Noel T. Brewer

Meta-Analysis of the Relationship Between Risk Perception and Health Behavior: The Example of Vaccination

BACKGROUND Risk perceptions are central to many health behavior theories. However, the relationship between risk perceptions and behavior, muddied by instances of inappropriate assessment and analysis, often looks weak. METHOD A meta-analysis of eligible studies assessing the bivariate association between adult vaccination and perceived likelihood, susceptibility, or severity was conducted. RESULTS Thirty-four studies met inclusion criteria (N = 15,988). Risk likelihood (pooled r = .26), susceptibility (pooled r = .24), and severity (pooled r = .16) significantly predicted vaccination behavior. The risk perception-behavior relationship was larger for studies that were prospective, had higher quality risk measures, or had unskewed risk or behavior measures. CONCLUSIONS The consistent relationships between risk perceptions and behavior, larger than suggested by prior meta-analyses, suggest that risk perceptions are rightly placed as core concepts in theories of health behavior.

Systematic Review: The Long-Term Effects of False-Positive Mammograms

Context Do false-positive mammograms affect womens well-being and behavior? Contribution This systematic review summarizes data from 23 observational studies that compared outcomes after false-positive results or normal results on screening mammograms. Women who received false-positive results had slightly higher levels of distress and more thoughts about cancer several months after screening than women who received normal results. They also performed breast self-examinations more frequently and, in the United States, were slightly more likely to return for repeated routine screening examinations (risk ratio, 1.07 [95% CI, 1.02 to 1.12]). Implication False-positive mammograms may have persistent small effects on some womens psychological well-being and behavior. The Editors Regular mammography has become part of routine health care in the developed world for women 40 years of age or older. Routine mammography is important because it reduces death due to breast cancer by detecting tumors early (13). Unfortunately, many women receive false-positive results on screening tests. In the United States, approximately 11% of screening mammograms lead to false-positive results, which can cause women to incur substantial personal and financial costs related to follow-up testing (4, 5). One study (6) estimated that increased medical care use related to false-positive results on mammography costs

Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review

100 million per year in the United States. Researchers have shown that false-positive results negatively influence womens psychological well-being during the period immediately surrounding tests (7). Although researchers have performed several studies (79) on the effect of false-positive mammograms on women, the long-term effect is poorly understood. Women who receive false-positive mammograms may be discouraged from further routine screening mammographies (10). Testing errors could undermine womens confidence in the benefit of mammography and in the medical systems ability to provide adequate care, making them less likely to return for routine mammography. The costly and time-consuming follow-up procedures prompted by false-positive results may be an additional disincentive for return. Alternatively, false-positive mammograms may not have a negative effect on subsequent screening mammographies. Only one half of women with abnormal mammograms are aware of having received false-positive results (11). A recent survey in the United States found that of the adults who recall having received false-positive results on screenings for cancer (including mammographies), 98% were still glad that they had had the tests performed (12, 13). Women are concerned about receiving overdiagnosis and overtreatment but not about receiving false-positive results per se (14). A final and less commonly argued alternative is that false-positive results might actually increase routine screening because they increase anxiety, worry, and perceived risk (7, 1520). Anxiety, in turn, may cause women who receive false-positive results to be more vigilant about early detection than women who receive normal results. Although extreme anxiety caused by screening seems to be rare, abnormal mammograms apparently prompted 2 British women to commit suicide (21). Many studies have addressed the long-term consequences for women who receive false-positive mammograms, but these studies have yielded contradictory results, with different studies supporting each of the 3 possibilities described. Other reviews (7, 9, 18, 2225) emphasized short-term psychological consequences, largely ignored health behaviors, were typically not systematic reviews, and did not screen studies for minimum quality criteria. Because mixed findings among diverse outcomes have thwarted the understanding of the presence and extent of the long-term effects of false-positive screening mammograms, we conducted a systematic review of the relevant literature. We aimed to characterize the long-term effects of false-positive screening mammograms on the behavior and well-being of women 40 years of age or older. Methods Data Sources and Searches We conducted the review by using the following protocol. Two reviewers independently searched the MEDLINE, Web of Science, EMBASE, CINAHL, PsycINFO, and ERIC databases for studies published through September 2006 whose title, abstract, or keywords included reference to both false-positive results and screening mammography. The search terms were (false positive OR abnormal OR benign) AND (breast cancer OR mammog*). We also manually searched the reference sections of relevant papers and circulated requests for unpublished studies among colleagues and the authors of the articles we identified. We limited the searches to English-language studies. Study Selection Two reviewers independently screened the titles, then abstracts, and then text of articles that seemed pertinent. We identified studies that examined the effects of false-positive mammograms on the behavior, well-being, or beliefs of women 40 years of age or older by using selection criteria that we specified before the review began, except as noted. We excluded studies that did not meet the following quality criteria. We required that initial mammography screening results (abnormal or normal) be obtained from routine mammography because mammographies conducted for reasons other than screening take place in a very different context. We excluded studies of mammography prompted by symptoms or initial screening by clinical breast examination. We required that women receiving false-positive results be compared with women from the same sample who received normal results. Unacceptable comparison groups included unscreened women and women screened at other times or in different settings. We defined false-positive results on mammograms as abnormal results that did not lead to a cancer diagnosis after follow-up mammography, ultrasonography, magnetic resonance imaging, fine-needle aspiration, or biopsy. While reviewing the studies, we decided to include 2 studies (26, 27) that did not report the resolution of abnormal screening results because very few abnormal results indicate cancer (28). The inclusion of these studies did not change our findings. We required that initial screening be real (not imagined in a hypothetical vignette) and that results be assessed from medical records or by patient self-report. Studies had to include the outcome of return for routine screening within the interval recommended in the country or health system in which the study was conducted; we did not consider mammographies that were follow-ups of abnormal results or were part of a clinical trial as routine, initial mammographies. We required that women who returned for screening be assessed from medical or registry records or by patient self-report; however, we did not include intention to be screened as an acceptable measure. Additional outcomes included behavior, well-being, and beliefs, such as self-report of conducting breast self-examinations, anxiety, worry, perceived risk, and depression. We required that these outcome measures be assessed at least 1 month after cancer was ruled out so that the data reflected long-term consequences of false-positive screening results and not immediate distress in the period between receiving an abnormal test result and the subsequent negative result for cancer. Although breast self-examination has not been shown to reduce death due to breast cancer (29), we included it in our analysis as an additional demonstration of the effect of false-positive results on womens behavior. We required that studies reported bivariate statistical analyses of original, quantitative data or reported data that could be reanalyzed, although we accepted studies that reported null effects without indicating their size or direction. In practice, we did not exclude studies that reported results only after adjustment for covariates, although we excluded several studies that reported complex analyses that did not allow us to determine the relevant main effect. Data Extraction and Quality Assessment Two investigators independently used a standardized data extraction form to code the studies on characteristics that could alter the effect of receiving a false-positive result. In addition, we coded variables that reflect study quality, such as study design and use of self-report. During our review process, we refined our coding criteria to exclude study results for women whose follow-up for an abnormal mammogram was not further testing but was instead early recall for their next screening mammography. We could not exclude data for these women in 2 studies included in the review because data on women placed on early recall were combined with data on women receiving diagnostic follow-up in the study analyses (30, 31). Two investigators independently calculated a risk ratio for each study of return for the next routine mammogram. Data Synthesis and Analysis For studies assessing whether women returned for mammography, we pooled risk ratios (1 per study) by using a random-effects meta-analysis (32). For the 1 study (33) that reported data about reattendance at several time intervals after the initial mammogram, we chose data from month 18 of the study because that was the next period after the recommended screening interval of 12 months. Our analysis weighted risk ratios according to the sample size in each study while taking into account the variability among studies. We created a funnel plot to assess possible publication bias. We conducted the analyses by using the metan procedure in Stata (Stata Corp., College Station, Texas). We used 2-tailed statistical tests (critical = 0.05). Role of the Funding Sources The study was funded by grants from the University of North Carolina Lineberger Comprehensive Cancer Center and the American Cancer Society. The funding sources had no role in conducting the review or in preparing and submitti

Longitudinal predictors of human papillomavirus vaccine initiation among adolescent girls in a high-risk geographic area.

Objective We sought to systematically review the literature on electronic nicotine delivery systems (ENDS, also called electronic cigarettes) awareness, use, reactions and beliefs. Data sources We searched five databases for articles published between 2006 and 1 July 2013 that contained variations of the phrases ‘electronic cigarette’, ‘e-cigarette’ and ‘electronic nicotine delivery’. Study selection Of the 244 abstracts identified, we excluded articles not published in English, articles unrelated to ENDS, dissertation abstracts and articles without original data on prespecified outcomes. Data extraction Two reviewers coded each article for ENDS awareness, use, reactions and beliefs. Data synthesis 49 studies met inclusion criteria. ENDS awareness increased from 16% to 58% from 2009 to 2011, and use increased from 1% to 6%. The majority of users were current or former smokers. Many users found ENDS satisfying, and some engaged in dual use of ENDS and other tobacco. No longitudinal studies examined whether ENDS serve as ‘gateways’ to future tobacco use. Common reasons for using ENDS were quitting smoking and using a product that is healthier than cigarettes. Self-reported survey data and prospective trials suggest that ENDS might help cigarette smokers quit, but no randomised controlled trials with probability samples compared ENDS with other cessation tools. Some individuals used ENDS to avoid smoking restrictions. Conclusions ENDS use is expanding rapidly despite experts’ concerns about safety, dual use and possible ‘gateway’ effects. More research is needed on effective public health messages, perceived health risks, validity of self-reports of smoking cessation and the use of different kinds of ENDS.

Pictorial cigarette pack warnings: a meta-analysis of experimental studies

Background: Human papillomavirus (HPV) vaccine uptake is low among adolescent girls in the United States. We sought to identify longitudinal predictors of HPV vaccine initiation in populations at elevated risk for cervical cancer. Methods: We interviewed a population-based sample of parents of 10- to 18-year-old girls in areas of North Carolina with elevated cervical cancer rates. Baseline interviews occurred in summer 2007 and follow-up interviews in fall 2008. Measures included health belief model constructs. Results: Parents reported that 27% (149/567) of their daughters had initiated HPV vaccine between baseline and follow-up. Of parents who at baseline intended to get their daughters the vaccine in the next year, only 38% (126/348) had done so by follow-up. Of parents of daughters who remained unvaccinated at follow-up but had seen a doctor since baseline, only 37% (122/388) received an HPV vaccine recommendation. Rates of HPV vaccine initiation were higher among parents who at baseline perceived lower barriers to getting HPV vaccine, anticipated greater regret if their daughters got HPV because they were unvaccinated, did not report “needing more information” as the main reason they had not already vaccinated, intended to get their daughters the vaccine, or were not born-again Christians. Conclusions: Missed opportunities to increase HPV vaccine uptake included unrealized parent intentions and absent doctor recommendations. While several health belief model constructs identified in early acceptability studies (e.g., perceived risk, perceived vaccine effectiveness) were not longitudinally associated with HPV vaccine initiation, our findings suggest correlates of uptake (e.g., anticipated regret) that offer novel opportunities for intervention.

The interaction of post-traumatic growth and post- traumatic stress symptoms in predicting depressive symptoms and quality of life

Objective To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. Data sources We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. Study selection We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria. Data extraction and synthesis Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. Results Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. Conclusions The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

HPV vaccine and adolescent males

Objective: We sought to explore whether post‐traumatic growth (PTG) (positive change or benefit finding resulting from trauma) moderates relationships between post‐traumatic stress symptoms (PTSS) and both depression and quality of life (QOL) among breast cancer survivors.

Opportunities and challenges of Web 2.0 for vaccination decisions

In 2009, the United States approved quadrivalent HPV vaccine for males 9-26 years old, but data on vaccine uptake are lacking. We determined HPV vaccine uptake among adolescent males, as well as stage of adoption and vaccine acceptability to parents and their sons. A national sample of parents of adolescent males ages 11-17 years (n=547) and their sons (n=421) completed online surveys during August and September 2010. Analyses used multivariate linear regression. Few sons (2%) had received any doses of HPV vaccine, and most parents and sons were unaware the vaccine can be given to males. Parents with unvaccinated sons were moderately willing to get their sons free HPV vaccine (mean=3.37, SD=1.21, possible range 1-5). Parents were more willing to get their sons vaccinated if they perceived higher levels of HPV vaccine effectiveness (β=0.20) or if they anticipated higher regret about their sons not getting vaccinated and later developing an HPV infection (β=0.32). Vaccine acceptability was also modest among unvaccinated sons (mean=2.98, SD=1.13, possible range 1-5). Sons were more willing to get vaccinated if they perceived higher peer acceptance of HPV vaccine (β=0.39) or anticipated higher regret about not getting vaccinated and later developing an HPV infection (β=0.22). HPV vaccine uptake was nearly nonexistent a year after permissive national recommendations were first issued for males. Vaccine acceptability was moderate among both parents and sons. Efforts to increase vaccine uptake among adolescent males should consider the important role of peer acceptance and anticipated regret.

HPV vaccine acceptability in a rural Southern area.

A growing number of people use the Internet to obtain health information, including information about vaccines. Websites that allow and promote interaction among users are an increasingly popular source of health information. Users of such so-called Web 2.0 applications (e.g. social media), while still in the minority, represent a growing proportion of online communicators, including vocal and active anti-vaccination groups as well as public health communicators. In this paper, the authors: define Web 2.0 and examine how it may influence vaccination decisions; discuss how anti-vaccination movements use Web 2.0 as well as the challenges Web 2.0 holds for public health communicators; describe the types of information used in these different settings; introduce the theoretical background that can be used to design effective vaccination communication in a Web 2.0 environment; make recommendations for practice and pose open questions for future research. The authors conclude that, as a result of the Internet and Web 2.0, private and public concerns surrounding vaccinations have the potential to virally spread across the globe in a quick, efficient and vivid manner. Web 2.0 may influence vaccination decisions by delivering information that alters the perceived personal risk of vaccine-preventable diseases or vaccination side-effects. It appears useful for public health officials to put effort into increasing the effectiveness of existing communication by implementing interactive, customized communication. A key step to providing successful public health communication is to identify those who are particularly vulnerable to finding and using unreliable and misleading information. Thus, it appears worthwhile that public health websites strive to be easy to find, easy to use, attractive in its presentation and readily provide the information, support and advice that the searcher is looking for. This holds especially when less knowledgeable individuals are in need of reliable information about vaccination risks and benefits.

Acceptability of HPV Vaccine Among a National Sample of Gay and Bisexual Men

BACKGROUND Although cervical cancer rates in the United States are highest in Southern and rural areas, research on human papillomavirus (HPV) vaccine acceptability has focused on other geographic areas. METHODS To address this gap, we surveyed women from a rural area in North Carolina with elevated rates of cervical cancer to identify predictors of HPV vaccine acceptability for themselves and their daughters. RESULTS One hundred forty-six women completed questionnaires about HPV infection, cervical cancer, and HPV vaccination. The majority (62%) of respondents were African American. Most respondents intended to vaccinate an adolescent daughter against HPV. Older and African American women reported lower vaccination intentions. Higher intentions to vaccinate an adolescent daughter against HPV were associated with knowing more about HPV, believing that HPV infection and cervical cancer are both likely and have negative consequences, and believing that the HPV vaccine is effective against cervical cancer. Women reported higher intentions to get the HPV vaccine for an adolescent daughter than for themselves. CONCLUSIONS HPV vaccine acceptability for an adolescent daughter was associated with womens beliefs about their own healthcare needs. These findings on the HPV vaccination decisions of women in North Carolina offer insights that can inform future health communication activities intended to increase vaccination uptake in other high-risk populations of rural Southern women.