Publications by authors named "Gregory Zimet"

241 Publications

Assessing licensed nurses COVID-19 vaccine attitudes and intentions: a cross-sectional survey in the state of Hawaii.

Hum Vaccin Immunother 2021 Jul 13:1-8. Epub 2021 Jul 13.

Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

Nurses are the largest single occupation of health care providers and at greatest risk for exposure to and acquisition of Coronavirus Disease 2019 (COVID-19). In December 2020, nurses in Hawaii were recruited for an online survey that measured perceived risk/threat of COVID-19, vaccine attitudes, and perceived safety of COVID-19 vaccines, as well as level of intention: primary, secondary (i.e., delayed), or no intention to vaccinate. The final sample consisted of 423 nurses. Participants were primarily Asian (27.9%) and White (45.2%). The majority were 18-50 years (65.5%) and female (87.0%), held an RN license (91.7%), and identified as a staff nurse (57.7%) in the hospital setting (56.7%). Among participants, 52.3% indicated primary intention, 27.9% secondary intention, and 19.9% no intention to vaccinate. The strongest predictors of any level of intention were greater positive attitudes toward COVID-19 vaccination and lower concerns related to COVID-19 vaccine safety. Findings can guide interventions to support vaccine acceptance for those who initially decline vaccination.
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http://dx.doi.org/10.1080/21645515.2021.1947097DOI Listing
July 2021

A qualitative study exploring the relationship between mothers' vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months.

Hum Vaccin Immunother 2021 Jun 30:1-10. Epub 2021 Jun 30.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.

Vaccine hesitancy is a top ten global health threat that can negatively impact COVID-19 vaccine uptake. It is assumed that vaccine refusers hold deep, negative beliefs, while acceptors hold strong, positive beliefs. However, vaccine hesitancy exists along a continuum and is multidimensional, varying by time, place, vaccine, subgroup, and person. Guided by the Health Belief Model and vaccine hesitancy frameworks, the study purpose was to qualitatively explore maternal COVID-19 threat perceptions and willingness to accept a COVID-19 vaccine in light of their expressed vaccine hesitancy toward past school required and routinely recommended vaccines and the HPV vaccine for their children. Researchers conducted twenty-five interviews with US Midwestern mothers during the early COVID-19 pandemic months. Mothers were grouped by vaccine hesitancy categories and thematic analysis was used to analyze the data within and across categories. Results showed that prior vaccine hesitancy attitudes and behavior did not fully capture maternal acceptance of COVID-19 vaccine or perception of COVID-19 threat. Perceptions of COVID-19 threat did influence mothers' decisions about COVID-19 protective behaviors (e.g., handwashing, mask wearing, and distancing). However, mothers were hesitant to accept the COVID-19 vaccine across vaccine hesitancy categories, primarily citing concerns about safety, efficacy, and confusion over conflicting information as barriers to immediate COVID-19 vaccine acceptance. Findings indicate that mothers cannot be grouped together based on hesitancy about, or acceptance of, other vaccines for purposes of assuming COVID-19 preventive behavior adherence or anticipated COVID-19 vaccine acceptance.
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http://dx.doi.org/10.1080/21645515.2021.1942713DOI Listing
June 2021

Efficacy of tailored messages to improve behavioral intent to accept HPV vaccination among mothers may be moderated by sociodemographics.

Prev Med Rep 2021 Sep 29;23:101413. Epub 2021 May 29.

Department of Family & Community Health, University of Pennsylvania School of Nursing, Division of Adolescent Medicine, Perelman School of Medicine, 418 Curie Boulevard, Office 401, Philadelphia, PA 19104, USA.

We assessed differences in response to a tailored recommendation intervention for HPV vaccine by participants' sociodemographic characteristics in this exploratory sub-analysis of a larger web-based, randomized-controlled trial on tailored messaging among mothers with low intent to vaccinate their 11-14-year-old child against HPV. The intervention consisted of pre-recorded video messages tailored to 1-5 common concerns about HPV vaccine. In these exploratory analyses, we used generalized linear models to assess differences in post-intervention intent across intervention arms, stratified by sociodemographic characteristics among 496 trial participants. We found significantly higher post-intervention intent in the intervention participants versus the control group among mothers: 1) with younger children; 2) with white vs. black children; 3) with Non-Hispanic children; 4) who were younger; 5) with some college or vocational training; with household incomes of ≥$100,000; and 7) with 1-2 children. Our findings of effect modification by certain sociodemographic factors such as age, race/ethnicity, and household income should be considered when designing similar tailored messaging interventions.
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http://dx.doi.org/10.1016/j.pmedr.2021.101413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192722PMC
September 2021

School-based HPV vaccination positively impacts parents' attitudes toward adolescent vaccination.

Vaccine 2021 Jul 12;39(30):4190-4198. Epub 2021 Jun 12.

Speciality of Child and Adolescent Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia.

Introduction: This qualitative study aimed to explore parental attitudes, knowledge and decision-making about HPV vaccination for adolescents in the context of a gender-neutral school-based Australian National Immunisation Program (NIP).

Methods: Semi-structured interviews with parents of adolescents eligible for HPV vaccination were undertaken as part of an evaluation of a cluster-randomised controlled trial of a complex intervention in 40 schools (2013-2015). In this qualitative study, we purposively recruited a nested sample of parents from 11 schools across two Australian jurisdictions. Interviews explored parent knowledge and understanding of the HPV vaccine program; HPV vaccination decision-making; their adolescent's knowledge about HPV vaccination; and their adolescent's understanding about HPV vaccination, sexual awareness and behaviour. Transcripts were analysed using inductive and deductive thematic analysis.

Results: Parents' of 22 adolescents had positive attitudes towards the program; the school-based delivery platform was the key driver shaping acceptance of and decision-making about HPV vaccination. They had difficulty recalling, or did not read, HPV vaccination information sent home. Some adolescents were involved in discussions about vaccination, with parents' responsible for ultimate vaccine decision-making. All parents supported in-school education for adolescents about HPV and HPV vaccination. Parents' knowledge about HPV vaccination was limited to cervical cancer and was largely absent regarding vaccination in males.

Conclusions: Parents' positive attitudes towards the NIP and inclusion of the HPV vaccine is central to their vaccine decision-making and acceptance. More intensive communication strategies including school education opportunities are required to improve parents' knowledge of HPV-related disease and to promote vaccine decision-making with adolescents.
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http://dx.doi.org/10.1016/j.vaccine.2021.05.051DOI Listing
July 2021

Corrigendum to: Human Challenge Studies Are Unlikely to Accelerate Coronavirus Vaccine Licensure due to Ethical and Practical Issues.

J Infect Dis 2021 May;223(10):1837

Department of Biostatistics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, USA.

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http://dx.doi.org/10.1093/infdis/jiab109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8083306PMC
May 2021

Influenza vaccination in the time of COVID-19: A national U.S. survey of adults.

Vaccine 2021 04 4;39(14):1921-1928. Epub 2021 Mar 4.

Indiana University School of Medicine, Department of Pediatrics, 410 W. 10th Street. Ste 1001, Indianapolis, IN 46202, USA. Electronic address:

Introduction: Decisions about influenza vaccination for fall-winter 2020 were made against the backdrop of the COVID-19 pandemic. During May 2020, the authors examined intended vaccination in the next 12 months in relationship to demographic variables, healthcare attitudes, and personal COVID-19 experiences for two samples of adults--those who did not receive influenza vaccine during the prior 12 months, and those who did.

Methods: In May 2020, a cross-sectional online survey was conducted with a national US sample. Participants reported prior influenza vaccination (yes/no during prior 12 months) and anticipated vaccination (yes/no during next 12 months). Covariates included demographic characteristics (e.g., gender, race-ethnicity, political ideology), general beliefs (e.g., benefits of vaccines, altruistic attitudes), and COVID-19 health beliefs and experiences (COVID-19 worry and severity, perception of COVID-19 as a community threat, knowing someone with COVID-19). For each group, hierarchical multivariable logistic regression was conducted with intent to vaccinate as the outcome.

Results: Among participants (n = 3502), 47% did not receive influenza vaccine in the prior 12 months and 53% had; 25.5% of non-vaccinators and 91.9% of vaccinators intended future vaccination. For non-vaccinators, odds of intending vaccination was associated with race/ethnicity (Hispanics were more likely to intend than white-NH; AOR = 1.74; 95% CI = 1.23-2.4), greater perceived benefits of vaccination (AOR = 2.19; 95% CI = 1.88-2.54), and perception of COVID-19 as a community threat (AOR = 1.91; 95% CI = 1.49-2.45). For vaccinators, odds of intending vaccination was associated with age (AOR = 1.04; 95% CI = 1.03-1.05), race/ethnicity (Black-NH and Other-NH were less likely to intend than white-NH, AOR = 0.60; 95% CI = 0.36-0.999; and AOR = 0.45; 95% CI = 0.24-0.84, respectively), greater perceived benefits of vaccination (AOR = 1.88; 95% CI = 1.45-2.45) and greater perception of collective benefits of vaccines (AOR = 1.48; 95% CI = 1.15-1.90).

Conclusions: The COVID-19 pandemic may have served as a cue to action for influenza vaccination intention among some prior non-vaccinators whereas intention among prior vaccinators is more related to positive attitudes toward vaccination.
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http://dx.doi.org/10.1016/j.vaccine.2021.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931729PMC
April 2021

A validated modification of the vaccine hesitancy scale for childhood, influenza and HPV vaccines.

Vaccine 2021 03 4;39(13):1831-1839. Epub 2021 Mar 4.

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, United States; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States. Electronic address:

Introduction: Vaccine hesitancy contributes to outbreaks of preventable disease worldwide. The Vaccine Hesitancy Scale (VHS), developed by the international WHO SAGE Working Group, has been validated previously for measuring hesitancy towards childhood vaccines; some psychometric properties were suboptimal.

Methods: We collected data using large, nationally-representative samples of parents in the U.S. We adapted the VHS items, and additional hesitancy items, to assess hesitancy towards influenza and HPV vaccines in addition to routine childhood vaccines. We then used exploratory and confirmatory factor analysis to identify latent constructs and create modified scales for childhood (VHS-child), influenza (VHS-flu) and HPV (VHS-HPV) vaccines with improved psychometric properties. Finally, we compared hesitancy scores on the VHS-child, VHS-flu, and VHS-HPV, to self-reported receipt of each vaccine category, and compared subscale scores to assess whether drivers of hesitancy differed by vaccine category.

Results: 2052 parents of children <18 years old completed the VHS-child and VHS-flu while 2020 parents of adolescents completed the VHS-HPV. A two-factor structure of 'risks' and a 'lack of confidence' was found for each vaccine category. Slight modifications to the VHS improved psychometric properties. Hesitancy was strongly associated with vaccine receipt: e.g., 76% of parents not hesitant towards influenza vaccine had vaccinated their child the past season, versus 9% of hesitant parents (p < 0.0001). Subscale scores also differed significantly between vaccines: lack of confidence was greater towards influenza (Median (IQR): 2.0 (1.2, 3.3)) and HPV (2.0 (1.3, 3.0)) vaccines than childhood (1.2 (1.0, 1.8), p < 0.0001 for both) vaccines; perceived risks of HPV vaccines (2.7 (1.7, 3.7)) were greater than for childhood vaccines (2.0 (1.3, 3.0), p < 0.0001).

Conclusions: Our modified VHS scales perform well psychometrically and allow for consistent measurement of the extent and reasons for hesitancy between vaccine categories. We suggest that future work use these scales to examine hesitancy towards other vaccines and to monitor hesitancy over time.
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http://dx.doi.org/10.1016/j.vaccine.2021.02.039DOI Listing
March 2021

Qualitative Study on the Acceptability of and Adherence to a Vaginal Ring for HIV Prophylaxis Among Adolescent Girls.

J Acquir Immune Defic Syndr 2021 Jul;87(3):944-950

Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA.

Objective: This study aims to assess the product-related, relationship-related, and sex-related factors that act as facilitators and barriers to the acceptability of a vaginal ring (VR) for HIV prevention among adolescent girls.

Design: Qualitative study.

Methods: Ninety-six girls aged 15-17 years from 6 urban US sites were enrolled in MTN-023/IPM 030, a 24-week randomized controlled trial, for assessing the safety and acceptability of a dapivirine VR for HIV prevention. At week 24, 21 girls were randomly selected to participate in in-depth interviews. Interviews were transcribed verbatim and data analyzed using a thematic analysis approach. Facilitators and barriers to VR acceptability related to participants' relationships, sexual activity, and characteristics of the VR product were identified.

Results: Factors related to relationships rarely seemed to act as barriers to VR acceptability; most participants disclosed VR use to sexual partners, and positive reactions from sexual partners, which were common, seemed to facilitate VR acceptability. Emotional and/or physical discomfort surrounding VR use during sex was mentioned occasionally as a barrier to VR acceptability. Product characteristics were most frequently mentioned as barriers to VR acceptability. Many participants reported concerns about the large size of the VR on first impression. Although most found the VR comfortable, some reported pain with VR insertion. Several participants were concerned about VR cleanliness, particularly during menstruation.

Conclusion: Product considerations, specifically size and use during menstruation, were the most commonly reported barriers to VR acceptability in this study. Adolescent girls may require additional counseling to assuage product concerns regarding a VR for HIV prevention.
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http://dx.doi.org/10.1097/QAI.0000000000002674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192420PMC
July 2021

Young Adults' COVID-19 Testing Intentions: The Role of Health Beliefs and Anticipated Regret.

J Adolesc Health 2021 03;68(3):460-463

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.

Purpose: Young adults are at high risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and transmission due to their social behaviors. The purpose of this study was to determine their attitudes toward coronavirus disease 2019 (COVID-19) testing, an important approach for minimizing infection and transmission.

Methods: One hundred seventy eight US individuals aged 19-25 years completed an online survey measuring COVID-19 health beliefs and testing intentions. Multivariable logistic regression evaluated the association of heath belief measures (perceived COVID-19 susceptibility, COVID-19 severity, barriers and benefits to testing, and social concerns) with testing intentions.

Results: Most respondents (86.0%) intended to accept a COVID-19 test if recommended by a health professional. High social concern and low perceived obstacles were associated with intent to get tested.

Conclusions: In this sample, most young adults intended to accept COVID-19 testing. Health beliefs predicted testing intention and point to possible intervention approaches to increase willingness to accept COVID-19 testing.
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http://dx.doi.org/10.1016/j.jadohealth.2020.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887449PMC
March 2021

Human Challenge Studies With Wild-Type Severe Acute Respiratory Sydrome Coronavirus 2 Violate Longstanding Codes of Human Subjects Research.

Open Forum Infect Dis 2021 Jan 28;8(1):ofaa615. Epub 2020 Dec 28.

Department of Pediatrics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, USA.

This manuscript explores the ethics of human inoculation experiments in young healthy adults with wild-type severe acute respiratory sydrome coronavirus 2 (SARS-CoV-2) as a tool to evaluate vaccine efficacy in the context of the Nuremberg Code, the Declaration of Helsinki, and the Belmont Report, and in the context of dose-response relationships with infectious agents. Despite societal pressure to develop a SARS-CoV-2 challenge model to evaluate vaccines, we argue that there are substantial risks that cannot be adequately defined because the dose of SARS-CoV-2 that causes severe disease in young adults is unknown. In the absence of curative therapy, even if a volunteer consents, longstanding ethical codes governing human subjects research preclude the conduct of such experiments.
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http://dx.doi.org/10.1093/ofid/ofaa615DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798584PMC
January 2021

Adolescent Consent for Human Papillomavirus Vaccine: Ethical, Legal, and Practical Considerations.

J Pediatr 2021 04 20;231:24-30. Epub 2021 Jan 20.

Center for Adolescent Health & the Law, Chapel Hill, NC.

We address ethical, legal, and practical issues related to adolescent self-consent for human papillomavirus (HPV) vaccination. HPV vaccination coverage continues to lag well behind the national goal of 80% series completion. Structural and behavioral interventions have improved vaccination rates, but attitudinal, behavioral, and access barriers remain. A potential approach for increasing access and improving vaccination coverage would be to permit adolescents to consent to HPV vaccination for themselves. We argue that adolescent self-consent is ethical, but that there are legal hurdles to be overcome in many states. In jurisdictions where self-consent is legal, there can still be barriers due to lack of awareness of the policy among healthcare providers and adolescents. Other barriers to implementation of self-consent include resistance from antivaccine and parent rights activists, reluctance of providers to agree to vaccinate even when self-consent is legally supported, and threats to confidentiality. Confidentiality can be undermined when an adolescent's self-consented HPV vaccination appears in an explanation of benefits communication sent to a parent or if a parent accesses an adolescent's vaccination record via state immunization information systems. In the context of the COVID-19 pandemic, which has led to a substantial drop in HPV vaccination, there may be even more reason to consider self-consent. The atmosphere of uncertainty and distrust surrounding future COVID-19 vaccines underscores the need for any vaccine policy change to be pursued with clear communication and consistent with ethical principles.
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http://dx.doi.org/10.1016/j.jpeds.2021.01.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005441PMC
April 2021

Measuring research mistrust in adolescents and adults: Validity and reliability of an adapted version of the Group-Based Medical Mistrust Scale.

PLoS One 2021 22;16(1):e0245783. Epub 2021 Jan 22.

Department of Pediatrics, Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.

Mistrust of health care providers among persons of color is a significant barrier to engaging them in research studies. Underrepresentation of persons of color is particularly problematic when the health problem under study disproportionately affects minoritized communities. The purpose of this study was to test the validity and reliability of an abbreviated and adapted version of the Group Based Medical Mistrust Scale. The GBMMS is a 12-item scale with three subscales that assess suspicion, experiences of discrimination, and lack of support in the health care setting. To adapt for use in the research setting, we shortened the scale to six items, and replaced "health care workers" and "health care" with "medical researchers" and "medical research," respectively. Using panelists from a market research firm, we recruited and enrolled a racially and ethnically diverse sample of American adults (N = 365) and adolescents aged 14-17 (N = 250). We administered the adapted scale in a web-based survey. We used Cronbach's alpha to evaluate measure internal reliability of the scale and external factor analysis to evaluate the relationships between the revised scale items. Five of the six items loaded onto a single factor, with (α = 0.917) for adolescents and (α = 0.912) for adults. Mean scores for each item ranged from 2.5-2.9, and the mean summary score (range 6-25) was 13.3 for adults and 13.1 for adolescents. Among adults, Black respondents had significantly higher mean summary scores compared to whites and those in other racia/ethnic groups (p<0.001). There was a trend toward significance for Black adolescents as compared to white respondents and those in other racial/ethnic groups (p = 0.09). This five-item modified version of the GBMMS is reliable and valid for measuring research mistrust with American adults and adolescents of diverse racial and ethnic identities.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245783PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7822238PMC
June 2021

The role of disclosure & perceptions about providers in health discussions among gay and bisexual young men.

Patient Educ Couns 2021 07 6;104(7):1712-1718. Epub 2021 Jan 6.

Department of Biobehavioral Health, The Pennsylvania State University, University Park, USA. Electronic address:

Objectives: Gay and bisexual men may feel discomfort discussing sensitive topics such as sexual behaviors and substance use with their health providers, which may prevent them from receiving important health information. This study investigates whether patients' perceptions of their provider's sexual orientation predicts patient-provider discussions of sexual and general health topics, and whether this relationship is moderated by patients' disclosure of sexual orientation to providers.

Methods: Data were collected online from a sample of 576 gay and bisexual men living in the USA, aged 18-26. Adjusted risk ratios were estimated by using modified Poisson regression with robust error variance.

Results: Participants who believed their providers were gay or bisexual were more likely to have discussed sexual health topics, but not general health topics; simple slopes analyses revealed that this effect was stronger among those who had not disclosed to their providers. Disclosure was also consistently associated with increased likelihood of discussing almost all topics.

Conclusions: Findings highlight differences in communication based on disclosure and perceived sexual orientation of provider, suggesting the need to further explore how these differences influence young gay and bisexual men's health.

Practice Implications: Dyads may be more likely to discuss sexual health topics when patients believe their providers are sexual minorities themselves. In addition, patient-provider dyads may be likelier to discuss various health topics when providers are aware of patients' sexual minority statuses.
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http://dx.doi.org/10.1016/j.pec.2020.12.032DOI Listing
July 2021

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination.

J Womens Health (Larchmt) 2021 Jan 11. Epub 2021 Jan 11.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). The sample ( = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively ( < 0.01). Participants reported lower benefits ( = 0.007) and higher barriers ( < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high ( = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.
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http://dx.doi.org/10.1089/jwh.2020.8727DOI Listing
January 2021

School-entry requirements for HPV vaccination: part of the patchwork for HPV-related cancer prevention.

Hum Vaccin Immunother 2021 07 17;17(7):1975-1979. Epub 2020 Dec 17.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.

Human papillomavirus (HPV) vaccination can prevent six types of HPV-related cancers, and approximately, 54.2% of adolescents are up-to-date with the HPV vaccine in the United States. While moderate success has been achieved with provider- and parent-focused interventions, HPV vaccination in the U.S. lags well behind desired goals. In order to maximize HPV vaccination and prevention of HPV-related cancers, it may be prudent to consider state policy approaches, such as school-entry requirements as part of the patchwork of provider, parent, and structural interventions. In this paper, we reviewed the history of efforts to implement school-entry requirements for HPV vaccine, the challenges and benefits associated with implementing these requirements, and the evidence for the effectiveness of school-entry requirements. In addition, we presented new data from Rhode Island's Immunization Information System (IIS) showing how their school-entry requirement, implemented in 2015, has impacted HPV vaccination rates. These registry data indicate that HPV vaccination rates improved significantly after the 2014-2015 school year and policy implementation, and add to the ongoing evidence supporting the value of school-entry requirements for HPV vaccination. School-entry requirements should be considered alongside other initiatives and policies for promoting HPV vaccine uptake. Taking a comprehensive systems approach to HPV vaccination is needed.
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http://dx.doi.org/10.1080/21645515.2020.1851130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8189085PMC
July 2021

"We fear the unknown": Emergence, route and transfer of hesitancy and misinformation among HPV vaccine accepting mothers.

Prev Med Rep 2020 Dec 5;20:101240. Epub 2020 Nov 5.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA.

Although licensed since 2006, US HPV vaccination rates remain suboptimal. Since mothers are decision-makers for young adults' vaccination, assessing ongoing knowledge deficits and misunderstanding among parents is important for determining the content and mode of interventions to reach parents. Guided by the social-ecological model and health belief model, 30 interviews with vaccine accepting mothers in the U.S. Midwest were conducted from January through June 2020. Researchers examined ecological determinants of acceptance, perceptions of vaccination barriers, and perceived cues to action for empowering other mothers to vaccinate their children. Data were analyzed using thematic analysis. Results found vaccine accepting mothers exhibited ongoing misconceptions and negative attitudes toward HPV vaccine. Physicians, peers and the media were identified as primary pro-HPV vaccine sources, yet hesitancy and misinformation occurred with each source. Trust in provider recommendation was the primary source for decision-making, yet trust was still lacking. While mothers looked to the media for HPV information, the media were identified as the main source of confusion and distrust. Results show that parents who accept the HPV vaccine can still be hesitant. Thus, mothers who have vaccinated their children for HPV may still need attitudinal and educational training prior to establishing them as role models in interventions for empowering other parents to vaccinate their children. Results showing that the media sow confusion and hesitancy also call for more attention to social media policies to guard against misinformation about the HPV vaccine.
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http://dx.doi.org/10.1016/j.pmedr.2020.101240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689543PMC
December 2020

The role of the media on maternal confidence in provider HPV recommendation.

BMC Public Health 2020 Nov 23;20(1):1765. Epub 2020 Nov 23.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA.

Background: Despite a growing understanding of the importance of provider HPV recommendation on parental acceptance, U.S. HPV vaccination rates remain suboptimal. Given the prevalence and use of the media for health decisions, this study examined the relationship between the media and provider HPV recommendation on maternal HPV vaccine hesitancy.

Methods: Thirty individual interviews with HPV vaccine-accepting mothers in the Midwest U.S. were conducted to examine their feelings of hesitancy around the decision to accept HPV vaccination at the time of provider recommendation and their suggestions for improving the recommendation experience by addressing media concerns.

Results: Media exposure was an antecedent to hesitancy for three main vaccination concerns: safety, protection/efficacy and sexual stigma. Although mothers accepted vaccination, they continued to feel confused and hesitant about HPV vaccination. They had several recommendations for how providers could combat hesitancy to improve confidence in HPV vaccine acceptance.

Conclusions: Providers' approach to HPV vaccination recommendation must consider concerns reported in the media with delivery techniques modified to adjust to maternal fears absorbed from adverse media information.
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http://dx.doi.org/10.1186/s12889-020-09877-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684709PMC
November 2020

Coronavirus Disease 2019 and Vaccination of Children and Adolescents: Prospects and Challenges.

J Pediatr 2021 04 5;231:254-258. Epub 2020 Nov 5.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.

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http://dx.doi.org/10.1016/j.jpeds.2020.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644179PMC
April 2021

Perceived social support and compliance with stay-at-home orders during the COVID-19 outbreak: evidence from Iran.

BMC Public Health 2020 Nov 4;20(1):1650. Epub 2020 Nov 4.

Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

Background: Strong evidence demonstrates that social support plays a key role in facilitating preventive health behaviors. The aim of the current study was to assess the effects of perceived social support on compliance with stay-at-home orders in response to a COVID-19 outbreak during the Persian New Year (Nowruz) holydays, since Nowruz holidays of 2020 coincided with the peak of the coronavirus epidemic in Iran.

Methods: This cross-sectional survey was carried out based on phone interviews of 1073 adults aged over 18 years from 4 to 12 April 2020 in Mashhad, Khorasan-Razavi Province, as the second largest city of Iran. A systematic random sampling was carried out using fixed phone number lists provided by Telecommunication Company of Khorasan-Razavi Province. Phone interviews were carried out by trained interviewers from the Iranian Students Polling Agency (ISPA) at various times of the day. The survey included sociodemographic questions, perceived social support scale (MSPSS) and questions about self-isolation during the Nowruz holiday. Statistical analysis included Chi-square test, Mann-Whitney test and multivariate logistic regression.

Results: 20.5% of participants reported poor compliance with stay at home orders during the first 2 weeks of Nowruz. Clear social gradients were not found in stay-at-home compliance. When controlling socio-demographic factors, perceived social support, interestingly, both fostered and hindered people's compliance with stay at home orders, depending on the source of support from family members (OR = .874, 95% CI = .803, .950, p < .005), friends (OR = 1.147, 95% CI = 1.076, 1.222, p < .001) and a significant other person (OR = .926, 95% CI = .849, 1.010, p = .084).

Conclusions: Public health messaging may need to emphasize the role that friends and families can play in helping to protect those in their friendship/family groups by promoting compliance with social distancing. Further in-depth studies are recommended to evaluate how this kind of messaging can most effectively encourage people to engage in social distancing practices.
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http://dx.doi.org/10.1186/s12889-020-09759-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609821PMC
November 2020

Public perceptions of the effectiveness of recommended non-pharmaceutical intervention behaviors to mitigate the spread of SARS-CoV-2.

PLoS One 2020 4;15(11):e0241662. Epub 2020 Nov 4.

Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, United States of America.

Background: The COVID-19 pandemic is an unprecedented public health threat, both in scope and response. With no vaccine available, the public is advised to practice non-pharmaceutical interventions (NPI) including social distancing, mask-wearing, and washing hands. However, little is known about public perceptions of the effectiveness of these measures, and high perceived effectiveness is likely to be critical in order to achieve widespread adoption of NPI.

Methods: In May 2020, we conducted a cross-sectional survey among U.S. adults (N = 3,474). The primary outcome was a six-item measure assessing perceived effectiveness of recommended behaviors to prevent SARS-CoV-2 infection from 1 (not at all effective) to 5 (extremely effective). The sample was divided into "higher" and "lower" perceived effectiveness groups. Covariates included demographics, healthcare characteristics, and health beliefs. Variables that were significant at p<0.01 in bivariate analyses were entered into a multivariable logistic regression and a best-fit model was created using a cutoff of p<0.01 to stay in the model.

Results: Mean age was 45.5 years and most participants were non-Hispanic White (63%) and female (52.4%). The high perceived effectiveness group was slightly larger than the low perceived effectiveness group (52.7% vs. 47.3%). Almost all health belief variables were significant in the best-fit regression model. COVID-19-related worry (aOR = 1.82; 95% CI = 1.64-2.02), and perceived threat to physical health (aOR = 1.32; 95% CI = 1.20-1.45) were positively associated with perceived effectiveness while perceived severity of COVID-19 (0.84; 95% CI = 0.73-0.96) and perceived likelihood of infection (0.85; 95% CI = 0.77-0.94) switched directions in the adjusted model and were negatively associated with perceived effectiveness.

Conclusions: This research indicates people generally believe NPI are effective, but there was variability based on health beliefs and there are mixed rates of engagement in these behaviors. Public health efforts should focus on increasing perceived severity and threat of SARS-CoV-2-related disease, while promoting NPI as effective in reducing threat.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241662PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641367PMC
November 2020

Mobile App Strategy to Facilitate Human Papillomavirus Vaccination Among Young Men Who Have Sex With Men: Pilot Intervention Study.

J Med Internet Res 2020 11 4;22(11):e22878. Epub 2020 Nov 4.

Division of Adolescent Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States.

Background: Mobile app-based interventions have been identified as potential facilitators for vaccination among young men who have sex with men (MSM).

Objective: This pilot study aimed to test the feasibility of a theoretically informed mobile health (mHealth) tool designed to reduce health disparities and facilitate human papillomavirus (HPV) vaccination among a sample of young MSM.

Methods: The development of the mHealth tool was guided by previous research, implementation intention theory, and design thinking. We recruited MSM aged 18-26 years through a popular online dating app and linked participants to our mHealth tool, which provided HPV vaccine information and fostered access to care.

Results: A total of 42 young MSM participated in this pilot study in Boston, Massachusetts. Participants reported variable HPV knowledge (ie, high knowledge of HPV risk factors and low knowledge of HPV-related cancer risks for men) and positive vaccine beliefs and attitudes. Of those who were either unvaccinated, not up to date, or did not report vaccine status, 23% (8/35) utilized the mHealth tool to obtain HPV vaccination. Participants primarily utilized the tool's (1) educational components and (2) capabilities facilitating concrete vaccine action plans.

Conclusions: We recruited an underserved at-risk population of youth via an online dating app for our mHealth intervention that resulted in in-person health care delivery. This study was limited by enrollment challenges, including low willingness to download the mHealth tool to mobile devices.
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http://dx.doi.org/10.2196/22878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673982PMC
November 2020

The association between maternal human papillomavirus (HPV) experiences and HPV vaccination of their children.

Hum Vaccin Immunother 2021 04 7;17(4):1000-1005. Epub 2020 Oct 7.

Department of Pediatrics-Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

HPV vaccination prevents most HPV-related cancers yet vaccination rates remain low. In this cross-sectional study, we examined the association between maternal HPV experiences and HPV vaccination uptake among children and whether this association may be explained by perceived benefits of vaccination. We used logistic regression models to estimate the effect of (1) maternal history of abnormal Pap smear, (2), family/friend history of cervical cancer, and (3) maternal history of cervical cancer on HPV vaccination uptake among children. Separate mediation analyses were conducted to determine if perceived benefits mediated the relationship between each maternal HPV experience and HPV vaccination uptake. History of abnormal Pap smear (OR = 1.50, 95% CI = 1.15, 1.97), family history of cervical cancer (OR = 1.72, CI = 1.26, 2.35), and personal history of cervical cancer (OR = 3.00, CI = 1.82, 4.95) predicted HPV vaccination of children. Perceived benefits mediated the relationship between history of abnormal Pap smear (indirect effect =.146, SE =.069, 95% CI =.014, .289), family history of cervical cancer (indirect effect =.228, SE =.079, CI =.080, .387), and personal history of cervical cancer (indirect effect =.298, SE =.116, CI =.082, .533) on HPV vaccination. Our results suggest that personal experiences with HPV-related disease may influence maternal HPV vaccine decision-making.
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http://dx.doi.org/10.1080/21645515.2020.1817714DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8018340PMC
April 2021

Psychometric Testing of Papanicolaou Testing Barriers and Self-efficacy Scales Among Black Women.

Cancer Nurs 2020 Sep 22. Epub 2020 Sep 22.

Author Affiliations: Indiana University School of Nursing, Indianapolis (Mrs Biederman and Dr Champion); and Department of Pediatrics-Adolescent Medicine, Indiana University School of Medicine, Indianapolis (Dr Zimet).

Background: Black women face cervical cancer disparities with higher rates of morbidity and mortality compared with White women. Identifying predictors of Papanicolaou (Pap) testing is a first step to decrease morbidity and mortality from cervical cancer, with barriers and self-efficacy being constructs that should be related to Pap testing adherence. Although barriers and self-efficacy scales have been developed, they have not been validated in Black women for Pap testing.

Objective: The purpose of this study was to modify and psychometrically test barriers and self-efficacy to Pap testing in a Black population.

Intervention/methods: Data were collected from a minority health fair. Internal consistency reliability testing was conducted using item analysis and Cronbach's α. Construct validity was assessed by exploratory factor analysis and logistic regression. Papanicolaou testing adherence was regressed on each scale (barriers and self-efficacy) while controlling for antecedents.

Results: Data demonstrated 2 reliable scales: (1) barriers (Cronbach's α = .79), item-total correlation = 0.479 to 0.628; and (2) self-efficacy (Cronbach's α = .85), item-total correlation = 0.560 to 0.697. Exploratory factor analysis supported 2 unidimensional scales. The regression models supported a relationship between each scale and Pap testing adherence.

Conclusions: The data suggested barriers and self-efficacy scales were reliable and valid among Black women. Barriers and self-efficacy could be tailored in future interventions to increase Pap testing adherence.

Implications For Practice: Nurses could use responses to these scales for framing discussions about Pap testing.
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http://dx.doi.org/10.1097/NCC.0000000000000879DOI Listing
September 2020

County-level correlates of missed opportunities for HPV vaccination in Indiana: An environmental scan.

Vaccine 2020 10 3;38(43):6730-6734. Epub 2020 Sep 3.

Indiana University School of Medicine, Department of Pediatrics-Adolescent Medicine, 410 W, 100th Street, Ste 100, Indianapolis, IN 46202, USA. Electronic address:

Background: The goal of this study was to examine variability across the 92 Indiana counties in missed opportunities for HPV vaccination and to assess county-level correlates of missed opportunities.

Methods: The Indiana immunization registry provided county level data on 2017 missed opportunity rates for adolescents ages 11-18. A missed opportunity was an encounter when a patient eligible for HPV vaccination received one or more other recommended vaccines, but not HPV. Potential county-level correlates of missed opportunities included race, income, population density, education, primary care providers per capita, smoking rates, mammography screening, diabetes monitoring, and Pap testing.

Results: The missed opportunity rate ranged from 31% to 85% across Indiana counties. Higher population density, mammography screening, income inequality, and diabetes monitoring were associated with fewer missed opportunities.

Conclusions: We found wide variability in missed opportunities across counties, which were associated with population density and county-level participation in other health-related behaviors.

Sources Of Support: This study was supported by the National Cancer Institute under Award Number P30 CA082709-18S4.
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http://dx.doi.org/10.1016/j.vaccine.2020.08.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774590PMC
October 2020

Human Challenge Studies Are Unlikely to Accelerate Coronavirus Vaccine Licensure Due to Ethical and Practical Issues.

J Infect Dis 2020 10;222(9):1572-1574

Department of Biostatistics, Indiana University School of Medicine, Indiana University, Indianapolis, Indiana, USA.

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http://dx.doi.org/10.1093/infdis/jiaa457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499586PMC
October 2020

Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US.

Vaccine 2020 08 2;38(38):6027-6037. Epub 2020 Aug 2.

Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA. Electronic address:

Background: While many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination.

Methods: In April 2019, we surveyed families with adolescents 11-17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal.

Results: 2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent's health-care provider's recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal.

Conclusions: HPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.
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http://dx.doi.org/10.1016/j.vaccine.2020.06.074DOI Listing
August 2020

Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey.

Pediatrics 2020 07 15;146(1). Epub 2020 Jun 15.

Department of Pediatrics, University of California at Los Angeles Mattel Children's Hospital and University of California at Los Angeles, Los Angeles, California.

Background And Objectives: The World Health Organization has designated vaccine hesitancy as 1 of the 10 leading threats to global health, yet there is limited current national data on prevalence of hesitancy among US parents. Among a nationally representative sample of US parents, we aimed to (1) assess and compare prevalence of hesitancy and factors driving hesitancy for routine childhood and influenza vaccination and (2) examine associations between sociodemographic characteristics and hesitancy for routine childhood or influenza vaccination.

Methods: In February 2019, we surveyed families with children using the largest online panel generating representative US samples. After weighting, we assessed hesitancy using a modified 5-point Vaccine Hesitancy Scale and labeled parents as hesitant if they scored >3.

Results: A total of 2176 of 4445 parents sampled completed the survey (response rate 49%). Hesitancy prevalence was 6.1% for routine childhood and 25.8% for influenza vaccines; 12% strongly and 27% somewhat agreed they had concerns about serious side effects of both routine childhood and influenza vaccines. A total of 70% strongly agreed that routine childhood vaccines are effective versus 26% for influenza vaccine ( < .001). In multivariable models, an educational level lower than a bachelor's degree and household income <400% of the federal poverty level predicted hesitancy about both routine childhood and influenza vaccines.

Conclusions: Almost 1 in 15 US parents are hesitant about routine childhood vaccines, whereas >1 in 4 are hesitant about influenza vaccine. Furthermore, 1 in 8 parents are concerned about vaccine safety for both routine childhood and influenza vaccines, and only 1 in 4 believe influenza vaccine is effective. Vaccine hesitancy, particularly for influenza vaccine, is prevalent in the United States.
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http://dx.doi.org/10.1542/peds.2019-3852DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329256PMC
July 2020

Persistent Disparities in Cervical Cancer Screening Uptake: Knowledge and Sociodemographic Determinants of Papanicolaou and Human Papillomavirus Testing Among Women in the United States.

Public Health Rep 2020 Jul/Aug;135(4):483-491. Epub 2020 Jun 9.

10668 Division of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN, USA.

Objectives: Cervical cancer is the second-most common type of cancer among women aged 15-44, and racial, ethnic, and economic disparities exist in survival rates despite widely available screening tests and early treatment options. The objective of this study was to describe the association among knowledge, sociodemographic characteristics, and cervical cancer screening, with the goal of developing interventions to prevent cervical cancer in populations at risk of the disease.

Methods: In 2017, we conducted a nationwide survey of women in the United States aged ≥18 who had ever received a Papanicolaou (Pap) test (N = 630). We conducted tests and one-way analysis of variance to determine sociodemographic differences (age, education, race, ethnicity, income, type of health insurance) in knowledge about cervical cancer screening (Pap test and human papillomavirus [HPV] test). We used logistic regressions to define significant determinants of cervical cancer screening behaviors in the previous 5 years.

Results: Of 629 respondents, 407 (64.7%) had an annual household income <$30 000, and 322 of 536 (60.1%) respondents had government-provided health insurance. Of 630 women who had ever had a Pap test, 425 (67.5%) had an HPV test. Hispanic and non-Hispanic white women were more likely than Hispanic and non-Hispanic black women (odds ratio [OR] = 2.49; 95% CI, 1.12-4.54; = .02) and women with government-provided health insurance (OR = 1.91; 95% CI, 1.08-3.37; = .03) were more likely than women with private health insurance to have received a Pap test in the previous 5 years. Knowledge of HPV was a significant predictor of having received an HPV test in the previous 5 years (OR = 1.37; 95% CI, 1.22-1.54; < .001).

Conclusion: Disparities in cervical cancer screening among sociodemographic groups of women suggest the need for targeted interventions to improve knowledge about Pap and HPV tests.
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http://dx.doi.org/10.1177/0033354920925094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383763PMC
August 2020
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