Translating self-persuasion into an adolescent HPV vaccine promotion intervention for parents attending safety-net clinics

A community-based, interdisciplinary approach to improving HPV vaccine uptake at a large urban public university

The purpose of this project was to pilot and determine the outcomes of a multi-faceted, interdisciplinary human papillomavirus awareness and vaccination campaign within a university community.

Students, faculty, and staff of a large urban Midwest-based public university.

METHODS

This consisted of five key interventions: promotion and outreach, volunteer training, patient education, access, and documentation. Perceived knowledge and attitudes toward HPV and the HPV vaccine, and HPV vaccine uptake were measured as outcome variables.

The project resulted in statistically significant increases in perceived knowledge regarding HPV and the HPV vaccine, willingness to receive HPV vaccination, and likeliness to recommend HPV vaccination (p < 0.001). The project also resulted in a 76.6% increase in the number of HPV vaccines administered at the university's Campus Health Center.

A novel HPV awareness and vaccination campaign led to increases in knowledge regarding HPV and HPV vaccines, and substantially increased HPV vaccinations administered at a large, urban public university.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Childhood Vaccine Attitude and Refusal among Turkish Parents

We aimed to understand and resolve anti-vaccine attitudes by examining the factors associated with vaccine attitudes and exploring potential strategies to improve childhood vaccination rates. Between 2014 and 2021, a total of 628 families refused vaccination in Adiyaman. A total of 300 families accepted visits and were visited. During the visits, the families were administered a questionnaire to determine the reasons for vaccine rejection and their opinions on the matter. While providing general information about the vaccine, parents were encouraged to reconsider their decision, and at the end, parents completed the questionnaire. The questionnaire included sociodemographic questions, reasons for vaccine refusal, and a vaccine attitude scale. Among the participants in the study, 9.3% were convinced about the vaccine. The mean vaccine attitude scale score was calculated as 23.6 ± 2.5 (min = 15-max = 29). Significantly higher rates of persuasion were observed among fathers (17.3%) compared to mothers (7.7%) (p = 0.038). Participants who had received some vaccinations had a higher rate of persuasion (11.6%) compared to those who had not received any vaccinations (2.6%) (p = 0.02). Childhood vaccine refusal is a complex issue that has been the subject of numerous studies. Studies on this subject will increase awareness of vaccines.

Overcoming Vaccine Hesitancy for Future COVID-19 and HIV Vaccines: Lessons from Measles and HPV Vaccines

BACKGROUND

The discovery of vaccines significantly reduced morbidity and mortality of infectious diseases and led to the elimination and eradication of some. Development of safe and effective vaccines is a critical step to the control of infectious diseases; however, there is the need to address vaccine hesitancy because of its potential impact on vaccine uptake.

METHODS

We conducted a narrative review of studies on interventions to address measles and human papillomavirus vaccine hesitancy. We discussed how lessons learned from these studies could be applied towards COVID-19 and future human immunodeficiency virus vaccines.

RESULTS

We found that there are several successful approaches to improving vaccine acceptance. Interventions should be context specific and build on the challenges highlighted in various settings.

CONCLUSION

Strategies could be used alone or in combination with others. The most successful interventions directly targeted the population for vaccination. Use of financial incentives could be a potential tool to improve vaccine uptake.

Vaccinating to Protect Others: The Role of Self-Persuasion and Empathy among Young Adults

Direct persuasion is usually less effective than self-persuasion. As research shows that most young adults are unafraid of COVID-19, this study aimed to investigate the effectiveness of self-persuasion targeted at protecting the health of others to encourage young adults to be vaccinated against COVID-19 and examined the link between empathy and vaccination intention. We conducted two studies: Study 1 (n = 352) compared the effectiveness of self-persuasion targeted at others’ health versus personal health and direct persuasion in encouraging COVID-19 vaccination intention; Study 2 (n = 375) investigated the applicability of self-persuasion through a poster framed as an open-ended question. The theory of planned behavior-based tools were used in both studies, and structural equation modeling was conducted. Study 1 found that self-persuasion targeted at others’ health (compared to other forms of persuasion) indirectly affects vaccination intention through utility and social norm beliefs. Higher empathy, utility, social norms, and control beliefs are associated with a greater vaccination intention. Study 2 found that the poster with self-persuasion targeted at others’ health enhanced vaccination intention compared with a direct persuasion poster. Our findings demonstrate that self-persuasion targeted at others’ health can potentially increase COVID-19 vaccination uptake among young adults.

Reducing COVID-19 vaccine hesitancy among African Americans: the effects of narratives, character's self-persuasion, and trust in science

This research examines the efficacy of self-persuasion narratives (i.e., narratives that describe how a character has changed their mind about the COVID-19 vaccines) in encouraging vaccine uptake among unvaccinated African Americans. A five-condition experiment (N = 394) was conducted in June 2021. Participants viewed one of the three pro-vaccine messages (a self-persuasion narrative, a narrative without self-persuasion, or a non-narrative message) or an irrelevant message or completed a self-persuasion task. Findings supported the persuasive benefits of the self-persuasion narrative compared to the narrative without self-persuasion, actual self-persuasion, and the irrelevant message. Its advantage over the narrative without self-persuasion was mediated by increased self-referencing, affective empathy, and perceived similarity with the character. Moreover, its psychological effects were moderated by participants’ trust in science. Unexpectedly, the non-narrative showed persuasive benefits compared to other intervention strategies. The theoretical implications for narrative persuasion and practical implications for vaccine promotion were discussed.

Parents' Experience With a Mobile Health Intervention to Influence Human Papillomavirus Vaccination Decision Making: Mixed Methods Study

BACKGROUND

Human papillomavirus (HPV)-attributed cancers are preventable, yet HPV vaccination rates severely lag behind other adolescent vaccinations. HPVcancerFree (HPVCF) is a mobile health (mHealth) intervention developed to influence parental HPV vaccination decision making by raising awareness of HPV, reducing HPV vaccination barriers, and enabling HPV vaccination scheduling and reminders through a smartphone app. Evaluating the user experience of mHealth interventions is a vital component in assessing their quality and success but tends to be underreported in mHealth intervention evaluation.

OBJECTIVE

We aimed to evaluate the user experience of HPVCF, an HPV cancer prevention app designed for a pediatric clinic network, using mixed methods data collected from log files, survey measures, and qualitative feedback.

METHODS

Study data were evaluated from parents in a large US pediatric clinic network using HPVCF in the treatment study condition of a group randomized controlled trial. Log data captured HPVCF retention and use. Postintervention rating scales and items assessed HPVCF utility, usefulness, understandability, appeal, credibility, and perceived impact. Overall quality was evaluated using the user version of the Mobile Application Rating Scale (uMars). Open-ended responses assessed parent recommendations for HPVCF enhancement.

RESULTS

The 98 parents were mainly female (n=94, 96%), 41 (5.67) years of age, college educated (n=55, 56%), and White and non-Hispanic (n=55, 56%) and had private health insurance for their children (n=75, 77%). Parents used HPVCF 197 times, with the average visit duration approximating 3.5 minutes. The uMARS app quality score was positively skewed (4.2/5.0). Mean ratings were highest for information (4.46 [SD 0.53]) and lowest for engagement (3.74 [SD 0.69]). In addition, of 95 parents, 45 (47%) rated HPVCF as helpful in HPV vaccination decision making and 16 (17%) attributed HPV vaccine initiation to HPVCF. Parents reported that HPVCF increased their awareness (84/95, 88%), knowledge (84/95, 88%), and HPV vaccination intentions (64/95, 67%). Most of the 98 parents rated the 4 HPVCF components as useful (72-92 [73%-94%]). Parents also agreed that HPVCF is clear (86/95, 91%), accurate (86/95, 91%), and more helpful than other HPV vaccine information they had received (89/95, 94%) and that they would recommend it to others (81/95, 85%). In addition, parents suggested ways to increase awareness and engagement with the app, along with opportunities to enhance the content and functionality.

CONCLUSIONS

HPVCF was well received by parents and performed well on indicators of quality, usefulness, utility, credibility, and perceived impact. This study contributes a multimethod and multimeasure evaluation to the growing body of literature focused on assessing the user experience of patient-focused technology-mediated applications for HPV education.

Mechanisms of self-persuasion intervention for HPV vaccination: Testing memory and autonomous motivation

Objective: Optimizing a self-persuasion intervention app for adolescent HPV vaccination requires investigating its hypothesized mechanisms. Guided by the experimental medicine approach, we tested whether (a) self-persuasion intervention components (verbalize vaccination reasons, choose HPV topics) changed putative mechanisms (memory, autonomous motivation) and (b) measures of the putative mechanisms were associated with HPV vaccination. Method: These are secondary analyses from a randomized 2 (cognitive processing: verbalize reasons vs. listen) × 2 (choice: choose HPV topics vs. assigned) factorial trial (Tiro et al., 2016). Undecided parents (N = 161) with an unvaccinated child (11-17 years old) used the self-persuasion app, recalled reasons for vaccination (memory measure), and completed an autonomous motivation measure. Adolescent vaccination status was extracted from electronic medical records 12 months postintervention. Results: The verbalize component resulted in greater recall accuracy of vaccination reasons (p < .001); however, the choose topics component did not increase autonomous motivation scores (p = .74). For associations with HPV vaccination, recall accuracy was not associated (ps > .51), but autonomous motivation scores significantly predicted vaccination (ps < .03), except when controlling for baseline motivation (p = .22). Conclusion: The intervention app engages parents in reasons for vaccination; however, memory may not be a viable mechanism of vaccination. Although the intervention did not affect autonomous motivation, associations with vaccination status suggest it is a viable intervention target for HPV vaccination but alternative strategies to change it are needed. Future testing of a refined app should examine implementation strategies to optimize delivery in clinical or community settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Future directions of the National Institutes of Health Science of Behavior Change Program

Background

The National Institutes of Health Science of Behavior Change Common Fund Program has accelerated the investigation of mechanisms of behavior change applicable to multiple health behaviors and outcomes and facilitated the use of the experimental medicine approach to behavior change research.

Purpose

This commentary provides a brief background of the program, plans for its next phase, and thoughts about how the experimental medicine approach to behavior change research can inform future directions in two areas of science—reproductive health and COVID-19 vaccine uptake.

Conclusions

The incorporation of a mechanisms-based approach into behavior intervention research offers new opportunities for improving health.

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Use of Apps to Promote Childhood Vaccination: Systematic Review

BACKGROUND

Vaccination is a critical step in reducing child mortality; however, vaccination rates have declined in many countries in recent years. This decrease has been associated with an increase in the outbreak of vaccine-preventable diseases. The potential for leveraging mobile platforms to promote vaccination coverage has been investigated in the development of numerous mobile apps. Although many are available for public use, there is little robust evaluation of these apps.

OBJECTIVE

This systematic review aimed to assess the effectiveness of apps supporting childhood vaccinations in improving vaccination uptake, knowledge, and decision making as well as the usability and user perceptions of these apps.

METHODS

PubMed, Excerpta Medica Database (EMBASE), Web of Science, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Education Resources Information Center (ERIC) databases were systematically searched for studies published between 2008 and 2019 that evaluated childhood vaccination apps. Two authors screened and selected studies according to the inclusion and exclusion criteria. Data were extracted and analyzed, and the studies were assessed for risk of bias.

RESULTS

A total of 28 studies evaluating 25 apps met the inclusion criteria and were included in this analysis. Overall, 9 studies assessed vaccination uptake, of which 4 reported significant benefits (P<.001 or P=.03) of the implementation of the app. Similarly, 4 studies indicated a significant (P≤.054) impact on knowledge and on vaccination decision making. Patient perceptions, usability, and acceptability were generally positive. The quality of the included studies was found to be moderate to poor, with many aspects of the methodology being unclear.

CONCLUSIONS

There is little evidence to support the use of childhood vaccination apps to improve vaccination uptake, knowledge, or decision making. Further research is required to understand the dichotomous effects of vaccination-related information provision and the evaluation of these apps in larger, more robust studies. The methodology of studies must be reported more comprehensively to accurately assess the effectiveness of childhood vaccination apps and the risk of bias of studies.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16929.

Tablet-Based Patient Education Regarding Human Papillomavirus Vaccination in Colposcopy Clinic

OBJECTIVE

The aim of this study was to use an electronic tablet-based education module to increase patient knowledge about human papillomavirus (HPV).

METHODS

Patients presenting to an academic colposcopy clinic were first queried as to whether they had been infected with HPV. A quality improvement project was then conducted using a 4-question pretest assessing baseline knowledge about HPV and cancer, followed by a tablet-based education module and a 5-question posttest.

RESULTS

Between June 2017 and January 2018, 119 patients participated in the tablet education. At their initial visit, only 50 (42.0%) of patients were aware that they had an HPV infection; however, medical records revealed that 74 women (62.2%) were presenting with a documented HPV infection. After the tablet education, 95% of women identified cervical cancer as a problem that can be caused by HPV, as compared with 88.2% in the pretest (p = .046). Knowledge of head and neck cancer as a disease that can be caused by HPV increased from 10.9% to 80.7% (p < .001). More patients answered that they "definitely" or "probably" would consider the vaccine for a child in their family: 108 (95.6%) pretest vs. 112 (99.1%) posttest (p = .046). The activities were ranked as "extremely" or "very" helpful by 93.3% of patients.

CONCLUSIONS

Patients presenting to colposcopy clinic are not well educated regarding the connection between an abnormal Pap test, HPV infection, and certain cancers. Tablet-based education improves patient knowledge of HPV-associated cancers in an outpatient clinic setting.

A retrospective and prospective look at strategies to increase adolescent HPV vaccine uptake in the United States

The HPV vaccine debuted more than ten years ago in the United States and many strategies have been evaluated to increase HPV vaccination rates, which include not only improving current vaccination behaviors but also sustaining these behaviors. Researchers and practitioners from a variety of backgrounds have engaged in this work, which has included efforts directed at public health and government policies, health education and health promotion programs, and clinical and patient-provider approaches, as well as work aimed to respond to and combat anti-HPV vaccination movements in society. Using a previously developed conceptual model to organize and summarize each of these areas, this paper also highlights the need for future HPV vaccine promotion work to adopt a multi-level and, when possible, integrated approach in order to maximize impact on vaccination rates.

Parent-Provider Communication of HPV Vaccine Hesitancy

: media-1vid110.1542/5754332185001PEDS-VA_2017-2312Video Abstract OBJECTIVES: To prevent human papillomavirus (HPV)-related cancers, providers must effectively communicate with HPV vaccine-hesitant parents. Here, we developed a typology characterizing parent-provider communication around HPV vaccine hesitancy.

METHODS

We audio-recorded 43 visits with unvaccinated adolescents at 6 pediatric clinics in Dallas, Texas in which parents were undecided about HPV vaccination. We qualitatively coded how parents verbally expressed hesitancy (assertive response, asking a question, or expressing concern) and whether providers responded with acquiescence (agree to defer vaccination) and/or persistence (continue discussion). We described the frequency of parent and provider communication codes and same-day vaccination.

RESULTS

Among the 43 visits, 37 parents expressed hesitancy ≥1 times in many ways. Assertive responses were most common (27 visits), followed by questions (16 visits), and concerns (12 visits). When the first expression of hesitancy was a question or concern, 71% and 75% of adolescents, respectively, received same-day vaccinations, whereas 33% of adolescents who received an initial assertive response were vaccinated. Providers responded with only persistence in 18 visits, a mix of acquiescence and persistence in 13 visits, and only acquiescence in 6 visits. When providers only used persistence, 17 of 18 adolescents were vaccinated; when providers responded with only acquiescence, no adolescents received the vaccine.

CONCLUSIONS

Our exploratory analysis reveals that providers engaging hesitant parents and addressing their concerns can lead to same-day HPV vaccination. Data reveal that even parents making assertive statements are amenable to influence by providers. Our findings reveal an important missed opportunity when providers simply acquiesce to parental hesitation.

Efficacy of a Media Literacy Intervention for Indoor Tanning Prevention

Indoor tanning leads to melanoma, the fifth most common cancer in the USA. The highest rate of indoor tanning is among young women whose exposure to tanned images in the media is linked to protanning attitudes. This study evaluated the efficacy of a media literacy intervention for reducing young women's indoor tanning. Intervention participants analyzed the content and functions of the media influencing protanning attitudes and produced counter-messages to help themselves and peers resist harmful media effects. The message production was of two types: digital argument production or digital story production. The control group received assessments only. This three-group randomized design involved 26 sorority chapters and 247 members in five Midwestern states where indoor tanning is prevalent. At 2- and 6-month follow-up assessments, those in the two intervention conditions were less likely to be indoor tanners (p = .033) and reported lower indoor tanning intentions (p = .002) compared to those in the control condition. No difference between the two intervention groups was found for behavior. Although the argument group exhibited slightly weaker indoor tanning intentions than the story group, the difference was not significant. The results provide the first evidence of the efficacy of a media literacy intervention for indoor tanning reduction. Implications for participative engagement interventions are discussed.

Adolescent human papillomavirus vaccination in the United States: Opportunities for integrating pharmacies into the immunization neighborhood

Human Papillomavirus (HPV) vaccination faces several barriers, including a social stigma which carries religious and philosophical implications among parents of adolescents as well as young adults. Hundreds of immunization interventions and programs have been developed to address these factors and boost HPV vaccination rates in the United States. We sought to review the existing literature highlighting barriers to HPV immunization, as well as programs targeting increased HPV vaccine uptake in effort to develop novel vaccination initiatives. The most impactful barriers identified were parental stigma and low quality of provider recommendations for the vaccine. Despite the implementation of many HPV initiatives, outcomes of these programs are largely limited to modest improvements in vaccine uptake in small, homogeneous populations. We describe pharmacies as distinctly advantageous but underutilized resources within the immunization neighborhood and propose a novel concept to improve vaccination rates as well as reduce HPV-related disease burden in all demographics.