William A. Calo

Provider communication and HPV vaccination: The impact of recommendation quality

BACKGROUND Receiving a healthcare providers recommendation is a strong predictor of HPV vaccination, but little is known empirically about which types of recommendation are most influential. Thus, we sought to investigate the relationship between recommendation quality and HPV vaccination among U.S. adolescents. METHODS In 2014, we conducted a national, online survey of 1495 parents of 11-17-year-old adolescents. Parents reported whether providers endorsed HPV vaccination strongly, encouraged same-day vaccination, and discussed cancer prevention. Using an index of these quality indicators, we categorized parents as having received no, low-quality, or high-quality recommendations for HPV vaccination. Separate multivariable logistic regression models assessed associations between recommendation quality and HPV vaccine initiation (≥ 1 dose), follow through (3 doses, among initiators), refusal, and delay. RESULTS Almost half (48%) of parents reported no provider recommendation for HPV vaccination, while 16% received low-quality recommendations and 36% received high-quality recommendations. Compared to no recommendation, high-quality recommendations were associated with over nine times the odds of HPV vaccine initiation (23% vs. 74%, OR=9.31, 95% CI, 7.10-12.22) and over three times the odds of follow through (17% vs. 44%, OR=3.82, 95% CI, 2.39-6.11). Low-quality recommendations were more modestly associated with initiation (OR=4.13, 95% CI, 2.99-5.70), but not follow through. Parents who received high- versus low-quality recommendations less often reported HPV vaccine refusal or delay. CONCLUSIONS High-quality recommendations were strongly associated with HPV vaccination behavior, but only about one-third of parents received them. Interventions are needed to improve not only whether, but how providers recommend HPV vaccination for adolescents.

Parents who refuse or delay HPV vaccine: Differences in vaccination behavior, beliefs, and clinical communication preferences

ABSTRACT Background: We sought to estimate the national prevalence of HPV vaccine refusal and delay in a nationally-representative sample of parents of adolescents. We also compared parents who refused versus delayed HPV vaccine in terms of their vaccination beliefs and clinical communication preferences. Methods: In 2014 to 2015, we conducted an online survey of 1,484 US parents who reported on an 11- to 17-year-old child in their household. We used weighted multinomial logistic regression to assess correlates of HPV vaccine refusal and delay. Results: Overall, 28% of parents reported that they had ever “refused or decided not to get” HPV vaccine for their child, and an additional 8% of parents reported that they had “delayed or put off getting” HPV vaccine. Compared to no refusal/delay, refusal was associated with lower confidence in adolescent vaccination (relative risk ratio [RRR] = 0.66, 95% confidence interval [CI], 0.48–0.91), lower perceived HPV vaccine effectiveness (RRR = 0.68, 95% CI, 0.50–0.91), and higher perceived harms (RRR = 3.49, 95% CI, 2.65–4.60). In contrast, delay was associated with needing more information (RRR = 1.76, 95% CI, 1.08–2.85). Most parents rated physicians and information sheets as helpful for making decisions about HPV vaccination, although parents who reported refusal endorsed these resources less often. Conclusions: Our findings suggest that HPV vaccine refusal is common among parents of adolescents and may have increased relative to previous estimates. Because the vaccination beliefs and communication preferences of parents who refuse appear to differ from those who delay, targeted communication strategies may be needed to effectively address HPV vaccine hesitancy.

Knowledge, attitudes, and beliefs about human papillomavirus (HPV) vaccination among Puerto Rican mothers and daughters, 2010: a qualitative study.

Introduction The incidence of human papillomavirus (HPV) infection and cervical cancer can be reduced by increasing vaccination for HPV. Yet vaccination uptake and completion of the 3-dose series remain low among Puerto Rican females. This study explored psychosocial factors associated with HPV vaccination uptake decisions among Puerto Rican mothers and daughters. Methods We conducted 7 focus groups with young women aged 16 to 24 (n = 21) and their mothers (n = 9) to assess knowledge, attitudes, and beliefs related to cervical cancer, HPV, and HPV vaccination. We analyzed the focus group transcripts and identified themes by using a constant comparison method of qualitative data analysis and interpretation, guided by a grounded theory approach. Results The analysis identified several emergent themes related to vaccine uptake: 1) low knowledge about cervical cancer, HPV, and the HPV vaccine; 2) inconsistent beliefs about susceptibility to HPV infection and cervical cancer; 3) vaccine effectiveness; 4) vaccine safety and side effects; 5) concerns that the vaccine promotes sexual disinhibition; and 6) availability of insurance coverage and overall cost of the vaccine. Conclusion Our study found that adolescent girls and young women in Puerto Rico have low levels of knowledge about HPV and cervical cancer, low perceived susceptibility to HPV, and concerns about the safety and efficacy of the vaccine, and these factors may influence uptake and completion of HPV vaccination. Interventions are needed for both mothers and daughters that address these psychosocial factors and increase access to vaccination.

Environmental Determinants of Smoking Behaviors: The Role of Policy and Environmental Interventions in Preventing Smoking Initiation and Supporting Cessation

Tobacco control strategies have contributed to substantial declines in smoking in the United States. However, smoking still remains the single largest preventable cause of disease and premature deaths in the country. Despite the continuing challenges of implementing tobacco control strategies and the pervasive influence of the tobacco industry to undermine such strategies, there are now unprecedented opportunities to prevent smoking initiation, facilitate cessation, and protect nonsmokers from secondhand smoke. In this paper, we briefly review the most recent literature discussing key strategies that have proven effective in tobacco control including regulations on marketing and sales of tobacco products, taxation, and smoke-free legislation. We focused on these 3 tobacco control strategies because of their potential to positively influence the environment of both minors and adults regardless of their smoking status. Although research has identified significant individual and social predictors of tobacco use, environmental influences are also important risk factors for tobacco use.

Associations between contextual factors and colorectal cancer screening in a racially and ethnically diverse population in Texas.

BACKGROUND Colorectal cancer is the third most commonly diagnosed cancer and the third leading cause of cancer death in the United States. Increased attention has been given to understanding the role of local contexts on cancer screening behaviors. We examined the associations between multiple tract-level socioeconomic measures and adherence to colorectal cancer screening (CRCS) in Harris County and the City of Houston, Texas. METHODS We conducted a cross-sectional multilevel study linking individual-level data on CRCS from the 2010 Health of Houston Survey with contextual data from the U.S. Census and the U.S. Department of Housing and Urban Development. We examined tract-level poverty, education, employment, income inequality, and foreclosure measures across 543 Census tracts. Analyses were limited to individuals aged 50-74 years (N=1720). RESULTS Overall, 58.0% of the sample was adherent to any recommended CRCS test. In bivariate analyses, increasing levels of area poverty, low education, unemployment, and foreclosures were associated with lower odds of adherence to CRCS. After controlling for individual-level covariates, only tract-level unemployment remained associated with adherence to CRCS (adjusted OR=0.80; 95% CI: 0.66-0.99; P=.037). CONCLUSIONS Neighborhood socioeconomic disadvantage is increasingly recognized as a determinant of health, and our study suggests that the contextual effect of area unemployment may extend to cancer screening outcomes. Our finding is important to cancer control planners because we identified a contextual marker of disparity that can be used to target local interventions to promote CRCS and thereby reduce cancer disparities among non-adherent individuals who reside in communities with high unemployment rates.

Physician support of HPV vaccination school-entry requirements

ABSTRACT School-entry requirements in the US have led to high coverage for several vaccines, but few states and jurisdictions have adopted these policies for human papillomavirus (HPV) vaccination. Because physicians play a key role in advocating for vaccination policies, we assessed physician support of requiring HPV vaccine for school entry and correlates of this support. Participants were a national sample of 775 physicians who provide primary care, including vaccines, to adolescents. Physicians completed an online survey in 2014 that assessed their support for school-entry requirements for HPV vaccination of 11 and 12 y olds. We used multivariable logistic regression to assess correlates of support for these requirements. The majority of physicians (74%) supported some form of school-entry requirements, with or without opt-out provisions. When opt-out provisions were not specified, 47% agreed that laws requiring HPV vaccination for school attendance were a “good idea.” Physicians more often agreed with requirements, without opt-out provisions, if they: had more years in practice (OR=1.49; 95% CI: 1.09-2.04), gave higher quality HPV vaccine recommendations (OR=2.06; 95% CI: 1.45-2.93), believed that having requirements for Tdap, but not HPV, vaccination undermined its importance (OR=3.33; 95% CI: 2.26-4.9), and believed HPV vaccination was as or more important than other adolescent vaccinations (OR=2.30; 95% CI: 1.65-3.18). In conclusion, we found that many physicians supported school-entry requirements for HPV vaccination. More research is needed to investigate the extent to which opt-out provisions might weaken or strengthen physician support of HPV vaccination school-entry requirements.

Experiences of Latinos with limited English proficiency with patient registration systems and their interactions with clinic front office staff: an exploratory study to inform community-based translational research in North Carolina

BackgroundHealth services research of Latinos with limited English proficiency (LEP) have largely focused on studying disparities related to patient-provider communication. Less is known about their non-provider interactions such as those with patient registration systems and clinic front office staff; these interactions precede the encounter with providers and may shape how comfortable patients feel about their overall health services experience. This study explored Latino patients with LEP experiences with, and expectations for, interactions with patient registration systems and front office staff.MethodsWe conducted 20 in-depth interviews with Latinos with LEP (≥18 years of age) who seek health services in the Piedmont Triad region, North Carolina. We analyzed participants’ quotes and identified themes by using a constant comparison method. This research was conducted by a community-academic partnership; partners were engaged in study design, instrument development, recruitment, data analysis, and manuscript writing.ResultsQualitative analysis allowed us to identify the following recurring themes: 1) inconsistent registration of multiple surnames may contribute to patient misidentification errors and delays in receiving health care; 2) lack of Spanish language services in front office medical settings negatively affect care coordination and satisfaction with health care; and 3) perceived discrimination generates patients’ mistrust in front office staff and discomfort with services.ConclusionLatino patients in North Carolina experience health services barriers unique to their LEP background. Participants identified ways in which the lack of cultural and linguistic competence of front office staff negatively affect their experiences seeking health services. Healthcare organizations need to support their staff to encourage patient-centered principles.

Reported Use of Electronic Health Records to Implement Evidence Based Approaches to Colorectal Cancer Screening in Community Health Centers

Background. Community health centers (CHCs) are critical sources of primary care for medically underserved populations. Electronic health records (EHRs) are important for implementation of evidence-based approaches for cancer control. Methods. Cross-sectional study of CHCs from the Cancer Prevention Control Research Network’s community health center Clinic Characteristics Survey. Proportions of CHCs using EHR data to: 1) measure colorectal cancer screening, 2) deliver reports, and 3) provide patient reminders for colorectal cancer screening. Results. Only 27% of CHCs perceive EHR system’s colorectal cancer screening data as very accurate. Over half (57%) of respondent CHCs with EHRs reported it is easy or very easy to do colorectal cancer screening activities using EHR systems. Conclusions. Poor EHR data quality and cumbersome EHR systems may be significant barriers to implementation of evidence-based approaches to colorectal cancer screening in CHCs.

Area-level Socioeconomic Inequalities in the Use of Mammography Screening: A Multilevel Analysis of the Health of Houston Survey

BACKGROUND An emerging literature reports that women who reside in socioeconomically deprived communities are less likely to adhere to mammography screening. This study explored associations between area-level socioeconomic measures and mammography screening among a racially and ethnically diverse sample of women in Texas. METHODS We conducted a cross-sectional, multilevel study linking individual-level data from the 2010 Health of Houston Survey and contextual data from the U.S. Census. Women ages 40 to 74 years (n = 1,541) were included in the analyses. We examined tract-level poverty, unemployment, education, Hispanic and Black composition, female-headed householder families, and crowding as contextual measures. Using multilevel logistic regression modeling, we compared most disadvantaged tracts (quartiles 2-4) to the most advantaged tract (quartile 1). RESULTS Overall, 64% of the sample was adherent to mammography screening. Screening rates were lower (p < .05) among Hispanics, those foreign born, women aged 40 to 49 years, and those with low educational attainment, unemployed, and without health insurance coverage. Women living in areas with high levels of poverty (quartile 2 vs. 1: odds ratio [OR], 0.50; 95% CI, 0.30-0.85), Hispanic composition (quartile 3 vs. 1: OR, 0.54; 95% CI, 0.32-0.90), and crowding (quartile 4 vs. 1: OR, 0.53; 95% CI, 0.29-0.96) were less likely to have up-to-date mammography screening, net of individual-level factors. CONCLUSION Our findings highlight the importance of examining area-level socioeconomic inequalities in mammography screening. The study represents an advance on previous research because we examined multiple area measures, controlled for key individual-level covariates, used data aggregated at the tract level, and accounted for the nested structure of the data.

Factors Associated with Perceived Patient- Provider Communication Quality among Puerto Ricans

Patient-provider communication is an important factor influencing patients’ health outcomes. This study examined the relationship between patient-provider communication quality and sociodemographic, health care access, trusted information sources, and health status variables. Data were from a representative sample of 450 Puerto Rican adults who participated in the Health Information National Trends Survey. A composite score rating perceived patient-provider communication quality was created from five items (Cronbach’s alpha = 0.87). A multivariate linear regression analysis was conducted. Patient-provider communication ratings were lower among the unemployed (p = 0.049), those who do not trust a lot in the information provided by their providers (p = 0.003), and respondents with higher depressive symptoms scores (p = 0.036). Perceived patient-provider communication quality, however, was higher among respondents who visited their providers five or more times in the last year (p = 0.023). Understanding patient perceptions of provider communication may serve to develop system-level interventions aimed at eliminating communication disparities and improving patients’ health outcomes.