Background/Objectives: Initiating the HPV vaccine series at ages 9/10 compared to 11+, results in on-time completion. This evidence is strong enough that several organizations in the United States, including the American Cancer Society and the American Academy of Peditrics, have updated their recommendation language to indicate conversations about HPV vaccination should begin at earlier ages. However, since little is known about factors associated with early initiation, our goal was to explore sociodemographic factors associated with early initiation using immunization registry data. Methods: Immunization registries are state-wide databases that are able to work bidirectionally with electronic medical record systems to keep immunization history up-to-date. Iowa, a rural, midwestern state, has a robust registry that captures nearly 100% of the immunizations that occur in the state. We used data from the Iowa Immunization Registry for children born between 2004 and 2013 to explore sociodemographic factors (e.g., gender, race/ethnicity, rurality, and insurance type) associated with early initiation. We then used logistic regression to model the factors associated with likelihood of early HPV vaccine initiation. Results: Of the 255,833 children who initiated the series in our data set, 3.2% (n=8,355) initiated at ages 9 or 10, 173,831 (67.9%) initiated at ages 11 or 12, and the remaining 73,647 (28.8%) initiated after 12. We observed significant differences between the children who initiated at ages 9/10 compared to later across all sociodemographic categories. Males were less likely to initiate early (OR: 0.77, 0.74;0.81) compared to females. Compared to white children, racial and ethnic minority children were more likely to initiate the series early; for example, black children had an odds ratio of 1.99 (CI: 1.87, 2.13) and Hispanic or Latino children had an odds ratio of 1.67 (CI: 1.57, 1.79). Those living in the most rural areas (OR: 0.76, CI: 0.72, 0.81) and those with either no insurance (OR: 0.84, CI: 0.80, 0.89) or public insurance (OR: 0.53, CI: 0.50, 0.56) were less likely to initiate early. Conclusions: Given the recent focus on early initiation for the series, our results contribute to a growing understanding of who is initiating the series earlier and where disparities are occurring. In some ways, these results echo patterns previously seen in analyses of initiation; males, racial/ethnic minorities, and adolescents living in rural areas are less likely to initiate the series in general compared to females, non-Hispanic white, and urban-dwelling adolescents. Whereas, national data has shown that adolescents with public insurance have higher initiation and completion rates, we found that public insurance was associated with a lower likelihood of early initiation. Immunization registry data are highly valuable in providing these nuanced, population-level details about immunization uptake and we can now use this data to inform development of tailored interventions to better promote early-initiation of HPV vaccination. Our future steps will include geospatial analysis so that we can not only develop tailored messaging based on these identified sociodemographic characteristics but also based on geographic areas where early initiation is lagging.

Background: Rural-urban vaccine inequities are a longstanding issue across the country, and Massachusetts is no exception. For example, in Franklin County, a rural county in the western part of the state, only 83% of 7th graders and 70% of 11th graders are up-to-date on their school-required vaccine series. Both school nurses and local public health nurses have an important role in vaccine promotion, but we need to better understand their perspectives to identify opportunities to support their efforts. Methods: We conducted a semi-structured qualitative data collection with school nurses and local public health nurses to better understand their perspectives and identify actionable opportunities for intervention. In August 2023, we used an online brainstorming software to collect data during a monthly meeting convened by regional school nurse leadership. We designed our data collection to capture perspectives on three key questions: (1) What are your biggest challenges in your current role related to child/adolescent vaccination? (2) What would help you the most in your current role related to child/adolescent vaccination? (3) What do you see as the biggest barriers to raising child and adolescent vaccination rates in your school/community? Individual responses to these three questions were downloaded and we used open coding to determine themes emerging from the data. Results: The most commonly reported challenge as related to current role in vaccination was a struggle to maintain up-to-date vaccine records. School nurses are responsible for tracking vaccine compliance, and many reported varied difficulties (i.e., time required, issues reaching parents) in keeping these records updated. For example, one school nurse reported that her biggest challenge is “accessing the information from parents [and] getting parents to forward records” Other challenges identified were lack of knowledge, hesitancy within the community, and competing priorities. One school nurse reported that “immunization is not a high priority while challenges in educational settings are growing.” When asked about facilitators to vaccine promotion, the primary theme that emerged was increased access—both to vaccination services and trusted information about vaccines. As one participant reported “getting school health providers to provide onsite immunizations with other school-based health services...would be great to increase access for COVID-19, HPV.” Finally, the biggest barrier identified was availability and accessibility of primary care, with participants citing specific barriers like the fact that “primary care offices are overwhelmed” to transportation issues to access providers. Discussion: It is clear there are multilevel, interrelated challenges affecting vaccination that will need to be addressed to improve vaccination rates in Franklin County. Focusing efforts on actionable and feasible changes will have the biggest impact. For example, developing a strategy to support school nurses in collecting vaccine records more efficiently while disseminating vaccine-promotion information to parents may be feasible, but improving wait-times at primary care offices may be less of an achievable goal. Based on these findings, we are now in the process of developing potential strategies to support school and public health nurses in these efforts, focusing on alleviating barriers and leveraging potential facilitators.

Purpose: We conducted a scoping review of studies to examine the implementation of interventions to promote adolescent cancer prevention in rural, primary care settings and identify barriers and facilitators. Methods: We followed the JBI scoping review protocol and used a systematic extraction and coding process. Our search of MEDLINE, PsycInfo, Cochrane, CINAHL, and Scopus identified articles related to implementation of interventions in the following areas: obesity, human papillomavirus (HPV) vaccination, tobacco use, and sun exposure. We used the Consolidated Framework for Implementation Research (CFIR), an implementation framework consisting of 5 domains (outer setting, inner setting, intervention characteristics, individual characteristics, process), each with a sub-set of constructs, to classify barriers and facilitators reported. Results: We identified 3046 references, excluded 2969 during initial screening, assessed 74 for full-text eligibility, and abstracted 24. Of these, 17 addressed obesity, 6 addressed HPV vaccination, 1 addressed skin cancer, and 1 addressed multiple behaviors. 10 studies were either non-randomized experimental designs (n=8) or randomized controlled trials (n=2). The remaining were observational or descriptive research. Barriers in the outer setting (e.g., lack of external funding sources, patients' beliefs) and inner setting (e.g., time available for implementation efforts and clinic infrastructure) were most common, compared to the other CFIR domains. Similarly, facilitators in the outer setting (e.g., partnerships with other organizations and parents' trust in health care providers) and inner setting (e.g., efficiency in practice protocols) were commonly reported. Conclusions: Adolescence is a critical growth window to establish healthy behaviors to prevent future cancers. Rural areas have higher rates of cancer morbidity and mortality than urban ones, putting rural adolescents at heightened risk for cancers. Yet, we found a dearth of studies addressing the implementation of adolescent cancer prevention in rural primary care settings. Further research is needed to understand the implementation challenges and potential strategies to improve implementation efforts to promote cancer prevention among rural adolescents.

Background: The American Academy of Pediatrics 2017 clinical practice guidelines (CPG) call for regular blood pressure (BP) screening in children ≥3 years. However, it is unknown to what extent the BP screening CPG has been implemented or if such implementation has been equitable. Methods: Cross-sectional data from January 1-December 31, 2018 were extracted from electronic health records from the largest health care system in Central Massachusetts. Outpatient visits for children aged 3-to-17-years without a prior hypertension diagnosis were included. Adherence was defined by the BP screening CPG recommending ≥1 BP screening per year for children of a healthy body mass index ((BMI) <85%) and at every encounter for children who are overweight (BMI ≥85%). Independent variables included social determinant of health indicators at the child-level (insurance, language, child opportunity index) and clinic-level (urban/rural, Medicaid population). Covariates included child’s age, gender, race/ethnicity, and BMI, as well as clinic’s specialty (pediatrics/family medicine), patient panel size, and number of providers. We used direct estimation to calculate prevalence estimates and multivariable mixed effects logistic regression to determine the odds of undergoing CPG adherent BP screening. Findings: We identified 44,947 visits for 19,787 children (median age 11 years) across 7 pediatric and 20 family medicine clinics in 2018. The prevalence of CPG adherent BP screening was 83%. In the multivariable adjusted model, children with private insurance (adjusted odds ratio (aOR) 1.22, 95% CI 1.09-1.35) and those seen in clinics with a lower Medicaid population (aOR 1.02, 95% CI 1.0-1.05 per 1% decrease) were more likely to undergo CPG adherent screening. CPG adherent screening was also more likely among older children, those with BMI <85%, those in family medicine clinics, and those in clinics with more providers. Implications for D&I Research: Despite overall high adherence to pediatric BP CPG indicating relatively successful implementation, our findings suggest that this implementation is not equitable. Adherence was lower for children who are more likely to be impoverished, have higher social needs, and benefit from preventive screenings (BMI ≥85%, publicly insured, and treated in Medicaid predominant clinics). Future implementation efforts should address structural factors, especially those related to insurance and pediatric practice to achieve more equitable implementation.

Background: American Indian/Alaskan Native (AI/AN) individuals were 3.5 times more likely to be hospitalized from the virus compared to other race/ethic groups (CDC, 2021). Despite being disproportionately impacted by COVID-19, the experiences of the AI/AN population during the pandemic have not been documented. There are approximately 93,123 individuals in Massachusetts (MA) that identify as AI/AN (U.S. Census, 2020). This study examined the impact of COVID-19 on the behavioral health of the MA AI/AN population. Methods: A web-based survey was completed by 452 AI/ANs. A focus group with members of the AN/AI/AN (n=10) community was conducted to provide insights into the survey results. Individuals were recruited through the Institute of New England Native American Studies research team’s Community Advisory Board. Results: Forty-two percent of sample were between 45-64 years of age, female (77.2%), and identified as AN/AN in combination with another race (85%). Almost half of AI/AN participants had 15 or more days of poor mental health in the past month with rates highest among younger individuals. Forty-four percent reported that their substance use was a lot or somewhat more than pre-pandemic. Focus group findings indicated that the pandemic exacerbated (1) behavioral health challenges; (2) isolation from others and from AI/AN organizations; (3) telehealth was helpful to some; but (4) 30% had limited broadband access. Conclusion & Implications: The AI/AN community in MA has experienced devastating behavioral health outcomes during the pandemic. Urgent action is needed to address with crisis. Funding for risk-reducing programs and culturally specific treatment interventions are needed.

Background: Emotional eating (EE), a dysfunctional eating behavior characterized by eating due to negative emotions or adversity, is prevalent among Latinos in the United States (US) and has been shown to be associated with risk factors for cardiovascular disease in this population. Optimism has been consistently linked with favorable cardiovascular health and health behaviors, likely due to more adaptive coping to negative emotions and adversity. However, the association between optimism and EE has remained largely understudied, especially among US Latinos. Objective: To examine the association between optimism and EE in a sample of US Latinos. Methods: This cross-sectional analysis used data from the Latino Health and Well-being Study, a cohort of Latino men and women aged 21-84 years residing in the northeast US (analytic sample: n=587). Optimism was measured with the Life Orientation Test – Revised version (categorized in tertiles: low, moderate, and high). EE was measured with the Three-Factor Eating Questionnaire R18-V2 (categorized as no EE, low EE, and high EE). Adjusted Poisson models with robust error variance estimated prevalence ratios (PR) and 95% confidence intervals (CI). Results: Overall, 50.3% of the sample were female, 73.3% self-identified as Dominicans, and mean (SD) age was 46.6 ± 15.5 yr. In the total sample, high EE was reported by 34.2%, low EE in 26.9%, and no EE in 38.8%. The proportion of individuals reporting high EE was greater in the low (39.0%) and moderate (36.8%) optimism groups than that in the high optimism group (24.8%; p=0.011). In adjusted models, individuals with high optimism (vs. low) were 32% less likely to report high EE over no EE (PR=0.68; 95% CI=0.53-0.88). Moderate optimism was not significantly associated with high EE. Optimism was not associated with low EE. Conclusion: High levels of optimism were negatively associated with high EE in a sample of US Latinos. Longitudinal studies are needed to confirm our findings. Interventions and clinical programs promoting optimism may hold promise for preventing EE in US Latinos.

Introduction: Evidence-based healthy eating (HE) policies can increase opportunities to engage in a healthy diet. The adoption of evidence-based policies into practice is limited and no study reports the status of HE policies nationally. Community Health Improvement Plans (CHIPs) strategically address health priorities, steer evidence-based strategy selection and implementation, and require collaboration. Local health departments (LHDs) are often key stakeholders. We aimed to determine the proportion of LHDs with a CHIP having evidence-based HE policies. Methods:A national probability survey of US LHDs serving populations of Results: 44.1% (95%CI: 34.7-54.0%) of US LHDs with a CHIP reported at least one evidence-based HE policy. The proportion of specific HE policies ranged from 28.9% for school district nutrition/procurement/vending policies to 1.3% for sugar-sweetened beverage tax. Conclusions: Increased implementation of evidence-based HE policy approaches are needed within communities.

Background Twelve percent of U.S. adults live in food insecure households, putting them at risk for adverse health outcomes. Relationships between food insecurity and cardiovascular disease (CVD) risk factors range from well-established to inconsistent and understudied. Food insecurity has been positively associated with poor glycemic control, tobacco use, and poor diet. The link with unhealthy body mass index (BMI) is only observed among women. Inconsistent evidence of relationships with hypertension and dyslipidemia has been found and literature examining physical activity is sparse. The relationships between food insecurity and overall cardiovascular health metrics have not been studied in a nationally representative sample of U.S. adults. Objective To quantify the extent to which food insecurity in U.S. adults is associated with poorer cardiovascular health, as measured by the Life Simple 7 metrics, and to assess gender differences in these associations. Methods This was a cross-sectional analysis of 1,446 National Health and Nutrition Examination Survey participants (2011-2012) aged >20 years. The United States Department of Agriculture Adult Food Security Module 10-item questionnaire assessed food insecurity status. Affirmative responses were summed and dichotomized as food secure (responses) or food insecure (>3). An ideal cardiovascular health score was generated from the sum of American Heart Association’s (AHA) Life’s Simple 7 metrics components achieved. The metrics included three health factors (blood glucose, cholesterol, and blood pressure) and four health behaviors (non-smoking, physical activity, healthy BMI, and healthy diet) as measured by laboratory values, anthropometric measures, self-reported questionnaires, and dietary recalls. Multiple linear and logistic regressions determined the associations between food insecurity and overall ideal cardiovascular health, defined as meeting all of the AHA Life Simple 7 metrics, and individual cardiovascular health components, respectively. The interaction between food insecurity and gender and ideal cardiovascular health was tested. Results No U.S. adults met all ideal cardiovascular health components. The 15.8% of adults living in food insecure households achieved a lower ideal cardiovascular health score (adjusted β coefficient: -0.27; 95% Confidence Interval (CI): [-0.50 to -0.04]) than adults living in food secure households. Tests for gender interaction were non-significant. In analyses assessing individual cardiovascular health components, only smoking was significant; adults living in food insecure households were half as likely to be non-smokers or recent quitters relative to their food secure counterparts (adjusted Odds Ratio 0.51; 95% CI: [0.31-0.81]). Conclusion Adults living in food insecure households achieved a lower ideal cardiovascular health score, which was driven by its association with smoking status. In addition to primary and secondary prevention, primordial prevention and cardiovascular health promotion approaches are necessary to reduce CVD burden. Effective policies and health behavior interventions are prudent, specifically to improve diet quality among all U.S. adults and tobacco cessation within food insecure populations.

Objective: Despite efforts to enhance inclusion, underrepresentation of minorities in research has been documented. The primary aim of this review was to evaluate representation of racial/ethnic sub-group members in behavioral weight loss interventions conducted among adults in the United States. The secondary aims were to assess recruitment and study design approaches to include racial/ethnic groups and the extent of racial/ethnic sub-group analyses conducted in these studies. Methods: PubMed, PsycInfo, and Medline were searched for behavioral weight loss intervention trials conducted in 2009-2015 using keywords: weight, loss, overweight, obese, intervention and trial. Results: The majority of the 87 studies reviewed included a majority White sample. Across the included studies, 61% of participants were White, 18% were Black/African American, 9% were Latino/Hispanic, 2% were Asian and 1% were American Indians. An additional 7.8% were categorized as “other”. Nine of the 87 studies enrolled exclusively minority samples. More than half (59.8%) of the studies did not report an intention, approach or specific site/location to recruit a sample that was racially or ethnically diverse. Of the 54 studies that included more than one racial/ethnic group, 8 included sub-group analyses of weight loss outcomes by race/ethnicity. Conclusions: Lack of adequate representation of racial and ethnic minority populations in behavioral trials limits the generalizability and potential public health impact of these interventions. Given persistent racial/ethnic disparities in obesity in the U.S., the high morbidity, mortality, and economic costs associated with obesity and obesity-related conditions among racial/ethnic minority groups, findings from this review emphasize the need to maximize representation of some underrepresented racial/ethnic groups in behavioral lifestyle weight loss trials.

Background: Latinos bear high burden of nutrition related cardiovascular disease (CVD) risk factors. Dysfunctional eating behaviors (emotional eating, uncontrolled eating and cognitive restraint of eating) may influence metabolic CVD risk factors but little is known about this relationship in Latinos. Objective: To examine associations between dysfunctional eating behaviors and metabolic risk factors for CVD in Latinos. Methods: Latino individuals were recruited from a community health center. Participants completed standardized interviews (i.e., demographics, Three Factor Eating Questionnaire-TFEQ-R18V2, Perceived Stress Scale-10) and anthropometric measurements. Data on diagnosis of type 2 diabetes, hypertension and hyperlipidemia were abstracted from medical records. Statistical analysis included multivariable logistic and Poisson regression models. Results: A total of 578 participants (51% female, 67% Dominican), ages 21-84, were included in this analysis. Controlling for age, sex, education and perceived stress high emotional eating (hEE) was associated with greater odds of obesity (OR=2.25 (1.47, 3.24)) and diabetes (OR=1.80 (1.07, 3.01)). High uncontrolled eating (hUE) was associated with obesity (OR=2.16 (1.34, 3.47)) and high cognitive restraint (hCR) was associated with greater odds of obesity (OR=2.55 (1.64, 3.98)), diabetes (OR=2.39 (1.40, 4.04) and hyperlipidemia (OR=1.92 (1.17, 3.14)). Lastly, hEE, hUE and hCR were significantly associated increased odds of having a greater number of the metabolic CVD risk factors (IRR=1.39 (1.20, 1.59), IRR=1.21 (1.04, 1.42), IRR=1.45 (1.24, 1.69); respectively). Conclusion: Interventions that target eating behaviors may facilitate reduction of metabolic CVD risk factors and health disparities in CVD among Latinos.