Comprehensive educational interventions at the provider-, school-, and community-level are needed to ensure that physicians, parents, patients, and educators receive accurate information. Provider trainings can equip physicians with the accurate knowledge needed to make confident recommendations; emphasize use of the opt-out approach for recommendations; and provide them with multilingual educational materials to share with parents and patients. Collaborative efforts with school board members and parent organizations/associations can encourage inclusion of HPV in the curriculum, and foster discussions among parents and educators. Community-based interventions should focus on innovative, culturally-appropriate ways to disseminate education messages in medically, underserved communities. Citation Format: Aba Coleman, Marva Mallory, Jane Montealegre, Peggy Smith, Ruth Buzi, Michael Scheurer, Maria Daheri, Maria Jibaja-Weiss, Matthew Anderson. Understanding the influential factors to human papillomavirus vaccination among youth in Harris County, Texas: A qualitative study. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr A46.