Evaluation of a Serious Video Game to Facilitate Conversations About Human Papillomavirus Vaccination for Preteens: Pilot Randomized Controlled Trial.

BACKGROUND: In the United States, the most common sexually transmitted infection, human papillomavirus (HPV), causes genital warts and is associated with an estimated 33,700 newly diagnosed cancer cases annually. HPV vaccination, especially for preteens aged 11 to 12 years, is effective in preventing the acquisition of HPV and HPV-associated cancers. However, as of 2018, completion of the 2- or 3-dose HPV vaccination series increased only from 48.6% to 51.1% in teens aged 13 to 17 years, and this increase was observed only in boys. By comparison, 88.7% of teens had more than one dose of the recommended vaccine against tetanus, diphtheria, and acellular pertussis (Tdap), and 85.1% of teens had more than one dose of meningococcal vaccine. Immunizations for Tdap, meningococcal disease, and HPV can occur at the same clinical visit but often do not. OBJECTIVE: Vaccination against HPV is recommended for routine use in those aged 11 to 12 years in the United States, yet it is underutilized. We aimed to develop an educational video game to engage preteens in the decision to vaccinate. METHODS: Land of Secret Gardens is a metaphor for protecting seedlings (body) with a potion (vaccine). We screened 131 dyads of parents and preteens from 18 primary practices in North Carolina who had not initiated HPV vaccination. We measured vaccination intentions, story immersion, and game play and documented HPV vaccination rates. A total of 55 dyads were enrolled, and we randomly assigned 28 (21 completed) to play the game and 27 (26 completed) to the comparison group. RESULTS: In total, 18 preteens reported playing the game. The vaccination self-efficacy score was higher in the comparison group than the intervention group (1.65 vs 1.45; P=.05). The overall mean decisional balance score trended toward greater support of vaccination, although differences between the groups were not significant.. Vaccine initiation and completion rates were higher in the intervention group (22% vs 15%; P=.31) than in the comparison group (9% vs 2%; P=.10), although the difference was not significant. CONCLUSIONS: Video games help preteens in the decision to pursue HPV vaccination. A serious video game on HPV vaccination is acceptable to parents and preteens and can be played as intended. Gamification is effective in increasing preteen interest in HPV vaccination, as game features support decision making for HPV vaccination. TRIAL REGISTRATION: ClinicalTrials.gov NCT04627298; https://www.clinicaltrials.gov/ct2/show/NCT04627298.

Toward Optimal Communication About HPV Vaccination for Preteens and Their Parents: Evaluation of an Online Training for Pediatric and Family Medicine Health Care Providers.

OBJECTIVE: Health care provider recommendation is a key determinant of human papillomavirus (HPV) vaccination. We developed an online training program for providers that addressed vaccine guidelines, hesitancy to strongly recommend the vaccine, and reluctance to discuss HPV infection as a sexually transmitted infection. DESIGN: Single-group evaluation with 3 waves. Providers completed a 29-item electronic survey with closed and open-ended response options after course completion. SETTING: Pediatric and family medicine practices in North Carolina. PARTICIPANTS: Prescribing clinicians (MD, DO, family nurse practitioner, physician assistant) who serve preteens aged 11 to 12 years. In wave 3, we expanded our communities to include nursing and medical staff. INTERVENTION: An asynchronous online course to promote preteen HPV vaccination. Topics included HPV epidemiology, vaccine recommendations from the Advisory Committee on Immunization Practices (ACIP), preteen-provider-parent communication, topics about hesitancy to seek vaccination, subjects related to sexual health, and practice-level strategies to increase vaccination rates. The course, approved for 12 CME and CNE credits, was live for 4 weeks and available on-demand for 3 additional months. MAIN OUTCOME MEASURES: Provider-reported change in vaccine communication, perceptions of course content in improving practice, and satisfaction with materials. RESULTS: A total of 113 providers from 25 practices enrolled in the course and 69 (61%) completed an evaluation. Providers spent an average of 6.3 hours on the course and rated the CDC (Centers for Disease Control and Prevention)-ACIP Web site and multiple resources on hesitancy and communication about sexually transmitted infection vaccines most highly of all materials across the 3 waves. Almost all (96%) agreed the course will improve their practice. About half of all participants said they were either "much more likely" (28%) or "more likely" (19%) to recommend the vaccine after course participation. CONCLUSIONS: An online format offers a highly adaptable and acceptable educational tool that promotes interpersonal communication and practice-related changes known to improve providers' vaccine uptake by their patients.

Developing a Serious Videogame for Preteens to Motivate HPV Vaccination Decision Making: Land of Secret Gardens.

INTRODUCTION: Vaccination against human papillomavirus (HPV) is routinely recommended for ages 11-12, yet in 2016 only 49.5% of women and 37.5% of men had completed the three-dose series in the United States. Offering information and cues to action through a serious videogame for preteens may foster HPV vaccination awareness, information seeking, and communication. MATERIALS AND METHODS: An iterative process was used to develop an interactive videogame, Land of Secret Gardens. Three focus groups were conducted with 16 boys and girls, ages 11-12, for input on game design, acceptability, and functioning. Two parallel focus groups explored parents' (n = 9) perspectives on the game concept. Three researchers identified key themes. RESULTS: Preteens wanted a game that is both entertaining and instructional. Some parents were skeptical that games could be motivational. A back-story about a secret garden was developed as a metaphor for a preteen's body and keeping it healthy. The goal is to plant a lush secret garden and protect the seedlings by treating them with a potion when they sprout to keep them healthy as they mature. Points to buy seeds and create the potion are earned by playing mini-games. Throughout play, players are exposed to messaging about HPV and the benefits of the vaccine. Both boys and girls liked the garden concept and getting facts about HPV. Parents were encouraged to discuss the game with their preteens. CONCLUSION: Within a larger communication strategy, serious games could be useful for engaging preteens in health decision making about HPV vaccination.

Immunization effects of a communication intervention to promote preteen HPV vaccination in primary care practices.

OBJECTIVES: HPV vaccination at the recommended ages of 11-12 is highly effective yet has stalled well below the goal of 80% of the population. We evaluated a statewide practice-based communication intervention (tools: brochures, posters, online training for providers and resources for parents, video game for preteens) to persuade parents, preteens and providers to vaccinate against HPV. The 9-month intervention started May 1, 2015. METHODS: We compared vaccine initiation and completion rates over three 9-month periods (baseline, intervention, post-intervention) between practices enrolled in the intervention and a comparable comparison group. All practices reported to the North Carolina Immunization Registry (NCIR) and had at least 100 11- and 12-year-olds who had not completed the HPV vaccine series. Of 175 eligible practices, the 14 intervention practices included 19,398 individuals and the 161 comparison practices included 127,896 individuals. An extended Cox model was used to test the intervention effect. RESULTS: The intervention had a significant effect on both initiation and completion during the intervention and post-intervention periods; the estimated hazard ratio (HR) for initiation was 1.17 (p = .004) during the intervention and 1.11 (p = .005) post-intervention. Likewise, completion during the intervention period was 17% higher in intervention practices, after controlling for baseline differences. This effect increased in the post-intervention period to 30% higher (p = .03). CONCLUSIONS: Individuals in the intervention practices were 17% more likely to initiate and complete HPV vaccination than in the comparison practices during the intervention period and the effect was sustained post-intervention. This intervention is promising for increasing rates of HPV vaccination at ages 11-12.

Assessing Opportunities to Enhance Comprehensive Health Promotion and Wellness Programming in a State Community College System.

BACKGROUND North Carolina has the third largest community college system in the nation and reaches residents in all 100 counties. Few studies have focused on the health of employees who work at these institutions. We assessed the current status of and interest in supporting health promotion efforts among North Carolina Community College System members.METHODS North Carolina Community College System presidents completed a brief 15-item survey assessing support for and interest in offering health promotion programs. Wellness coordinators completed a 60-item questionnaire assessing current health promotion programming and organizational, environmental, and policy supports for health promotion efforts. Onsite interviews with a sub-sample of Wellness coordinators offered insights into important implementation considerations. We examined differences by campus size with Fisher's exact test.RESULTS All 58 presidents (100%) and 51 wellness coordinators (88%) completed surveys. Ten percent of colleges offered comprehensive employee health promotion programming. Most offered physical activity (70.6%), tobacco cessation (51.0%), weight loss/management (49.0%), and/or nutrition counseling (47.1%). Larger colleges were more likely to offer programming and environmental support. Nearly all presidents (89.7%) believed it is "very" or "extremely" important to offer health promotion programs to employees, and most (84%) were interested in promoting health through a university partnership.LIMITATIONS Despite very high survey response rates from presidents and wellness coordinators at each community college, onsite interviews were only done at select campuses, limiting the generalizability and scope of conclusions derived from interview data.CONCLUSION Community colleges in North Carolina are promising settings for promoting employee health. Findings identify resources, barriers, and technical assistance that could facilitate greater adoption and implementation of programs.

Bridging Research, Practice, and Policy: The "Evidence Academy" Conference Model.

Innovative models to facilitate more rapid uptake of research findings into practice are urgently needed. Community members who engage in research can accelerate this process by acting as adoption agents. We implemented an Evidence Academy conference model bringing together researchers, health care professionals, advocates, and policy makers across North Carolina to discuss high-impact, life-saving study results. The overall goal is to develop dissemination and implementation strategies for translating evidence into practice and policy. Each 1-day, single-theme, regional meeting focuses on a leading community-identified health priority. The model capitalizes on the power of diverse local networks to encourage broad, common awareness of new research findings. Furthermore, it emphasizes critical reflection and active group discussion on how to incorporate new evidence within and across organizations, health care systems, and communities. During the concluding session, participants are asked to articulate action plans relevant to their individual interests, work setting, or area of expertise.

Applying Cognitive Interviewing to Inform Measurement of Partnership Readiness: A New Approach to Strengthening Community-Academic Research.

BACKGROUND: Partnerships between academic and community-based organizations (CBOs) can richly inform the research process and speed translation of findings. Although immense potential exists to co-conduct research, a better understanding of how to create and sustain equitable relationships between entities with different organizational goals, structures, resources, and expectations is needed. OBJECTIVE: We sought to engage community leaders in the development of an instrument to assess CBOs' interest and capacity to engage with academia in translational research partnerships. METHODS: Leaders from CBOs partnered with our research team in the design of a 50-item instrument to assess organizational experience with applying for federal funding and conducting research studies. Respondents completed a self-administered, paper/pencil survey and a follow-up structured cognitive interview (n = 11). A community advisory board (CAB; n = 8) provided further feedback on the survey through guided discussion. Thematic analysis of the cognitive interviews and a summary of the CAB discussion informed survey revisions. RESULTS: Cognitive interviews and discussion with community leaders identified language and measurement issues for revision. Importantly, they also revealed an unconscious bias on the part of researchers and offered an opportunity, at an early research stage, to address imbalances in the survey perspective and to develop a more collaborative, equitable approach. CONCLUSIONS: Engaging community leaders enhanced face and content validity and served as a means to form relationships with potential community co-investigators in the future. Cognitive interviewing can enable a bidirectional approach to partnerships, starting with instrument development.

Intervention effects from a social marketing campaign to promote HPV vaccination in preteen boys.

OBJECTIVES: Adoption of human papillomavirus (HPV) vaccination in the US has been slow. In 2011, HPV vaccination of boys was recommended by CDC for routine use at ages 11-12. We conducted and evaluated a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys. METHODS: We targeted parents and providers of 9-13 year old boys in a 13 county NC region. The 3-month intervention included distribution of HPV vaccination posters and brochures to all county health departments plus 194 enrolled providers; two radio PSAs; and an online CME training. A Cox proportional hazards model was fit using NC immunization registry data to examine whether vaccination rates in 9-13 year old boys increased during the intervention period in targeted counties compared to control counties (n=15) with similar demographics. To compare with other adolescent vaccines, similar models were fit for HPV vaccination in girls and meningococcal and Tdap vaccination of boys in the same age range. Moderating effects of age, race, and Vaccines for Children (VFC) eligibility on the intervention were considered. RESULTS: The Cox model showed an intervention effect (ß=0.29, HR=1.34, p=.0024), indicating that during the intervention the probability of vaccination increased by 34% in the intervention counties relative to the control counties. Comparisons with HPV vaccination in girls and Tdap and meningococcal vaccination in boys suggest a unique boost for HPV vaccination in boys during the intervention. Model covariates of age, race and VFC eligibility were all significantly associated with vaccination rates (p<.0001 for all). HPV vaccination rates were highest in the 11-12 year old boys. Overall, three of every four clinic visits for Tdap and meningococcal vaccines for preteen boys were missed opportunities to administer HPV vaccination simultaneously. CONCLUSIONS: Social marketing techniques can encourage parents and health care providers to vaccinate preteen boys against HPV.

Circles of Care: Implementation and Evaluation of Support Teams for African Americans With Cancer.

BACKGROUND: Community-based peer support may help meet the practical, emotional, and spiritual needs of African Americans with advanced cancer. Support teams are a unique model of peer support for persons facing serious illness, but research is rare. This study sought to (a) implement new volunteer support teams for African Americans with advanced cancer in two distinct regions and (b) evaluate support teams' ability to improve support, awareness of services, and quality of life for these patients. METHODS: The study used a pre-post design. Community and academic partners collaborated to implement volunteer support teams and evaluate the intervention using pre-post surveys of volunteers and patients. Patients who declined support teams were also interviewed as a comparison group. RESULTS: Investigators enrolled and trained 130 volunteers who formed 25 support teams in two geographic regions. Volunteers supported 25 African American patients with advanced cancer (72%) or other diseases. After 2 months, patients with support teams reported fewer needs for practical, emotional, and spiritual support on a structured checklist. They more often communicated with someone about their cancer care needs (48% vs. 75%, p = .04), and were more aware of Hospice (4% vs. 25%, p = .04), but quality of life scores were unchanged. Comparison patients who refused a support team had fewer support needs at baseline and follow-up, suggesting that refusals were based on a lack of need. CONCLUSION: Coordinated volunteer support teams are a promising new model to provide peer support for African Americans facing cancer and other serious illnesses. Further testing in a pragmatic clinical trial is warranted.

Evaluating a County-Sponsored Social Marketing Campaign to Increase Mothers' Initiation of HPV Vaccine for their Pre-teen Daughters in a Primarily Rural Area.

Routine vaccination against human papillomavirus (HPV), the main cause of cervical cancer, is recommended for 11-12 year old girls, yet vaccine uptake is low. This study evaluates a social marketing campaign initiated by 13 North Carolina counties to raise awareness among parents and reduce barriers to accessing the vaccine in a primarily rural area. The 3-month campaign targeted mothers of girls ages 11-12 and healthcare practices serving pre-teen girls in four counties. Principles of social marketing were: product (recommended vaccine against HPV), price (cost, perception of safety and efficacy, and access), promotion (posters, brochures, website, news releases, doctor's recommendation), and place (doctors' offices, retail outlets). We analyzed (1) website traffic, hotline calls, and media placement; (2) cross-sectional surveys of mothers and providers; and (3) HPV immunization rates in intervention versus non-intervention counties. Of respondent mothers (n=225), 82% heard or saw campaign messages or materials. Of respondent providers (n=35), 94% used campaign brochures regularly or occasionally in conversations with parents. HPV vaccination rates within six months of campaign launch were 2% higher for 9-13 year old girls in two of the four intervention counties compared to 96 non-intervention counties. This evaluation supports campaign use in other primarily rural and underserved areas.

Asking mom: formative research for an HPV vaccine campaign targeting mothers of adolescent girls.

Vaccination against the types of human papillomavirus (HPV) that cause about 70% of cervical cancers is approved for use in girls and women between 9 and 26 years of age and recommended routinely in 11-12-year-old girls. This article reports on the systematic theory-based formative research conducted to develop HPV vaccine messages for a campaign targeting racially diverse mothers of nonvaccinated 11-12-year-old girls in rural Southeastern United States. A consortium of 13 county health departments concerned about high rates of cervical cancer in their region relative to state and national averages initiated the campaign. The research examined behavioral determinants for vaccination decisions as well as mothers' reactions to message frames and emotional appeals. On the basis of focus groups and intercept interviews (n = 79), the authors demonstrated how preproduction message research and production message testing were used to develop messages that would motivate mothers of preteen girls. Core emotional truths that emerged were a mother's instinct to protect her daughter from harm and to embrace aspirations for her daughter's future. Mothers also reacted more positively to text about preventing cervical cancer than about preventing HPV, a sexually transmitted disease. Mothers preferred message concepts with photos of minorities and Caucasian mothers and daughters.

An evaluation of the National Public Health Leadership Institute--1991-2006: part II. Strengthening public health leadership networks, systems, and infrastructure.

CONTEXT: The year-long National Public Health Leadership Institute's (PHLI) goals are to develop the capacity of individual leaders and networks of leaders so that both can lead improvements in public health systems, infrastructure, and population health. OBJECTIVE: To evaluate PHLI's impact on networks, systems, and infrastructure. PARTICIPANTS: Senior leaders from government, health care, associations, and other organizations who graduated from PHLI between 1992 and 2006. INTERVENTION: Retreats; readings, conference calls, and webinars; personal assessments, feedback, and coaching; and action learning projects. METHODS: A cross-sectional survey sent in 2007 to all leaders from the program's first 15 cohorts. Between 1992 and 2006, PHLI graduated 806 leaders. Of the 646 graduates located, 393 (61%) responded, for an overall response rate of 49% (393/806). Telephone interviews of 35 key informants were also conducted. RESULTS: Graduates fostered changes in systems, policies, organizations, and programs and frequently described these changes as resulting from their work as or with networks. Many graduates formed an informal national network of "thought leaders" and volunteered with professional associations to help in creating methods for improving systems and infrastructure. At the state level, graduates worked as informal networks and with associations to restructure services, reorganize agencies, catalyze new laws, and develop programs. Locally, graduates developed coalitions, fostered new laws, and improved programs, among other changes. CONCLUSION: The Centers for Disease Control and Prevention's multiyear sponsorship of a national program fostered national networks among "thought leaders" who helped to lead the development and diffusion of numerous innovations. Public health leadership development program sponsors should foster collaborative leadership by engaging leaders in systems thinking, team leadership, dialogue, conflict resolution, and negotiation, recommend using networks for sustained personal and system development, and link leaders to networks and associations. Networks provide the collective creativity and broad support needed to enact system and infrastructure changes.

A comparison of birth outcomes among US-born and non-US-born Hispanic Women in North Carolina.

OBJECTIVE: To compare birth outcomes between non-US-born and US-born Hispanic women in North Carolina (NC). METHODS: A retrospective comparison of birth outcomes from linked NC birth/death certificate data (1993-1997) for 22,234 Hispanic births by mother's place of birth was conducted. RESULTS: Mexico-born Hispanic women (58%) had significantly fewer medical risks, tobacco or alcohol use during pregnancy; however, they also had significantly less education and prenatal care than US-born Hispanic women (21%). Infant mortality rate, low birth weight, and prematurity were low and did not differ significantly. Lethal anomalies were the primary cause of infant mortality in non-US-born Hispanics versus Sudden Infant Death Syndrome (SIDS) in US-born Hispanics. CONCLUSIONS: Despite increased risk factors among US-born women, we found no difference in Hispanic birth outcomes in NC by mother's place of birth. These data contradict national data and may be related to findings of both positive and negative aspects of acculturation in NC.

Preoperative serum CA-125 levels in treating endometrial cancer.

OBJECTIVE: To evaluate preoperative levels of CA-125 for the prediction of advanced stages of uterine cancer. STUDY DESIGN: Retrospective chart review of 141 women with endometrial cancer who were treated by a single gynecologic oncologist at a community teaching hospital in North Carolina between November 1994 and September 2002. RESULTS: Ninety-three of 106 patients (87.7%) with surgical stage I or II endometrial cancer had normal preoperative CA-125 levels. Ten of 11 (91%) women with stage IV endometrial cancer had elevated preoperative CA-125 levels. High CA-125 levels and positive lymph vascular space invasion correlated most strongly with advanced stage (p < 0.01). Similar trends in correlation of CA-125 levels were seen with the highest grade and the deepest myometrial invasion. The sensitivity and specificity of a CA-125 cutoff level of 35 U/mL were 63% and 88%, respectively, with a positive predictive value of 61% and negative predictive value of 89%. CONCLUSION: Measurement of preoperative CA-125 is a clinically useful test in endometrial cancer patients. CA-125 appears to be a significant independent predictor of the extrauterine spread of disease and is a better predictor of disease than depth of invasion or grade. This evidence complements a growing body of literature that supports the strong relationship between CA-125 level and stage of disease. A CA-125 level should be included as part of the preoperative workup for all patients with endometrial cancer.

Infant mortality, low birth weight, and prematurity among Hispanic, white, and African American women in North Carolina.

OBJECTIVES: The study was undertaken to compare Hispanic birth outcomes with those of white and African American women in North Carolina and to examine variables associated with adverse birth outcomes among Hispanic women. STUDY DESIGN: Retrospective comparison of birth outcomes by ethnicity/race, from linked birth/infant death certificates in North Carolina (1993-1997) was conducted. Multivariate, binary logistic regression and chi(2) analysis were used to examine relationships between available medical and sociodemographic index values and composite birth outcomes among Hispanic women. RESULTS: Infant mortality rates were lowest among Hispanic women. Low birth weight and prematurity rates were similar to those of white women and lower than those of African American women. Variables significantly related to healthy composite birth outcomes among Hispanic women included higher education, no preterm delivery history, prenatal care, marriage, and no daily tobacco use. CONCLUSION: Hispanic birth outcomes in North Carolina were better than those of African American women and similar to those of white women, despite use of prenatal care and socioeconomic characteristics similar to African American women.