Developing a Tablet-Based Self-Persuasion Intervention Promoting Adolescent HPV Vaccination: Protocol for a Three-Stage Mixed-Methods Study

Exploring Intergenerational Communication on Social Media Group Chats as a Cancer Prevention Intervention Opportunity Among Vietnamese American Families: Qualitative Study

BACKGROUND

Families use social media group chats to connect with each other about daily life and to share information. Although cancer is not a frequent topic of conversation in family settings, the adoption of mobile technology in the family context presents a novel opportunity to promote cancer prevention information. To the best of our knowledge, few studies have used private social media group chats to promote cancer prevention information to family members.

OBJECTIVE

In this formative study, we investigated how family group chat platforms can be leveraged to encourage colorectal cancer screening, human papillomavirus vaccination, and cervical cancer screening among intergenerational Vietnamese American families. This study aimed to cocreate a family-based communication intervention for introducing cancer screening information in family group chats. We sought to understand family members' motivations for using group chats, family dynamics and conversation patterns, and group chat experiences and cultural norms for interacting with family members.

METHODS

Overall, 20 audio-recorded and semistructured interviews were conducted with young Vietnamese adults. The study was conducted between August and October 2018. Participants were Vietnamese Americans; aged between 18 and 44 years; living in Orange County, California; had an existing family group chat; and expressed an interest in becoming family health advocates. Data were analyzed using a framework analysis.

RESULTS

In total, 13 (65%) of the 20 young adults reported having >1 group chat with their immediate and extended family. Preventive health was not a typical topic of family conversations, but food, family announcements, personal updates, humorous videos or photos, and current events were. Young adults expressed openness to initiating conversations with family members about cancer prevention; however, they also raised concerns that may influence family members' receptivity to the messages. Themes that could potentially impact family members' willingness to accept cancer prevention messages included family status and hierarchy, gender dynamics, relational closeness in the family, and source trust and credibility. These considerations may impact whether families will be open to receiving cancer screening information and acting on it. The participants also mentioned practical considerations for intervention and message design, which included the Vietnamese cultural conversation etiquette of hỏi thăm, respect for a physician's recommendation, prevention versus symptom orientation, the family health advocate's bilingual capacity, and the busy lives of family members. In response to exemplar messages, participants mentioned that they preferred to personalize template messages to accommodate conversational norms in their family group chats.

CONCLUSIONS

The findings of this study inform the development of a social media intervention for increasing preventive cancer screening in Vietnamese American families.

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).

COVID-19 Communication From Seven Health Care Institutions in North Texas for English- and Spanish-Speaking Cancer Patients: Mixed Method Website Study

Background

The COVID-19 pandemic has created an urgent need to rapidly disseminate health information, especially to those with cancer, because they face higher morbidity and mortality rates. At the same time, the pandemic’s disproportionate impact on Latinx populations underscores the need for information to reach Spanish speakers. However, the equity of COVID-19 information communicated through institutions’ online media to Spanish-speaking cancer patients is unknown.

Objective

We conducted a multimodal, mixed method document review study to evaluate the equity of online information about COVID-19 and cancer available to English- and Spanish-speaking populations from seven health care institutions in North Texas, where one in five adults is Spanish-speaking. Our focus was less on the “digital divide,” which conveys disparities in access to computers and the internet based on the race/ethnicity, education, and income of at-risk populations; rather, our study asks the following question: to what extent is online content useful and culturally appropriate in meeting Spanish speakers’ information needs?

Methods

We reviewed 50 websites (33 English and 17 Spanish) over a period of 1 week in the middle of May 2020. We sampled seven institutions’ main oncology and COVID web pages, and both internal (institutional) and external (noninstitutional) linked content. We conducted several analyses for each sampled page, including (1) thematic content analysis, (2) literacy level analysis using Readability Studio software, (3) coding using the Patient Education and Materials Assessment Tool (PEMAT), and (4) descriptive analysis of video and diversity content.

Results

The themes most frequently addressed on English and Spanish websites differed. While “resources/FAQs” were frequently cited themes on both websites, English websites more frequently addressed “news/updates” and “cancer+COVID,” and Spanish websites addressed “protection” and “COVID data.” Spanish websites had on average a lower literacy level (11th grade) than English websites (13th grade), although still far above the recommended guideline of 6th to 8th grade. The PEMAT’s overall average accessibility score was the same for English (n=33 pages) and Spanish pages (n=17 pages) at 82%. Among the Dallas-Fort Worth organizations, the average accessibility of Spanish pages (n=7) was slightly lower than that of English pages (n=19) (77% vs 81%), due mostly to the discrepancy in English-only videos and visual aids. Of the 50 websites, 12 (24%) had embedded videos; however, 100% of videos were in English, including one on a Spanish website.

Conclusions

We identified an uneven response among the seven health care institutions for providing equitable information to Spanish-speaking Dallas-Fort Worth residents concerned about COVID and cancer. Spanish speakers lack equal access in both diversity of content about COVID-19 and access to other websites, leaving an already vulnerable cancer patient population at greater risk. We recommend several specific actions to enhance content and navigability for Spanish speakers.

Reducing "I Don't Know" Responses and Missing Survey Data: Implications for Measurement

BACKGROUND

"I don't know" (DK) responses are common in health behavior research. Yet analytic approaches to managing DK responses may undermine survey validity and researchers' ability to interpret findings.

OBJECTIVE

Compare the usefulness of a methodological strategy for reducing DK responses to 3 analytic approaches: 1) excluding DKs as missing data, 2) recoding them to the neutral point of the response scale, and 3) recoding DKs with the mean.

METHODS

We used a 4-group design to compare a methodological strategy, which encourages use of the response scale after an initial DK response, to 3 methods of analytically treating DK responses. We examined 1) whether this methodological strategy reduced the frequency of DK responses, and 2) how the methodological strategy compared to common analytic treatments in terms of factor structure and strength of correlations between measures of constructs.

RESULTS

The prompt reduced DK response frequency (55.7% of 164 unprompted participants vs. 19.6% of 102 prompted participants). Factorial invariance analyses suggested equivalence in factor loadings for all constructs throughout the groups. Compared to excluding DKs, recoding strategies and use of the prompt improved the strength of correlations between constructs, with the prompt resulting in the strongest correlations (.589 for benefits and intentions, .446 for perceived susceptibility and intentions, and .329 for benefits and perceived susceptibility).

LIMITATIONS

This study was not designed a priori to test methods for addressing DK responses. Our analysis was limited to an interviewer-administered survey, and interviewers did not probe about reasons for DK responses.

CONCLUSION

Findings suggest that use of a prompt to reduce DK responses is preferable to analytic approaches to treating DK responses. Use of such prompts may improve the validity of health behavior survey research.

Evaluation of a Mobile Phone-Based Intervention to Increase Parents' Knowledge About the Measles-Mumps-Rubella Vaccination and Their Psychological Empowerment: Mixed-Method Approach

BACKGROUND

There is mixed evidence on the effectiveness of vaccination-related interventions. A major limitation of most intervention studies is that they do not apply randomized controlled trials (RCTs), the method that, over the last 2 decades, has increasingly been considered as the only method to provide proof of the effectiveness of an intervention and, consequently, as the most important instrument in deciding whether to adopt an intervention or not. This study, however, holds that methods other than RCTs also can produce meaningful results.

OBJECTIVE

The aim of this study was to evaluate 2 mobile phone-based interventions aimed at increasing parents' knowledge of the measles-mumps-rubella (MMR) vaccination (through elements of gamification) and their psychological empowerment (through the use of narratives), respectively. The 2 interventions were part of an RCT.

METHODS

We conducted 2 studies with the RCT participants: a Web-based survey aimed at assessing their rating of the tool regarding a number of qualities such as usability and usefulness (N=140), and qualitative telephonic interviews to explore participants' experiences with the app (N=60).

RESULTS

The results of the survey showed that participants receiving the knowledge intervention (alone or together with the empowerment intervention) liked the app significantly better compared with the group that only received the empowerment intervention (F_2,137=15.335; P<.001). Parents who were exposed to the empowerment intervention complained that they did not receive useful information but were only invited to make an informed, autonomous MMR vaccination decision.

CONCLUSIONS

The results suggest that efforts to empower patients should always be accompanied by the provision of factual information. Using a narrative format that promotes parents' identification can be an appropriate strategy, but it should be employed together with the presentation of more points of views and notions regarding, for instance, the risks and benefits of the vaccination at the same time.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number 30768813; http://www.isrctn.com/ ISRCTN30768813 (Archived by WebCite at http://www.webcitation.org/6xOQSJ3w8).

Nudging Resisters Toward Change: Self-Persuasion Interventions for Reducing Attitude Certainty

PURPOSE

To identify effective self-persuasion protocols that could easily be adapted to face-to-face clinical sessions or health-related computer applications as a first step in breaking patient resistance.

DESIGN

Two self-persuasion interventions were tested against 2 controls in a between-subject randomized control experiment.

SETTING

GuidedTrack-a web-based platform for social science experiments.

PARTICIPANTS

Six hundred seventeen adult participants recruited via Mechanical Turk.

INTERVENTION

The experimental interventions prompted participants for self-referenced pro- and counterattitudinal arguments to elicit attitude-related thought (ART) and subsequent doubt about the attitude. The hypothesis was that the self-persuasion interventions would elicit larger and more frequent attitude certainty decreases than the controls. In the experimental groups, we also predicted a correlation between the amount of ART and attitude certainty decreases.

MEASURES

Changes in attitude certainty were measured by participants' pre- and post-ratio scale ratings; ART was measured by the number of words participants used to respond to the interventions.

ANALYSIS

Analysis of variance (ANOVA), χ², and correlation.

RESULTS

A goodness-of-fit χ² showed that the number of participants who decreased their attitude certainty was not equally distributed between the combined experimental groups (n = 104) and the combined control groups (n = 39), χ²(1, n = 143) = 28.64, P < .001. Within each intervention, goodness-of-fit χ² with a Bonferroni correction ( P = .01 or .05/4) indicated there were significantly more "decreasers" than "increasers" in intervention 1, χ²(1, n = 86) = 6.16, P = .01, but not intervention 2, χ²(1, n = 84) = 2.02, P = .16, the nonsense control, χ²(1, n = 42) = .22, P = .64), or the distraction control, χ²(1, n = 34) = .02, P = .89. A 1-way ANOVA revealed a significant main effect for intervention on mean certainty change ( F_3,613 = 4.62, P = .003). Five post hoc comparisons using Tukey's honest significant difference (HSD) test indicated that the mean decrease in attitude certainty resulting from intervention 1 (M = -3.29) was significantly larger than the mean decrease in attitude certainty resulting from the nonsense control (M = -0.62, t = -2.72, P = .03), the distraction control (M = 0.11, t = 3.48, P = .003), but not intervention 2 (M = -0.87, t = -2.54, P = .06). Attitude-related thought was significantly correlated with attitude certainty change in intervention 1, r(158) = -.17, t = -4.28, P = .02, but not intervention 2, r(161) = -.002, t = -.03, P = .98.

CONCLUSION

The implication for clinical practitioners and designers of health applications is that it may be worthwhile to let patients elaborate on their personal reasons for initially forming an unhealthy attitude to increase doubt about the strongly held attitude.

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

OBJECTIVE

Self-persuasion is an effective behavior change strategy, but has not been translated for low-income, less educated, uninsured populations attending safety-net clinics or to promote human papillomavirus (HPV) vaccination. We developed a tablet-based application (in English and Spanish) to elicit parental self-persuasion for adolescent HPV vaccination and evaluated its feasibility in a safety-net population.

METHODS

Parents (N=45) of age-eligible adolescents used the self-persuasion application. Then, during cognitive interviews, staff gathered quantitative and qualitative feedback on the self-persuasion tasks including parental decision stage.

RESULTS

The self-persuasion tasks were rated as easy to complete and helpful. We identified six question prompts rated as uniformly helpful, not difficult to answer, and generated non-redundant responses from participants. Among the 33 parents with unvaccinated adolescents, 27 (81.8%) reported deciding to get their adolescent vaccinated after completing the self-persuasion tasks.

CONCLUSIONS

The self-persuasion application was feasible and resulted in a change in parents' decision stage. Future studies can now test the efficacy of the tablet-based application on HPV vaccination.

PRACTICE IMPLICATIONS

The self-persuasion application facilitates verbalization of reasons for HPV vaccination in low literacy, safety-net settings. This self-administered application has the potential to be more easily incorporated into clinical practice than other patient education approaches.

Modification and validation of the Treatment Self Regulation Questionnaire to assess parental motivation for HPV vaccination of adolescents

BACKGROUND

According to Self-Determination Theory, the extent to which the motivation underlying behavior is self-determined or controlled influences its sustainability. This is particularly relevant for behaviors that must be repeated, such as completion of the human papillomavirus (HPV) vaccine series. To date, no measures of motivation for HPV vaccination have been developed.

METHODS

As part of a larger study, parents (N=223) whose adolescents receive care at safety-net clinics completed a telephone questionnaire about HPV and the vaccine. We modified the Treatment Self-Regulation Questionnaire to assess parents' motivation for HPV vaccination in both Spanish and English. We used confirmatory factor analysis to test a three-factor measurement model.

RESULTS

The three-factor model fit the data well (RMSEA=0.04, CFI=0.98, TLI=0.96), and the scales' reliabilities were adequate (autonomous: α=0.87; introjected: α=0.72; external: α=0.72). The factor loading strength for one item was stronger for Spanish- than English-speaking participants (p<0.05); all others were equivalent. The intercorrelations among the scales ranged from -0.17 to 0.32, suggesting discriminant factors. The scales displayed the expected pattern of correlations with other psychosocial determinants of behavior. Vaccination intentions showed a strong correlation with autonomous motivation (r=0.52), but no correlation with external motivation (r=0.02), suggesting autonomous motivation may be particularly important in vaccine decision-making.

CONCLUSION

Findings support the use of three subscales to measure motivation in HPV vaccination and suggest possible cultural differences in motivation.

Characterizing safety-net providers' HPV vaccine recommendations to undecided parents: A pilot study

OBJECTIVE

Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations.

METHODS

We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination.

RESULTS

We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale.

CONCLUSION

Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction.

PRACTICE IMPLICATIONS

Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale.