mHealth video gaming for human papillomavirus vaccination among college men-qualitative inquiry for development.

Background: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Persistent infection with HPV can cause various cancers; however, HPV vaccination can prevent infections associated with high risk, cancerous strains of the virus. As it relates to HPV, college age men have been identified as one of the catch-up vaccination groups. Among college age men, gaming is an extremely popular extracurricular activity. Further, video games have emerged as a popular public health intervention tool. Therefore, this study aims to collect qualitative data on how to develop, implement and evaluate the effectiveness of a gaming intervention to increase HPV risk perceptions, improve self-efficacy and increase intention to receive the HPV vaccine among male college students (18-26 years old). Methods: Four focus group sessions ranging from eight to ten individuals were conducted among male college students from one large research-intensive university in the South. Using grounded theory, data from focus group interviews were coded using NVivo software to identify emergent themes. Results: Participants emphasized that although customization was not viewed as important by college aged males, the ability to tailor in game experiences or experience different things each time they played (creative freedom) was more important. They encouraged that the digital game be created on a mobile platform, incorporate health messages, and be informative to reach their population. Furthermore, they suggested innovative way to disseminate the game, which included having health department/health care providers prescribe the game to patients as an end of clinical interaction strategy. Conclusions: College age men, are natural avid gamers, enjoy game play, and can engage in learning online or offline. While platform preference varies among gamer type, college age men in our study emphasized that mobile based gaming is the most advantageous way to increase knowledge/awareness and encourage positive in game behavior which can impact out of game behaviors such as vaccination. Because of the level of access and natural disposition of mHealth technology seen as an "extension of the self", games for health developers should consider the mobile platform as the ideal for the target demographic.

The Male Domain-Digital Game-Based Learning for Human Papillomavirus Vaccination Among Young Males.

Background: Human papillomavirus (HPV) is the most common sexually transmitted disease, with the highest infection rates among those sexually active under 25. Although vaccination can reduce HPV cancers among men, public health interventions have primarily targeted females. Increased gaming rates among men provide innovative opportunities to motivate behavior change. This study sought to explore which game development and design strategies are most effective in a game for sexual health, specifically focused on HPV. We also sought to capture information relevant to preferred gaming platforms and game mechanics (health messages, avatars, and visual imagery). Materials and Methods: Twenty-two (n = 22) qualitative interviews were conducted with experts. Using grounded theory, interview data was coded, and emergent themes were identified. Results: Game mechanics most mentioned included simulation/role-playing, social interaction, narrative, and rewards. Experts felt it was important to keep the game in the context of the target audience and integrate the game into an existing game/game scenario or application. Experts also felt the game should link to external resources and enlist partnerships or collaborations with external health agencies. Moreover, while there are benefits to each gaming platform, games on mobile phones and tablets are most appropriate. Conclusion: Digital games are a nonconfrontational approach to discussing HPV and can increase knowledge/awareness and positively influence behavior change toward vaccine uptake. Digital games present a safe environment for role-playing through simulated activities without real-world consequences.

Utilizing Theories and Evaluation in Digital Gaming Interventions to Increase Human Papillomavirus Vaccination Among Young Males: Qualitative Study.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. HPV attributes to most cancers including anal, oral, cervical, and penile. Despite infection rates in the United States, recommendations and communication campaigns have traditionally focused on females. Because of this, males lack knowledge about reasons for vaccination, the benefits of being vaccinated, and their HPV risk, overall. Gaming as a health education strategy can be beneficial as mechanism that can promote behavior change for this key demographic because of the popularity of gaming. OBJECTIVE: We sought to explore the relationship between gamification and HPV vaccine uptake. METHODS: Interviews were conducted with experts (n=22) in the fields of cancer prevention, sexual and reproductive health, public health, game design, technology, and health communication on how a game should be developed to increase HPV vaccination rates among males. RESULTS: Overwhelmingly, theoretical models such as the health belief model were identified with key constructs such as self-efficacy and risk perception. Experts also suggested using intervention mapping and logic models as planning tools for health promotion interventions utilizing a digital game as a medium. In game and out of game measures were discussed as assessments for quality and impact by our expert panel. CONCLUSIONS: This study shows that interventions should focus on whether greater utilization of serious games, and the incorporation of theory and standardized methods, can encourage young men to get vaccinated and to complete the series of HPV vaccinations.

Community Engagement and Outreach Programs for Lead Prevention in Mississippi.

The objective of the project was to encourage health promotion through education, outreach, and community-based training. The people attending health fairs (n = 467), community events (n = 469), and Kindergarten classes (n = 241) were the study participants. Hands-on training was offered at homebuilding retail stores (n = 25). U.S. Department of Housing and Urban Development (HUD)'s online visual training was given to realtors (n = 220), and inspectors, contractors, and Do-It-Yourself (DIY) workers (n = 75). Training workshops were attended by home-buyers and rental home owners at the Neighborhood Association Meetings (n = 91). The impact of training was evaluated by pre- and posttests. Nearly, 90% of the participants (n = 25) reported the hands-on training was useful. At posttest after the HUD online training, 59.4%, 67.9%, 65.1% of the participants (n = 220) identified soil, car batteries, and paint as sources of lead in the environment, respectively. Nearly 70% identified lead as a poison in the environment while 77.5% and 47.2% demonstrated two behaviors which help prevent lead poisoning. A total of 62.3%, 48.1%, and 58.5%, at posttest identified three complications or illnesses-behavioral, physical, and psychological, respectively. The home owners are required to get permission from the City for housing repair. In coordination with the federally funded housing repair or lead abatement programs, the trained inspectors are authorized to certify the renovation or repair works. These outreach activities were successful in improving the knowledge of the community people on lead poisoning prevention.

Transactional eHealth Literacy: Developing and Testing a Multi-Dimensional Instrument.

Theoretically informed measures of eHealth literacy that consider the social affordances of eHealth are limited. This study describes the psychometric testing of a multi-dimensional instrument to measure functional, communicative, critical, and translational eHealth literacies, as informed by the Transactional Model of eHealth Literacy (TMeHL). A 3-phase rating scale construction process was conducted to engage eHealth experts and end-users. In Phase 1, Experts (N = 5) and end-users (N = 25) identified operational behaviors to measure each eHealth literacy dimension. End-users (N = 10) participated in think-aloud interviews to provide feedback on items reviewed and approved by experts. A field test was conducted with a random sample of patients recruited from a university-based research registry (N = 283). Factor analyses and Rasch procedures examined the internal structure of the scores produced by each scale. Pearson's r correlations provided evidence for external validity of scores. The instrument measures four reliable (ω = .92-.96) and correlated (r= .44-.64) factors: functional (4 items), communicative (5 items), critical (5 items), and translational (4 items). Researchers and providers can use this new instrument as a theory-driven instrument to measure four eHealth literacies that are fundamental to the social affordances of the eHealth experience.

How Health Care Providers Can Use Digital Health Technologies to Inform Human Papillomavirus (HPV) Decision Making and Promote the HPV Vaccine Uptake Among Adolescents and Young Adults.

High-risk stains of human papillomavirus (HPV) is linked to causing cancer, is highly prevalent, and has increased incidence among adolescents and young adults. However, vaccination rates are low. Health care provider recommendation is the biggest influencer toward vaccine uptake. Since more health care providers are using digital health technologies in their medical practices, this study investigated the feasibility of technology to increase informed decision making. A convenience sample of 210 students completed an online survey. Participants were 18-25 years of age (88%), female (85%), Caucasian (60%), and never been diagnosed with HPV (92.9%). Overwhelmingly, participants owned a smartphone (98.9%) and used mobile apps for health/health tracking (65.5%). However, only 29.3% indicated that they received text messages from their health care provider. Digital health technology can be a cost-effective way for increasing HPV knowledge, removing barriers, and increasing vaccine uptake. Health care providers should explore using various platforms to empower their health care decision making.

Proposing a Transactional Model of eHealth Literacy: Concept Analysis.

BACKGROUND: Electronic health (eHealth) literacy was conceptualized in 2006 as the ability of internet users to locate, evaluate, and act upon web-based health information. Now, advances in eHealth technology have cultivated transactional opportunities for patients to access, share, and monitor health information. However, empirical evidence shows that existing models and measures of eHealth literacy have limited theoretical underpinnings that reflect the transactional capabilities of eHealth. This paper describes a conceptual model based on the Transactional Model of Communication (TMC), in which eHealth literacy is described as an intrapersonal skillset hypothesized as being dynamic; reciprocal; and shaped by social, relational, and cultural contexts. OBJECTIVE: The objective of our study was to systematically examine eHealth literacy definitions, models, and measures to propose a refined conceptual and operational definition based on the TMC. METHODS: Walker and Avant's concept analysis method was used to guide the systematic review of eHealth literacy definitions (n=10), rating scales (n=6), models (n=4), and peer-reviewed model applications (n=16). Subsequent cluster analyses showed salient themes across definitions. Dimensions, antecedents, and consequences reflected in models and measures were extracted and deductively analyzed based on codes consistent with the TMC. RESULTS: Systematic review evidence revealed incongruity between operational eHealth literacy included in definitions compared with literacies included within models and measures. Theoretical underpinnings of eHealth literacy also remain dismal. Despite the transactional capabilities of eHealth, the role of "communication" in eHealth literacy remains underdeveloped and does not account for physical and cognitive processing abilities necessary for multiway transactions. CONCLUSIONS: The Transactional Model of eHealth Literacy and a corresponding definition are proposed. In this novel model, eHealth literacy comprises a hierarchical intrapersonal skillset that mediates the reciprocal effect of contextual factors (ie, user oriented and task oriented) on patient engagement in health care. More specifically, the intrapersonal skillset counteracts the negative effect of "noise" (or impediments) produced by social and relational contexts. Cutting across health and technology literacies, the intrapersonal skillset of eHealth literacy is operationalized through four literacies that correspond with discrete operative skills: (1) functional (ie, locate and understand); (2) communicative (ie, exchange); (3) critical (ie, evaluate); and (4) translational (ie, apply).

mHealth Technology Use and Implications in Historically Underserved and Minority Populations in the United States: Systematic Literature Review.

BACKGROUND: The proportion of people in the United States who are members of at least two ethnic groups is projected to increase to 10% by the year 2050. This makes addressing health disparities and health inequities in minority populations increasingly more difficult. Minority populations, including those who classify themselves as African American and Hispanic, are using mobile phones to access health information via the internet more frequently than those who classify themselves as white, providing unique opportunities for those in public health and health education to reach these traditionally underserved populations using mobile health (mHealth) interventions. OBJECTIVE: The objective of this review was to assess studies conducted in the United States that have used mHealth tools and strategies to develop and implement interventions in underserved populations. This review also examines the ways in which mHealth strategies are being employed in public health interventions to these priority population groups, as mobile phone capabilities include text messaging, mobile apps, internet access, emails, video streaming, social media, instant messaging, and more. METHODS: A systematic literature review was conducted using key search phrases, the matrix method, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart diagram to identify key studies conducted between the years of 2009-2016 in the United States. These studies were reviewed for their use of mHealth interventions in historically underserved and minority populations. RESULTS: A total of 16,270 articles were initially identified using key search phrases in three databases. Titles were reviewed and articles not meeting criteria were excluded, leaving 156 articles for further review. After additional review for relevance and inclusion criteria, 16 articles were qualified and analyzed. CONCLUSIONS: mHealth is a promising area of development for public health and health education. While successful research has been done using text messaging (short message service, SMS) and other mHealth strategies, there is a need for more research using mobile phones and tablet applications. This literature review demonstrates mHealth technology has the ability to increase prevention and health education in health disparate communities and concludes that more specified research is needed.

Designing and Testing an Inventory for Measuring Social Media Competency of Certified Health Education Specialists.

BACKGROUND: Social media can promote healthy behaviors by facilitating engagement and collaboration among health professionals and the public. Thus, social media is quickly becoming a vital tool for health promotion. While guidelines and trainings exist for public health professionals, there are currently no standardized measures to assess individual social media competency among Certified Health Education Specialists (CHES) and Master Certified Health Education Specialists (MCHES). OBJECTIVE: The aim of this study was to design, develop, and test the Social Media Competency Inventory (SMCI) for CHES and MCHES. METHODS: The SMCI was designed in three sequential phases: (1) Conceptualization and Domain Specifications, (2) Item Development, and (3) Inventory Testing and Finalization. Phase 1 consisted of a literature review, concept operationalization, and expert reviews. Phase 2 involved an expert panel (n=4) review, think-aloud sessions with a small representative sample of CHES/MCHES (n=10), a pilot test (n=36), and classical test theory analyses to develop the initial version of the SMCI. Phase 3 included a field test of the SMCI with a random sample of CHES and MCHES (n=353), factor and Rasch analyses, and development of SMCI administration and interpretation guidelines. RESULTS: Six constructs adapted from the unified theory of acceptance and use of technology and the integrated behavioral model were identified for assessing social media competency: (1) Social Media Self-Efficacy, (2) Social Media Experience, (3) Effort Expectancy, (4) Performance Expectancy, (5) Facilitating Conditions, and (6) Social Influence. The initial item pool included 148 items. After the pilot test, 16 items were removed or revised because of low item discrimination (r<.30), high interitem correlations (Ρ>.90), or based on feedback received from pilot participants. During the psychometric analysis of the field test data, 52 items were removed due to low discrimination, evidence of content redundancy, low R-squared value, or poor item infit or outfit. Psychometric analyses of the data revealed acceptable reliability evidence for the following scales: Social Media Self-Efficacy (alpha=.98, item reliability=.98, item separation=6.76), Social Media Experience (alpha=.98, item reliability=.98, item separation=6.24), Effort Expectancy(alpha =.74, item reliability=.95, item separation=4.15), Performance Expectancy (alpha =.81, item reliability=.99, item separation=10.09), Facilitating Conditions (alpha =.66, item reliability=.99, item separation=16.04), and Social Influence (alpha =.66, item reliability=.93, item separation=3.77). There was some evidence of local dependence among the scales, with several observed residual correlations above |.20|. CONCLUSIONS: Through the multistage instrument-development process, sufficient reliability and validity evidence was collected in support of the purpose and intended use of the SMCI. The SMCI can be used to assess the readiness of health education specialists to effectively use social media for health promotion research and practice. Future research should explore associations across constructs within the SMCI and evaluate the ability of SMCI scores to predict social media use and performance among CHES and MCHES.

How to Design Tobacco Prevention and Control Games for Youth and Adolescents: A Qualitative Analysis of Expert Interviews.

OBJECTIVE: Games for health, including digital videogames and gaming-based approaches, are increasingly being used in health promotion research and practice. Recently published research has shown that videogames have significant potential to promote healthy behaviors among youth and adolescents. Yet, there is a lack of available evidence-based resources to guide practitioners on the integration of games into tobacco prevention and smoking cessation interventions. To address this gap, expert researchers and game developers were interviewed to further define games for health, explore the current research, and provide recommendations for developing, evaluating, and promoting effective anti-tobacco games. MATERIALS AND METHODS: Nationally recognized experts on game development, games for health, tobacco, and health behavior were asked to participate. A qualitative analysis of 25 in-depth individual interviews using a constant comparative approach for emerging themes was conducted. RESULTS: Main themes that emerged from the data analysis included the following: (1) the current state of games for health research to facilitate health behavior change, (2) strategies for how to develop and evaluate games for quality and impact, and (3) recommendations for how to effectively design tobacco prevention and smoking cessation educational videogames that engage youth and adolescents. CONCLUSIONS: The synthesized findings identified through these expert interviews offer stakeholders strategies for how to incorporate games for health within their current and future work. Specific recommendations are presented for developers and researchers to consider when developing and evaluating videogames for tobacco prevention and smoking cessation targeted at youth and adolescents.

Improvements in blood pressure among undiagnosed hypertensive participants in a community-based lifestyle intervention, Mississippi, 2010.

INTRODUCTION: Effective strategies are needed to reach and treat people who lack awareness of or have uncontrolled hypertension. We used data from a community-based participatory research initiative, Hub City Steps, to quantify the prevalence of undiagnosed hypertension and determine the relationship between hypertension status at baseline and postintervention improvements in blood pressure and health-related quality of life. METHODS: Hub City Steps was a 6-month preintervention-postintervention lifestyle intervention targeting hypertension risk factors. Outcome measures were collected at baseline, 3 months, and 6 months. Generalized linear mixed models were used to test for effects by time and hypertension status. RESULTS: Of the enrolled sample (N = 269), most were overweight or obese (91%), African American (94%), and women (85%). When considering hypertension status, 42% had self-reported diagnosis of hypertension (self-reported subgroup; 84% with antihypertensive medication use); 36% had no self-reported medical history of hypertension, but when blood pressure was measured they had a clinical diagnosis of prehypertension or hypertension (undiagnosed subgroup); and 22% had no self-reported or clinical hypertension diagnosis (no hypertension subgroup). From baseline to 6 months, systolic blood pressure significantly improved for participants with self-reported hypertension [8.2 (SD, 18.2) mm Hg] and undiagnosed hypertension [12.3 (SD, 16.3) mm Hg], with undiagnosed participants experiencing the greatest improvements (P < .001). Effects remained significant after controlling for covariates. Health-related quality of life significantly improved for all 3 hypertension subgroups, with no apparent subgroup differences. CONCLUSION: This study reveals advantages of a culturally appropriate community-based participatory research initiative to reach those with undetected hypertension and effectively improve blood pressure status and health-related quality of life.

Explaining and improving breast cancer information acquisition among African American women in the Deep South.

OBJECTIVES: A major challenge facing contemporary cancer educators is how to optimize the dissemination of breast cancer prevention and control information to African American women in the Deep South who are believed to be cancer free. The purpose of this research was to provide insight into the breast cancer information-acquisition experiences of African American women in Alabama and Mississippi and to make recommendations on ways to better reach members of this high-risk, underserved population. METHODS: Focus group methodology was used in a repeated, cross-sectional research design with 64 African American women, 35 years old or older who lived in one of four urban or rural counties in Alabama and Mississippi. RESULTS: Axial-coded themes emerged around sources of cancer information, patterns of information acquisition, characteristics of preferred sources, and characteristics of least-preferred sources. CONCLUSIONS: It is important to invest in lay health educators to optimize the dissemination of breast cancer information to African American women who are believed to be cancer free in the Deep South.

Using mixed methods to measure the perception of community capacity in an academic-community partnership for a walking intervention.

H.U.B. City Steps is a 5-year community-based participatory research walking intervention designed to help lower blood pressure in a majority African American population in southern Mississippi via community collaboration and capacity building, increased walking, culturally tailored health education sessions, and motivational interviewing. Building community capacity for physical activity is a key component of this intervention. Qualitative and quantitative methods have been used to assess how project stakeholders perceive the community capacity-building efforts of the project. This article illustrates the baseline results of this mixed methods approach from the perspective of three groups of stakeholders: project researchers and staff, community advisory board, and intervention walking coaches. Eight constructs were examined, including leadership, resources, external networking, visibility and recognition, personnel sustainability, ability and commitment to organize, communication with community members, and relationships with influential others. Quantitative results indicated significant differences among stakeholder groups for project leadership and personnel sustainability. Qualitative perspectives provided an opportunity to examine possible reasons for these differences. Overall findings provide direction related to improving intervention outcomes and sustainability.

Patterns of information behavior and prostate cancer knowledge among African-American men.

The purposes of this study are to explore cancer information acquisition patterns among African-American men and to evaluate relationships between information acquisition patterns and prostate cancer prevention and control knowledge. A random sample of 268 men participated in a statewide interviewer-administered, telephone survey. Men classified as non-seekers, non-medical source seekers, and medical source seekers of prostate cancer information differed on household income, level of education, and beliefs about personal risk for developing prostate cancer. Results from multiple regression analysis indicated that age, education, and information-seeking status were associated with overall levels of prostate cancer knowledge. Results from logistic regression analyses indicated that men who included physicians as one of many information resources (medical source seekers) had superior knowledge over non-seekers and non-medical source seekers on 33% of individual knowledge details. The findings emphasize the need to connect lower-income and lower-educated African-American men to physicians as a source of prostate cancer control information.

Developing a community action plan to eliminate cancer disparities: lessons learned.

BACKGROUND: African Americans bear an unequal burden of breast, cervical, and colorectal cancer. The Deep South Network for Cancer Control (DSN) is a community-academic partnership operating in Alabama and Mississippi that was funded by the National Cancer Institute (NCI) to address cancer disparities using community-based participatory research approaches. OBJECTIVE: In addition to reporting on the plans of this work in progress, we describe the participatory process that local residents and the DSN used to identify needs and priorities, and elaborate on lessons learned from applying a participatory approach to the development of a community action plan. METHODS: We conducted 24 community discussion groups involving health care professionals, government officials, faith-based leaders, and other stakeholders to identify cancer health disparity needs, community resources/assets, and county priorities to eliminate cancer health disparities. To develop a community action plan, four working groups explored the themes that emerged from the discussion groups, taking into consideration evidence-based strategies and promising community practices. RESULTS: The DSN formulated a community action plan focusing on (1) increasing physical activity by implementing a campaign for individual-level focused activity; (2) increasing the consumption of fruits and vegetables by implementing NCI's Body and Soul Program in local churches; (3) increasing cancer screening by raising awareness through individual, system, and provider agents of change; and (4) training community partners to become effective advocates. CONCLUSIONS: A community-academic partnership must involve trust, respect, and an appreciation of partners' strengths and differences. The DSN applied these guiding principles and learned pivotal lessons.

Getting on Target with Community Health Advisors (GOTCHA): an innovative stroke prevention project.

Health disparities along with insufficient numbers of healthcare providers and resources have created a need for effective and efficient grassroots approaches to improve community health. Community-based participatory research (CBPR), more specifically the utilization of community health advisors (CHAs), is one such strategy. The Getting on Target with Community Health Advisors (GOTCHA) project convened an interdisciplinary team to answer the call from 10 counties in the rural Mississippi Delta area of 'The Stroke Belt' to meet the region's identified health needs, and to impact the health of a disparaged state. This article explores this CBPR project including the community involvement strategies, innovative CHA training curriculum, evaluation plan, and implications to healthcare professionals, particularly nurses.

The theory of reasoned action and intention to seek cancer information.

OBJECTIVES: To evaluate the applicability of the theory of reasoned action to explain men's intentions to seek prostate cancer information. METHODS: Three hundred randomly selected African American men participated in telephone interviews. Correlational and regression analyses were conducted to examine relationships among measures. RESULTS: All relationships were significant in regression analyses. Attitudes and subjective norm were significantly related to intentions. Indirect measures of beliefs derived from elicitation research were associated with direct measures of attitude and subjective norms. CONCLUSIONS: The data are sufficiently clear to support the applicability of the theory for this behavioral domain with African American men and suggest several important areas for future research.

Toward a model of prostate cancer information seeking: identifying salient behavioral and normative beliefs among African American men.

Public health actions to improve African American men's ability to make informed decisions about participation in prostate cancer control activities have a greater likelihood of success when they are theory driven and informed by members of the target population. This article reports on formative research to evaluate the usefulness of the theory of reasoned action as a model to explain and predict prostate cancer information-seeking behavior by African American men. Fifty-two men participated in eight focus group interviews. Positive behavioral beliefs for obtaining prostate cancer information from physicians included increasing awareness of and obtaining accurate information about the disease, early detection and screening, and treatment. Negative beliefs included fear, distrust, and inconvenience. Significant others, peers, siblings, and religious leaders were identified as individuals who could influence this behavior. These findings provide additional insight into ways to reach and intervene with African American men to influence this important cancer control activity.

Community health advisors as research partners: an evaluation of the training and activities.

The feasibility of training large numbers of community health advisors as research partners (CHARPs) was evaluated using talking circles data and cancer activity questionnaires and logs. The talking circles data indicated that the CHARPs (n=108) valued their training and believed they learned necessary research partner skills. A review of contacts (n=7,956) provided evidence that CHARPs (n=883) could work as a team to deliver a variety of services over time to the community. The findings suggested that implementing a large scale intervention with CHARPs has the potential to increase the dissemination of cancer information and to reduce cancer disparities.