Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine

BACKGROUND

Assessment and feedback is a common implementation strategy to improve healthcare provider fidelity to clinical guidelines. For immunization guidelines, fidelity is often measured with doses administered during eligible visits. Adding a patient refusal measure captures provider fidelity more completely (i.e., all instances of a provider recommending a vaccine, resulting in vaccination or refusal) and enables providers to track patient vaccine hesitancy patterns. However, many electronic health record (EHR) systems have no structured field to document multiple instances of refusals for specific vaccines, and existing billing codes for refusal are not vaccine specific. This study assessed the feasibility of a novel method for refusal documentation used in a study focused on human papillomavirus (HPV) vaccine.

METHODS

An observational, descriptive-comparative, mixed-methods study design was used to conduct secondary data analysis from an implementation-effectiveness trial. The parent trial compared coach-based versus web-based practice facilitation, including assessment and feedback, to increase HPV vaccination in 21 community-based private pediatric practices. Providers were instructed to document initial HPV vaccine refusals in the EHR's immunization forms and subsequent refusals using dummy procedure codes, for use in assessment and feedback reports. This analysis examined adoption and maintenance of the refusal documentation method during eligible well visits, identified barriers and facilitators to documentation and described demographic patterns in patient refusals.

RESULTS

Seven practices adopted the refusal documentation method. Among adopter practices, documented refusals started at 2.4% of eligible well visits at baseline, increased to 14.2% at the start of implementation, peaked at 24.0%, then declined to 18.8%. Barriers to refusal documentation included low prioritization, workflow integration and complication of the billing process. Facilitators included high motivation, documentation instructions and coach support. Among adopter practices, odds of refusing HPV vaccine were 25% higher for patients aged 15-17 years versus 11-12 years, and 18% lower for males versus females.

CONCLUSIONS

We demonstrated the value of patient refusal documentation for measuring HPV vaccination guideline fidelity and ways that it can be improved in future research. Creation of vaccine-specific refusal billing codes or EHR adaptations to enable documenting multiple instances of specific vaccine refusals would facilitate consistent refusal documentation. Trial Registration NCT03399396 Registered in ClinicalTrials.gov on 1/16/2018.

Patient and Provider Perspectives on Pediatric Telemedicine During the COVID-19 Pandemic

The COVID-19 pandemic led to rapid expansion of telemedicine services. We surveyed parent/guardians from March 10 to June 29, 2020, in an academic and community pediatric practice, and community pediatric providers from June 5 to July 13, 2020, to better understand their perceptions of telemedicine and compare parent/guardian satisfaction between in-person and telemedicine encounters. Overall patient satisfaction scores were high in both settings and did not differ between in-person and telemedicine visits (community setting: 93.36 ± 12.87 in-person vs. 88.04 ± 22.04 telemedicine; academic setting: 92.25 ± 11.2 vs. 95.37 ± 8.21). Most providers (82.5%) would be willing to use telemedicine in a nonpandemic situation. Telemedicine should remain available for primary care pediatrics during and after resolution of the pandemic.

Providers' Perceptions of Parental Human Papillomavirus Vaccine Hesitancy: Cross-Sectional Study

Background

Human papillomavirus (HPV) vaccine hesitancy among parents contributes to low vaccination coverage in adolescents. To improve health care provider communication and vaccine recommendation practices with hesitant parents, it is important to understand how providers perceive parental HPV vaccine hesitancy.

Objective

This study aimed to characterize perceived reasons for parental HPV vaccine hesitancy and identify factors associated with perceived parental hesitancy among providers at community-based pediatric clinics.

Methods

In 2018, providers in 23 community-based pediatric clinics in Tennessee were invited to complete a Web-based baseline survey as part of a larger quality improvement study focused on HPV vaccine uptake. These survey data were used for a cross-sectional, secondary data analysis. Scale scores ranging from 0 to 100 were calculated for provider self-efficacy (confidence in ability to recommend HPV vaccine), provider outcome expectations (expectations that recommendation will influence parents’ decisions), and perceived parental HPV vaccine hesitancy. Provider confidence in HPV vaccine safety and effectiveness were categorized as high versus low. Clinic-level exposures examined were clinic size and rural-urban location. Descriptive analyses were used to characterize perceived parental barriers by provider type. Mixed-effects linear regression models were fit taking one exposure variable at a time, whereas controlling for provider type, age, gender, and race to identify provider- and clinic-level factors associated with perceived parental barriers to HPV vaccination.

Results

Of the 187 providers located in the 23 clinics, 137 completed the survey. The majority of physician providers were white and female, with a higher percentage of females among nurse practitioners (NPs) and physician assistants (PAs). The most common parental barriers to HPV vaccination perceived by providers were concerns about HPV vaccine safety (88%), child being too young (78%), low risk of HPV infection for child through sexual activity (70%), and mistrust in vaccines (59%). In adjusted mixed models, perceived parental HPV vaccine hesitancy was significantly associated with several provider-level factors: self-efficacy (P=.001), outcome expectations (P<.001), and confidence in HPV vaccine safety (P=.009). No significant associations were observed between perceived parental HPV vaccine hesitancy and clinic-level factors clinic size nor location.

Conclusions

Researchers developing provider-focused interventions to reduce parental HPV vaccine hesitancy should consider addressing providers’ self-efficacy, outcome expectations, and confidence in HPV vaccine safety to help providers communicate more effectively with HPV vaccine hesitant parents.

Alcohol intake and ovarian cancer risk: a pooled analysis of 10 cohort studies

Alcohol has been hypothesized to promote ovarian carcinogenesis by its potential to increase circulating levels of estrogen and other hormones; through its oxidation byproduct, acetaldehyde, which may act as a cocarcinogen; and by depletion of folate and other nutrients. Case–control and cohort studies have reported conflicting results relating alcohol intake to ovarian cancer risk. We conducted a pooled analysis of the primary data from ten prospective cohort studies. The analysis included 529 638 women among whom 2001 incident epithelial ovarian cases were documented. After study-specific relative risks (RR) and 95% confidence intervals (CI) were calculated by Cox proportional hazards models, and then were pooled using a random effects model; no associations were observed for intakes of total alcohol (pooled multivariate RR=1.12, 95% CI 0.86–1.44 comparing ⩾30 to 0 g day⁻¹ of alcohol) or alcohol from wine, beer or spirits and ovarian cancer risk. The association with alcohol consumption was not modified by oral contraceptive use, hormone replacement therapy, parity, menopausal status, folate intake, body mass index, or smoking. Associations for endometrioid, mucinous, and serous ovarian cancer were similar to the overall findings. This pooled analysis does not support an association between moderate alcohol intake and ovarian cancer risk.

Patterns of physical activity among American Indian children: an assessment of barriers and support

Estimates indicate that 10% to 50% of American Indian and non-Indian children in the U.S. are obese, defined as a body mass index > or = 95th percentile of the NHANES II reference data. Pathways is a two-phase, multi-site study to develop and test a school-based obesity prevention program in American Indian schoolchildren in grades three through five. During Phase I feasibility prior to initiation of the Pathways trial, data were collected related to physical activity patterns, and the supports of, and barriers to, physical activity. Nine schools from communities representing six different tribal groups participated in this study. Multiple measures were used for data collection including direct observation, paired child interviews, and in-depth interviews and focus groups with adults. Students completed the self-administered Knowledge, Attitudes, and Behaviors (KAB) survey, and a Physical Activity Questionnaire (PAQ). Barriers to physical activity at schools included a lack of facilities, equipment, and trained staff persons for PE. Adults were not consistently active with their children, but they were highly supportive of their children's activity level. Children reported a strong enjoyment of physical activity and strong peer support to be physically active. Weather conditions, safety concerns, and homework/chores were common barriers to physical activity reported by children and adult caregivers. The information was used to design culturally and age-appropriate, practical interventions including the five physical activity programs for schoolchildren in the Pathways study.

Effect of health lifestyle pattern on dietary change

PURPOSE

To examine the effect of lifestyle on the effectiveness of a low-intensity dietary intervention.

DESIGN

A secondary data analysis was performed using data from the Eating Patterns Study, a randomized controlled trial that found that self-help materials with physician advice was effective in changing dietary intake and behavior.

SETTING

Primary care clinics in a large health maintenance organization.

SUBJECTS

A total of 2111 patients with a routine scheduled appointment with their primary care physicians.

MEASURES

Participants were grouped into one of six health lifestyle patterns based on similarities in baseline measures of alcohol intake, smoking, diet quality, and exercise. Within each lifestyle pattern, changes from baseline in usual fat and fiber intake (based on a food frequency) and a fat and fiber behavior score were compared at 3 months and 12 months for intervention vs. control participants.

INTERVENTION

Self-help materials delivered by a physician with advice to change diet.

RESULTS

Intervention participants in the fitness lifestyle group made the largest changes relative to controls for each dietary outcome at 3 and 12 months. For intervention participants defined by their alcohol intake or current smoking, either no changes in diet were observed compared with controls, or early changes were not sustained over time. Intervention-control comparisons within the remaining lifestyle patterns showed smaller dietary changes compared with the fitness lifestyle. This finding was similar to previously published results.

CONCLUSIONS

This randomized controlled trial had limited power to detect subgroup differences; however, these results suggest that lifestyle patterns may be useful in the development of effective, targeted interventions to change behavior.

Fast food restaurant use among women in the Pound of Prevention study: dietary, behavioral and demographic correlates

OBJECTIVE

To examine demographic, behavioral and dietary correlates of frequency of fast food restaurant use in a community-based sample of 891 adult women.

DESIGN

A survey was administered at baseline and 3 y later as part of a randomized, prospective intervention trial on weight gain prevention.

SUBJECTS

Women (n = 891) aged 20-45 y who enrolled in the Pound of Prevention study.

MEASUREMENTS

Frequency of fast food restaurant use, dietary intake, demographic and behavioral measures were self-reported. Dietary intake was measured using the 60-item Block Food Frequency Questionnaire. Body weight and height were directly measured.

RESULTS

Twenty-one percent of the sample reported eating > or = 3 fast food meals per week. Frequency of fast food restaurant use was associated with higher total energy intake, higher percentage fat energy, more frequent consumption of hamburgers, French fries and soft drinks, and less frequent consumption of fiber and fruit. Frequency of fast food restaurant use was higher among younger women, those with lower income, non-White ethnicity, greater body weight, lower dietary restraint, fewer low-fat eating behaviors, and greater television viewing. Over 3 y, increases in frequency of fast food restaurant use were associated with increases in body weight, total energy intake, percentage fat intake, intake of hamburgers, French fries and soft drinks, and with decreases in physical activity, dietary restraint and low-fat eating behaviors. Intake of several other foods, including fruits and vegetables, did not differ by frequency of fast food restaurant use.

CONCLUSION

Frequency of fast food restaurant use is associated with higher energy and fat intake and greater body weight, and could be an important risk factor for excess weight gain in the population.

Relationships between vitamin and mineral supplement use, dietary intake, and dietary adequacy among adolescents

OBJECTIVE

To examine patterns of supplement use among US adolescents and the relationship between supplement use and dietary intake and adequacy.

DESIGN

Adolescents self-reported 2 days of food intake using the 24-hour recall method and supplement use during a personal interview conducted as part of the 1994 Continuing Survey of Food Intakes of Individuals (CSFII).

SUBJECTS

A national sample of 423 adolescents included in the 1994 CSFII survey.

STATISTICAL ANALYSIS

chi 2 analysis was used to determine which demographic factors were significantly related to patterns of supplement use. Weighted percentages of adolescents by category of supplement use for selected vitamins and minerals (calcium; iron; zinc; folic acid; and vitamins A, B-6, C, and E) are presented. Relationships between dietary intake of macronutrients and vitamins and minerals among adolescents and supplement use were determined using a least-squares model of general linear regression.

RESULTS

Approximately one-third of adolescents reported using supplements, with 15.6% of youth using them on a daily basis. The majority of supplement users reported taking multivitamins (N = 95; 65.5%) whereas only one-third of supplement users reported taking individual vitamins or minerals. Supplement use was found to vary by gender, household size, and US region of residence. Adolescents who reported using supplements had higher mean dietary intakes of most micronutrients and lower intakes of total and saturated fat than those who did not use supplements. More than one-third of adolescents had dietary intakes of vitamins A and E, calcium, and zinc that were < 75% of the US Recommended Dietary Allowance.

APPLICATIONS/CONCLUSIONS

The majority of US adolescents do not use vitamin or mineral supplements. Interestingly, adolescents who do use supplements, even on an infrequent basis, consume diets that are more nutrient-dense than those who do not use supplements. Dietary intakes of several micronutrients were inadequate among all adolescents in this study, regardless of supplement use status. There is a need to develop and implement programs aimed at improving the dietary intakes of US adolescents.

An interactive CD-ROM for nutrition screening and counseling

OBJECTIVES

The goal of this project was to develop an interactive CD-ROM for nutrition screening and counseling, designed to produce dietary behavior change in fat and fruit and vegetable intake.

METHODS

The design was based on principles of relevance to the learner, readiness for change, feedback, individualization, facilitation of skills, and goal setting. It was tested in community settings such as libraries, senior centers, and Women, Infants, and Children clinics.

RESULTS

Nearly 80% of the respondents (n = 284), including numerous low-income persons, reported learning something new about nutrition and health or their own dietary habits. More than 50% of those recontacted 2 to 4 weeks later had put some of their dietary goals into practice.

CONCLUSIONS

This program is useful for dietary screening, feedback, skill building, and motivation in settings in which in-person counseling by nutrition professionals is not feasible.

Weight-loss practices, nutrition beliefs, and weight-loss program preferences of urban American Indian women

OBJECTIVE

To describe health beliefs, weight concern, dieting practices, and weight-loss program preferences of American Indian women residing in an urban setting.

DESIGN

Face-to-face interviews using a semistructured questionnaire were conducted and height and weight were measured.

SUBJECTS/SETTING

Subjects were 203 American Indian adult women in an urban community setting.

STATISTICAL ANALYSIS

Frequency distributions and chi 2 analysis were performed using the Statistical Analysis System software.

RESULTS

About two-thirds of the subjects were overweight. Most women were concerned about obesity and reported attempting to manage their weight. Healthful weight-loss practices (e.g., eating more fruits and vegetables, increasing physical activity) were used most frequently. However, unhealthful practices, such as skipping meals/fasting, using laxatives/diuretics, and self-induced vomiting were also mentioned. Regular bingeing was reported by 10% of respondents.

APPLICATIONS

Weight-management intervention efforts should focus on helping clients modify their diet and physical activity patterns. Low-cost programs offered in convenient locations would attract more participants, as would the provision of child care. Education about the dangers and ineffectiveness of unhealthful weight-loss practices will be necessary, given the high rates of such behaviors in this population.

Diet and physical activity patterns of Lakota Indian adults

OBJECTIVES

This study assessed specific dietary practices and overall physical activity patterns of Lakota adults residing on Indian reservations in South Dakota. Perceived barriers to changing dietary and physical activity behaviors were also examined.

DESIGN

A convenience sample of Lakota adults was surveyed. Data on consumption of higher-fat foods, fruit and vegetable intake, use of sugar-sweetened beverages, physical activity patterns, and barriers to change in diet and physical activity were collected via in-person interviews.

SUBJECTS/SETTING

A total of 219 adults from 2 adjacent reservations in South Dakota participated.

RESULTS

Higher-fat foods consumed most frequently included margarine and butter (32.0% > or = 5 times per week); eggs (30.1% > or = 5 times per week); whole milk (25.7% > or = 5 times per week); potato chips, corn chips, and popcorn (15.1% > or = 5 times per week); and bacon and sausage (13.3% > or = 5 times per week). Few subjects reported consuming fruit on a daily basis. Vegetables were consumed somewhat more frequently. Most subjects reported engaging in mild or moderate physical activities 3 or more times per week, although women were found to engage in moderate and strenuous physical activities less frequently than men. Major barriers to fruit intake included expense (16.4%), quality (14.2%), and availability (13.2%). Barriers to vegetable intake mentioned most frequently included availability (11.4%), cost (10.4%), and quality (9.1%). Taste was the most frequently mentioned barrier to cutting intake of high-fat foods (27.9%). Lack of child care (15.8%), lack of time (14.7%), and safety concerns (14.6%) were the most salient barriers to regular exercise.

APPLICATIONS/CONCLUSIONS

Nutrition interventions are needed that address the major barriers to diet change reported by Lakota adults. Efforts to increase physical activity should focus on Lakota women and should address the identified barriers to regular exercise.

Soft drink consumption among US children and adolescents: nutritional consequences

OBJECTIVE

To determine whether carbonated soft drink consumption is associated with consumption of milk, fruit juice, and the nutrients concentrated in these beverages.

DESIGN

Data collected as part of the 1994 Continuing Survey of Food Intakes by Individuals were analyzed. Information on food and nutrient intake was derived from 2 days of dietary recall data collected via an in-person interview.

SUBJECTS AND PARTICIPANTS

Nationally representative sample of people of all ages residing in the United States (response rate = 76.2%). Analyses were restricted to children aged 2 to 18 years (N = 1,810).

STATISTICAL ANALYSES PERFORMED

Logistic regression analyses were conducted to predict the odds of low milk and juice consumption by soft drink consumption level. To determine whether intake of select nutrients varied by soft drink consumption, multiple linear regression modeling was conducted. Analyses were conducted using sample weights and software appropriate for the survey design.

RESULTS

Energy intake was positively associated with consumption of nondiet soft drinks. For example, mean adjusted energy intake was 1,830 kcal/day for school-aged children who were nonconsumers of soft drinks compared with 2,018 kcal/day for children in this age group who consumed an average of 9 oz of soda or more per day. Those in the highest soft drink consumption category consumed less milk and fruit juice compared with those in the lowest consumption category (nonconsumers).

CONCLUSIONS

Nutrition education messages targeted to children and/or their parents should encourage limited consumption of soft drinks. Policies that limit children's access to soft drinks at day care centers and schools should be promoted.

Diet and physical activity patterns of urban American Indian women

A cross sectional survey was conducted of American Indian women ages 18 years and older and residing in Minneapolis to assess dietary and physical activity practices. Results indicate a high amount of fat foods and low amount of fruits or vegetables consumed, and little regular physical activity. For adequate dietary intake, barriers included expense, and for physical activity barriers included lack of child care, health problems and safety concerns.

Guess who's cooking? The role of men in meal planning, shopping, and preparation in US families

OBJECTIVES

To determine the role of men in meal-related tasks in households with both a male and female head, and to identify households in which the man is more likely to be involved in these tasks.

DESIGN

Data collected as part of the US Department of Agriculture's 1994 Continuing Survey of Food Intakes of Individuals were analyzed.

SUBJECTS/SETTING

All analyses were restricted to sampled persons who were identified as a male head of household residing in a household that also had a female head (N = 1,204).

STATISTICAL ANALYSES

Frequency distributions were calculated and logistic regression analyses were conducted.

RESULTS

Approximately 23%, 36%, and 27% of men reportedly were involved in meal planning, shopping, and preparation, respectively. Men in lower income and smaller households were more likely to be involved in each of the meal activities. Younger men and men in households in which the female head of household worked full-time were more likely to be involved in meal planning and preparation.

IMPLICATIONS

Current education efforts to improve family nutrition tend to target the female rather than the male head of household. Our findings confirm that this focus is appropriate for most dual-headed households.

Association of cancer prevention-related nutrition knowledge, beliefs, and attitudes to cancer prevention dietary behavior

OBJECTIVE

To examine the relationship of cancer prevention-related nutrition knowledge, beliefs, and attitudes to cancer prevention dietary behavior.

SUBJECTS/SETTING

Noninstitutionalized US adults aged 18 years and older.

METHODS

Data collected in the 1992 National Health Interview Survey Cancer Epidemiology Supplement were analyzed. The supplement included questions to ascertain knowledge, beliefs, and attitudes and a food frequency questionnaire to ascertain nutrient intake.

STATISTICS

Multivariate linear regression modeling was conducted to assess the hypothesized relationships.

RESULTS

After adjustment for relevant covariates (age, sex, education, total energy, perceived barriers to eating a more healthful diet), knowledge and belief constructs were predictive of dietary behavior. Specifically, fat, fiber, and fruit and vegetable intakes more closely approximated dietary recommendations for persons with more cancer-prevention knowledge. The strength of the associations between these constructs and dietary behavior varied in some cases according to level of education and perceived barriers to eating a healthful diet. Of the perceived barriers to eating a healthful diet, perceived ease of eating a healthful diet was most strongly and consistently predictive of intake.

CONCLUSIONS

Research findings challenge dietetics practitioners to design diet- and health-promotion programs and activities that not only educate the public about the importance of diet to health, but also address barriers to dietary change.

US trends in nutrient intake: the 1987 and 1992 National Health Interview Surveys

OBJECTIVES

This study examined US trends in nutrient intake, using almost identical methods and nutrient databases in two time periods.

METHODS

An extensive dietary intake questionnaire was included in supplements to the 1987 and 1992 National Health Interview Surveys. Dietary data from approximately 11,000 persons in each of those years were analyzed.

RESULTS

The total and saturated fat intake and the percentage of energy from fat declined among Whites and Hispanics, but only minimal changes were seen in Black Americans. The changes in fat intake were attributable principally to behavioral changes in frequency and type of fat-containing foods consumed rather than to the increased availability of leaner cuts of meat. Dietary cholesterol showed one of the largest declines of the nutrients examined. Less desirable changes were also seen. Cereal fortification played an important role in the observed changes in several micronutrients.

CONCLUSIONS

Educational campaigns on dietary fat and cholesterol have been moderately effective, but not in all racial/ethnic groups. Future campaigns should emphasize maintaining or increasing micronutrient intake.