Implementation costs of a multi-component program to increase human papillomavirus (HPV) vaccination in a network of pediatric clinics

Introduction: HPV vaccination is both a clinically and cost-effective way to prevent HPV-related cancers. Increased focus on preventing HPV infection and HPV-related cancers has motivated development of strategies to increase adolescent vaccination rates. This analysis estimates the average cost associated with implementing programs aimed at increasing HPV vaccination from the perspective of the clinic decision makers. As providers and healthcare organizations consider vaccination initiatives, it is important for them to understand the costs associated with implementing these programs. Methods: Healthcare provider assessment and feedback, reminders, and education; and parent education/reminder strategies were implemented in a large pediatric clinic network between October 2015 and February 2018 to improve HPV vaccination rates. A micro-costing method was used in 2018 to prospectively estimate program implementation costs with the clinic as the unit of analysis. A sensitivity analysis assessed the effects of variability in levels of participation. Results: Assessment and feedback reports and provider education were implemented among 51 clinics at average per clinic cost of $786 and$368 respectively. Electronic vaccination reminders were delivered to providers and parents at a per clinic cost of $824. The parent education implementation cost was$2,126 per clinic. Conclusion: The four complimentary HPV evidence-based strategies were delivered at a total cost of $157,534 or$4,749 per clinic, including staff training and participant recruitment, reaching 155,000 HPV vaccine eligible adolescents

Using Intervention Mapping to Develop an Efficacious Multicomponent Systems-Based Intervention to Increase Human Papillomavirus (HPV) Vaccination in a Large Urban Pediatric Clinic Network

Background: The CDC recommends HPV vaccine for all adolescents to prevent cervical, anal, oropharyngeal, vaginal, vulvar, and penile cancers, and genital warts. HPV vaccine rates currently fall short of national vaccination goals. Despite evidence-based strategies with demonstrated efficacy to increase HPV vaccination rates, adoption and implementation of these strategies within clinics is lacking. The Adolescent Vaccination Program (AVP) is a multicomponent systems-based intervention designed to implement five evidence-based strategies within primary care pediatric practices. The AVP has demonstrated efficacy in increasing HPV vaccine initiation and completion among adolescents 10-17 years of age. The purpose of this paper is to describe the application of Intervention Mapping (IM) toward the development, implementation, and formative evaluation of the clinic-based AVP prototype. Methods: Intervention Mapping (IM) guided the development of the Adolescent Vaccination Program (AVP). Deliverables comprised: a logic model of the problem (IM Step 1); matrices of behavior change objectives (IM Step 2); a program planning document comprising scope, sequence, theory-based methods, and practical strategies (IM Step 3); functional AVP component prototypes (IM Step 4); and plans for implementation (IM Step 5) and evaluation (IM Step 6). Results: The AVP consists of six evidence-based strategies implemented in a successful sequenced roll-out that (1) established immunization champions in each clinic, (2) disseminated provider assessment and feedback reports with data-informed vaccination goals, (3) provided continued medical and nursing education (with ethics credit) on HPV, HPV vaccination, message bundling, and responding to parent hesitancy, (4) electronic health record cues to providers on patient eligibility, and (5) patient reminders for HPV vaccine initiation and completion. Conclusions: IM provided a logical and systematic approach to developing and evaluating a multicomponent systems-based intervention to increase HPV vaccination rates among adolescents in pediatric clinics

Parents\u27 Stigmatizing Beliefs About the HPV Vaccine and Their Association With Information Seeking Behavior and Vaccination Communication Behaviors

Parents\u27 stigmatizing beliefs about the HPV vaccine, such as beliefs that it promotes adolescent sexual activity, constitute a notable barrier to vaccine uptake. The purpose of this study is to describe the associations between parents\u27 stigmatizing beliefs about the HPV vaccine, psychosocial antecedents to vaccination, and parents\u27 intentions to vaccinate their children. Parents of vaccine-eligible children

Increasing HPV Vaccination in a Network of Pediatric Clinics using a Multi-component Approach

Background: Despite continued public health efforts to increase human papillomavirus (HPV) vaccination among adolescents, initiation remains below the level needed to reach the Healthy People 2020 goal of 80% series completion by age 13. Methods: We developed, implemented, and evaluated a multi-component program that used evidence-based strategies to increase HPV vaccine initiation in a network of 51 pediatric clinics in Houston, Texas. Our target populations were the clinic network, healthcare providers, male and female patients ages 11-17, and their parents. The program, called the Adolescent Vaccination Program (AVP), was conducted from March 2016 through March 2019 and contained strategies to increase vaccination including: HPV immunization champions; provider assessment and feedback; provider continuing education; provider reminders; and patient reminders. We used a single group pre/post design with an external comparison – NIS-Teen. Our primary outcome was initiation of the HPV vaccine based on the electronic health record. We used interrupted time series analysis (ITSA) to measure change in initiation over time. We calculated monthly, quarterly, and annual rates of initiation for each physician, clinic, and the network. We examined patterns of initiation by patient age, sex, race/ethnicity, and type of insurance. Results: By the end of the project, the 51 clinics averaged 77.4% initiation. Rates increased annually from September 2015 through March 2019. ITSA analysis over 75 months showed an increase in vaccine initiation of 0.396% per month from the introduction of the program in March 2016. Average individual clinic improvement was 0.37% per month ranging from -0.04% to 0.68% through March 2019. Data for the 11-12 year olds, the target age group for initiating the vaccine, showed a greater percentage increase (54.2%) compared with the 13-17 year olds (29.6%). Hispanics and African Americans had the highest initiation rates in all years while non-Hispanic whites had the lowest. Families without insurance had the lowest rates while those with Medicaid/Medicare had the highest. Conclusions: We observed a secular trend upward in both the network and NIS-Teen data; however, the network showed a steeper increase. The AVP is a promising program of strategies to increase HPV vaccination in a clinic setting

The function of the RNA-binding protein TEL1 in moss reveals ancient regulatory mechanisms of shoot development

The shoot represents the basic body plan in land plants. It consists of a repeated structure composed of stems and leaves. Whereas vascular plants generate a shoot in their diploid phase, non-vascular plants such as mosses form a shoot (called the gametophore) in their haploid generation. The evolution of regulatory mechanisms or genetic networks used in the development of these two kinds of shoots is unclear. TERMINAL EAR1-like genes have been involved in diploid shoot development in vascular plants. Here, we show that disruption of PpTEL1 from the moss Physcomitrella patens, causes reduced protonema growth and gametophore initiation, as well as defects in gametophore development. Leafy shoots formed on ΔTEL1 mutants exhibit shorter stems with more leaves per shoot, suggesting an accelerated leaf initiation (shortened plastochron), a phenotype shared with the Poaceae vascular plants TE1 and PLA2/LHD2 mutants. Moreover, the positive correlation between plastochron length and leaf size observed in ΔTEL1 mutants suggests a conserved compensatory mechanism correlating leaf growth and leaf initiation rate that would minimize overall changes in plant biomass. The RNA-binding protein encoded by PpTEL1 contains two N-terminus RNA-recognition motifs, and a third C-terminus non-canonical RRM, specific to TEL proteins. Removal of the PpTEL1 C-terminus (including this third RRM) or only 16–18 amino acids within it seriously impairs PpTEL1 function, suggesting a critical role for this third RRM. These results show a conserved function of the RNA-binding PpTEL1 protein in the regulation of shoot development, from early ancestors to vascular plants, that depends on the third TEL-specific RRM

NOTCH2 Mutations Cause Alagille Syndrome, a Heterogeneous Disorder of the Notch Signaling Pathway

Alagille syndrome (AGS) is caused by mutations in the gene for the Notch signaling pathway ligand Jagged1 (JAG1), which are found in 94% of patients. To identify the cause of disease in patients without JAG1 mutations, we screened 11 JAG1 mutation-negative probands with AGS for alterations in the gene for the Notch2 receptor (NOTCH2). We found NOTCH2 mutations segregating in two families and identified five affected individuals. Renal manifestations, a minor feature in AGS, were present in all the affected individuals. This demonstrates that AGS is a heterogeneous disorder and implicates NOTCH2 mutations in human disease

Informing Content and Feature Design of a Parent-Focused Human Papillomavirus Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Group Study

BackgroundHuman papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making. ObjectiveThis study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI. MethodsWe conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network. ResultsThe 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience. ConclusionsSynchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child’s pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents

Overexpression of the Vacuolar Sugar Carrier AtSWEET16 Modifies Germination, Growth, and Stress Tolerance in Arabidopsis

Here, we report that SUGARS WILL EVENTUALLY BE EXPORTED TRANSPORTER (SWEET16) from Arabidopsis (Arabidopsis thaliana) is a vacuole-located carrier, transporting glucose (Glc), fructose (Fru), and sucrose (Suc) after heterologous expression in Xenopus laevis oocytes. The SWEET16 gene, similar to the homologs gene SWEET17, is mainly expressed in vascular parenchyma cells. Application of Glc, Fru, or Suc, as well as cold, osmotic stress, or low nitrogen, provoke the down-regulation of SWEET16 messenger RNA accumulation. SWEET16 overexpressors (35S(Pro):SWEET16) showed a number of peculiarities related to differences in sugar accumulation, such as less Glc, Fru, and Suc at the end of the night. Under cold stress, 35S(Pro):SWEET16 plants are unable to accumulate Fru, while under nitrogen starvation, both Glc and Fru, but not Suc, were less abundant. These changes of individual sugars indicate that the consequences of an increased SWEET16 activity are dependent upon the type of external stimulus. Remarkably, 35S(Pro):SWEET16 lines showed improved germination and increased freezing tolerance. The latter observation, in combination with the modified sugar levels, points to a superior function of Glc and Suc for frost tolerance. 35S(Pro):SWEET16 plants exhibited increased growth efficiency when cultivated on soil and showed improved nitrogen use efficiency when nitrate was sufficiently available, while under conditions of limiting nitrogen, wild-type biomasses were higher than those of 35S(Pro):SWEET16 plants. Our results identify SWEET16 as a vacuolar sugar facilitator, demonstrate the substantial impact of SWEET16 overexpression on various critical plant traits, and imply that SWEET16 activity must be tightly regulated to allow optimal Arabidopsis development under nonfavorable conditions