Society for Adolescent Health and Medicine (SAHM): Annual Meeting

Car crashes are the leading cause of death among teens, accounting for one-third of deaths in this age group in the United States.

The good news is that the rate of motor vehicle deaths among adolescents has been on the decline over the past decade in most U.S. states. The success of efforts by state and local governments in bringing down traffic deaths, especially among teens, is rated among the top 10 public health achievements of the past decade, according to the Centers for Disease Control and Prevention (MMWR, 2011;60:619-23).

Photo (c) Rich Legg/iStock.com

The CDC analyzed data from the Fatality Analysis Report System to assess crash death risk among teens. The rate for drivers aged 16 or 17 years involved in a fatal car accident declined approximately 38%, from 27.1 per 100,000 population in 2004 to 16.7 in 2008 (MMWR 2010;59:1329-34). The decline as been attributed to a variety of factors including increased use of seat belts and decreased rates of drunk driving among teens, but also changing driver behavior brought about by training and other public health interventions.

Several innovative approaches hold promise for making teens safer drivers, according to Dr. Beth Ebel, director of the Harborview Injury Prevention & Research Center and a physician at Seattle Children’s Hospital, Seattle.

"We know that learning to drive is risky," she commented. Despite the decline in fatal crashes among teens, "this still remains such a high risk for kids that we really need to consider how we can do better."

Research is helping to sort out what works – and what doesn’t – for reducing teen drivers’ risk to themselves and others. For example, "policy and frameworks that work for adults work for kids, and more so with seat belt and alcohol and texting laws," said Dr. Ebel.

Driver education has been found ineffective, Dr. Ebel said. In fact, a 1999 study associated such education with an increased risk of motor vehicle crashes (Am. J. Prev. Med. 1999;16:40-6).

"This isn’t because driver’s ed is teaching you to drive in a risky way," she explained. "Driver’s ed gives you early exposure to a vehicle before your frontal lobe and everything else has fully matured. So it basically gets you in the vehicle at a younger age."

On the other hand, graduated driver licensing (GDL), in which teens’ driving privileges are slowly expanded, has been a success. This legislation has three components – a restriction on passengers in the vehicle, a restriction on nighttime driving, and a zero-tolerance policy for the combination of alcohol and driving – the specifics of which vary by state.

Implementation of GDL has been associated with a 25% reduction in numbers of crashes (JAMA 2001;286:1593-8), "so we should do this," Dr. Ebel recommended. "It gives parents some guidance on what to advise their kids. GDL’s effect isn’t that it really makes you a safer driver; it tends to reduce driving exposure."

It is difficult to enforce because law enforcement officers can’t reliably identify teen drivers by appearance. "So GDL is working primarily through parents and kids knowing what the law is and being willing to implement that," she said. "And that’s of course not always going to work for some of the kids at highest risk."

Parent-teen driving contracts, such as one used in the Checkpoints Program, an education-based intervention, also have shown promise. It’s a chance to sit down with your kids, like in other areas ... and discuss what your expectations are when they are in the vehicle, Dr. Ebel commented at the annual meeting of the Society for Adolescent Health and Medicine in Seattle.

Parents participating in the program put more limits on their teens’ driving privileges, although risky driving and rates of violations and crashes are not reduced (J. Safety Res. 2006;37:9-15). "But I think having that discussion is probably a good starting point," she said.

Additional help in improving the safety of teen drivers may come from several novel technologies. One is event-triggered video, in which a camera installed on the rearview mirror captures data both inside and outside the car if, for example, the driver slams on the brakes or swerves. It is available free through some auto insurance companies.

"[Driving] still remains such a high risk for kids that we really need to consider how we can do better."

"Effectively, the trigger camera is there to basically extend this parent-in-the-vehicle concept when the parent is no longer in the vehicle," Dr. Ebel explained. The data are transmitted to a central server, collated, and e-mailed back to parents and their teens so that they can be used as an educational tool.

Research that she and her colleagues have done has found event-triggered video to be acceptable to teens, eventually. "Kids of course hated it at first, but at the end they saw a lot of value and they learned a lot about how to reduce their [event] scores," she said. And a study looking at quantitative impact has found a 61% reduction in the so-called coachable events when this technology is used (Am. J. Public Health 2010;100:1101-6).

"This is worth thinking about," Dr. Ebel asserted. "But it definitely has implications for privacy, and I think basically from a broader information perspective, who is going to take this up."

A second new technology, an electronics-disabling device, ironically uses cell phone technology to reduce the distraction of mobile devices in the car. This is important given that evidence shows, for example, that texting drivers are 23 times more likely to have a crash or near-crash than are their nondistracted counterparts (Virginia Tech Transportation Institute, July 2009).

"These are basically devices that stop your cell phone and text message service while you are in the car," she explained. "They can tell that you are moving, so it activates at 10 mph. They can send a message to your buddies, so you don’t feel like they are just hanging there."

Additional features include the ability to generate reports about driving parameters such as speed, according to Dr. Ebel. And drivers can still make emergency calls and use navigation systems.

A third technology, being introduced by auto manufacturers, is making it possible to tailor the vehicle environment depending on who’s driving, for example, through development of cars that recognize different keys used by parents and their teens.

The car key that you hand your kid could limit the vehicle speed and the audio volume, as well, she explained, thereby favoring safer driving conditions.

Dr. Ebel said that she had no relevant financial disclosures.

Therese Borden contributed to this article.

Car crashes are the leading cause of death among teens, accounting for one-third of deaths in this age group in the United States.

The good news is that the rate of motor vehicle deaths among adolescents has been on the decline over the past decade in most U.S. states. The success of efforts by state and local governments in bringing down traffic deaths, especially among teens, is rated among the top 10 public health achievements of the past decade, according to the Centers for Disease Control and Prevention (MMWR, 2011;60:619-23).

Photo (c) Rich Legg/iStock.com

The CDC analyzed data from the Fatality Analysis Report System to assess crash death risk among teens. The rate for drivers aged 16 or 17 years involved in a fatal car accident declined approximately 38%, from 27.1 per 100,000 population in 2004 to 16.7 in 2008 (MMWR 2010;59:1329-34). The decline as been attributed to a variety of factors including increased use of seat belts and decreased rates of drunk driving among teens, but also changing driver behavior brought about by training and other public health interventions.

Several innovative approaches hold promise for making teens safer drivers, according to Dr. Beth Ebel, director of the Harborview Injury Prevention & Research Center and a physician at Seattle Children’s Hospital, Seattle.

"We know that learning to drive is risky," she commented. Despite the decline in fatal crashes among teens, "this still remains such a high risk for kids that we really need to consider how we can do better."

Research is helping to sort out what works – and what doesn’t – for reducing teen drivers’ risk to themselves and others. For example, "policy and frameworks that work for adults work for kids, and more so with seat belt and alcohol and texting laws," said Dr. Ebel.

Driver education has been found ineffective, Dr. Ebel said. In fact, a 1999 study associated such education with an increased risk of motor vehicle crashes (Am. J. Prev. Med. 1999;16:40-6).

"This isn’t because driver’s ed is teaching you to drive in a risky way," she explained. "Driver’s ed gives you early exposure to a vehicle before your frontal lobe and everything else has fully matured. So it basically gets you in the vehicle at a younger age."

On the other hand, graduated driver licensing (GDL), in which teens’ driving privileges are slowly expanded, has been a success. This legislation has three components – a restriction on passengers in the vehicle, a restriction on nighttime driving, and a zero-tolerance policy for the combination of alcohol and driving – the specifics of which vary by state.

Implementation of GDL has been associated with a 25% reduction in numbers of crashes (JAMA 2001;286:1593-8), "so we should do this," Dr. Ebel recommended. "It gives parents some guidance on what to advise their kids. GDL’s effect isn’t that it really makes you a safer driver; it tends to reduce driving exposure."

It is difficult to enforce because law enforcement officers can’t reliably identify teen drivers by appearance. "So GDL is working primarily through parents and kids knowing what the law is and being willing to implement that," she said. "And that’s of course not always going to work for some of the kids at highest risk."

Parent-teen driving contracts, such as one used in the Checkpoints Program, an education-based intervention, also have shown promise. It’s a chance to sit down with your kids, like in other areas ... and discuss what your expectations are when they are in the vehicle, Dr. Ebel commented at the annual meeting of the Society for Adolescent Health and Medicine in Seattle.

Parents participating in the program put more limits on their teens’ driving privileges, although risky driving and rates of violations and crashes are not reduced (J. Safety Res. 2006;37:9-15). "But I think having that discussion is probably a good starting point," she said.

Additional help in improving the safety of teen drivers may come from several novel technologies. One is event-triggered video, in which a camera installed on the rearview mirror captures data both inside and outside the car if, for example, the driver slams on the brakes or swerves. It is available free through some auto insurance companies.

"[Driving] still remains such a high risk for kids that we really need to consider how we can do better."

"Effectively, the trigger camera is there to basically extend this parent-in-the-vehicle concept when the parent is no longer in the vehicle," Dr. Ebel explained. The data are transmitted to a central server, collated, and e-mailed back to parents and their teens so that they can be used as an educational tool.

Research that she and her colleagues have done has found event-triggered video to be acceptable to teens, eventually. "Kids of course hated it at first, but at the end they saw a lot of value and they learned a lot about how to reduce their [event] scores," she said. And a study looking at quantitative impact has found a 61% reduction in the so-called coachable events when this technology is used (Am. J. Public Health 2010;100:1101-6).

"This is worth thinking about," Dr. Ebel asserted. "But it definitely has implications for privacy, and I think basically from a broader information perspective, who is going to take this up."

A second new technology, an electronics-disabling device, ironically uses cell phone technology to reduce the distraction of mobile devices in the car. This is important given that evidence shows, for example, that texting drivers are 23 times more likely to have a crash or near-crash than are their nondistracted counterparts (Virginia Tech Transportation Institute, July 2009).

"These are basically devices that stop your cell phone and text message service while you are in the car," she explained. "They can tell that you are moving, so it activates at 10 mph. They can send a message to your buddies, so you don’t feel like they are just hanging there."

Additional features include the ability to generate reports about driving parameters such as speed, according to Dr. Ebel. And drivers can still make emergency calls and use navigation systems.

A third technology, being introduced by auto manufacturers, is making it possible to tailor the vehicle environment depending on who’s driving, for example, through development of cars that recognize different keys used by parents and their teens.

The car key that you hand your kid could limit the vehicle speed and the audio volume, as well, she explained, thereby favoring safer driving conditions.

Dr. Ebel said that she had no relevant financial disclosures.

Therese Borden contributed to this article.

Car crashes are the leading cause of death among teens, accounting for one-third of deaths in this age group in the United States.

The good news is that the rate of motor vehicle deaths among adolescents has been on the decline over the past decade in most U.S. states. The success of efforts by state and local governments in bringing down traffic deaths, especially among teens, is rated among the top 10 public health achievements of the past decade, according to the Centers for Disease Control and Prevention (MMWR, 2011;60:619-23).

Photo (c) Rich Legg/iStock.com

The CDC analyzed data from the Fatality Analysis Report System to assess crash death risk among teens. The rate for drivers aged 16 or 17 years involved in a fatal car accident declined approximately 38%, from 27.1 per 100,000 population in 2004 to 16.7 in 2008 (MMWR 2010;59:1329-34). The decline as been attributed to a variety of factors including increased use of seat belts and decreased rates of drunk driving among teens, but also changing driver behavior brought about by training and other public health interventions.

Several innovative approaches hold promise for making teens safer drivers, according to Dr. Beth Ebel, director of the Harborview Injury Prevention & Research Center and a physician at Seattle Children’s Hospital, Seattle.

"We know that learning to drive is risky," she commented. Despite the decline in fatal crashes among teens, "this still remains such a high risk for kids that we really need to consider how we can do better."

Research is helping to sort out what works – and what doesn’t – for reducing teen drivers’ risk to themselves and others. For example, "policy and frameworks that work for adults work for kids, and more so with seat belt and alcohol and texting laws," said Dr. Ebel.

Driver education has been found ineffective, Dr. Ebel said. In fact, a 1999 study associated such education with an increased risk of motor vehicle crashes (Am. J. Prev. Med. 1999;16:40-6).

"This isn’t because driver’s ed is teaching you to drive in a risky way," she explained. "Driver’s ed gives you early exposure to a vehicle before your frontal lobe and everything else has fully matured. So it basically gets you in the vehicle at a younger age."

On the other hand, graduated driver licensing (GDL), in which teens’ driving privileges are slowly expanded, has been a success. This legislation has three components – a restriction on passengers in the vehicle, a restriction on nighttime driving, and a zero-tolerance policy for the combination of alcohol and driving – the specifics of which vary by state.

Implementation of GDL has been associated with a 25% reduction in numbers of crashes (JAMA 2001;286:1593-8), "so we should do this," Dr. Ebel recommended. "It gives parents some guidance on what to advise their kids. GDL’s effect isn’t that it really makes you a safer driver; it tends to reduce driving exposure."

It is difficult to enforce because law enforcement officers can’t reliably identify teen drivers by appearance. "So GDL is working primarily through parents and kids knowing what the law is and being willing to implement that," she said. "And that’s of course not always going to work for some of the kids at highest risk."

Parent-teen driving contracts, such as one used in the Checkpoints Program, an education-based intervention, also have shown promise. It’s a chance to sit down with your kids, like in other areas ... and discuss what your expectations are when they are in the vehicle, Dr. Ebel commented at the annual meeting of the Society for Adolescent Health and Medicine in Seattle.

Parents participating in the program put more limits on their teens’ driving privileges, although risky driving and rates of violations and crashes are not reduced (J. Safety Res. 2006;37:9-15). "But I think having that discussion is probably a good starting point," she said.

Additional help in improving the safety of teen drivers may come from several novel technologies. One is event-triggered video, in which a camera installed on the rearview mirror captures data both inside and outside the car if, for example, the driver slams on the brakes or swerves. It is available free through some auto insurance companies.

"[Driving] still remains such a high risk for kids that we really need to consider how we can do better."

"Effectively, the trigger camera is there to basically extend this parent-in-the-vehicle concept when the parent is no longer in the vehicle," Dr. Ebel explained. The data are transmitted to a central server, collated, and e-mailed back to parents and their teens so that they can be used as an educational tool.

Research that she and her colleagues have done has found event-triggered video to be acceptable to teens, eventually. "Kids of course hated it at first, but at the end they saw a lot of value and they learned a lot about how to reduce their [event] scores," she said. And a study looking at quantitative impact has found a 61% reduction in the so-called coachable events when this technology is used (Am. J. Public Health 2010;100:1101-6).

"This is worth thinking about," Dr. Ebel asserted. "But it definitely has implications for privacy, and I think basically from a broader information perspective, who is going to take this up."

A second new technology, an electronics-disabling device, ironically uses cell phone technology to reduce the distraction of mobile devices in the car. This is important given that evidence shows, for example, that texting drivers are 23 times more likely to have a crash or near-crash than are their nondistracted counterparts (Virginia Tech Transportation Institute, July 2009).

"These are basically devices that stop your cell phone and text message service while you are in the car," she explained. "They can tell that you are moving, so it activates at 10 mph. They can send a message to your buddies, so you don’t feel like they are just hanging there."

Additional features include the ability to generate reports about driving parameters such as speed, according to Dr. Ebel. And drivers can still make emergency calls and use navigation systems.

A third technology, being introduced by auto manufacturers, is making it possible to tailor the vehicle environment depending on who’s driving, for example, through development of cars that recognize different keys used by parents and their teens.

The car key that you hand your kid could limit the vehicle speed and the audio volume, as well, she explained, thereby favoring safer driving conditions.

Dr. Ebel said that she had no relevant financial disclosures.

Therese Borden contributed to this article.

SEATTLE – Both a high rate of trichomoniasis among sexually active teenage and adult women who seek self-testing and the elevated rate of adverse reproductive health outcomes in infected women raise the question of whether trichomoniasis should be a reportable infection in the United States, Charlotte A. Gaydos said.

Some 10% of the more than 1,500 women who were recruited through the Internet and offered free self-testing, and who then submitted vaginal samples, were positive for this sexually transmitted infection (STI) in an observational study reported at the annual meeting of the Society for Adolescent Health and Medicine. Rates were highest among those aged 25-29 years and among blacks.

These findings, coupled with the adverse health effects of trichomoniasis, may have implications for tracking the infection in the population, according to lead investigator Charlotte A. Gaydos, Dr.P.H., a professor in the division of infectious diseases at Johns Hopkins University in Baltimore.

Trichomoniasis is currently not reportable to the Centers for Disease Control and Prevention, she noted. But study estimates from the CDC suggest that there are 7-8 million new cases every year in the United States.

Infected men and – in particular – women have elevated rates of adverse reproductive health outcomes, including pelvic inflammatory disease, low infant birth weight, and premature delivery. Furthermore, this STI has been increasingly implicated as a risk factor for HIV transmission, she said.

"My question to the proponents of adolescent health and health for women in general is, should we start to do surveillance for Trichomonas [vaginalis] in the United States, so that we can have good data?" Dr. Gaydos asked. "I think more studies are needed."

Additionally, "should we make this a reportable infection in the future?" she inquired, given the many negative outcomes associated with trichomoniasis and the fact that it can be asymptomatic.

The investigators studied women who were recruited through IWantTheKit.org, an educational Internet program on STIs that offers free self-testing to sexually active individuals aged 14 years or older in Denver, Philadelphia, Alaska, Maryland, West Virginia, selected counties in Illinois, and Washington, D.C.

"We know that submission of self-collected samples at home can remove some barriers for adolescents and other women in testing for sexually transmitted diseases," Dr. Gaydos commented. "We have shown in the past that an Internet-recruited population can do this for Chlamydia and gonorrhea."

Starting in mid-2006, the program added testing for trichomoniasis to its existing testing for Chlamydia and gonorrhea. Women ordered the kit online and sent self-collected vaginal samples by U.S. mail to the testing lab. They also completed questionnaires on demographics and risk factors.

The lab tested for trichomoniasis using a nucleic acid amplification test, which has a sensitivity of about 90%, compared with roughly 50% for wet prep and 70% for culture, according to Dr. Gaydos.

The women were instructed to call for their test results in 1-2 weeks, and – should they forget to call – to indicate their preferred method of notification (e-mail, cell phone, letter, or text message).

A total of 1,525 women requested and returned self-collected vaginal swab kits in 2006-2010.

Overall, 10% of women tested positive for trichomoniasis, Dr. Gaydos reported. In addition, 10% tested positive for Chlamydia, 1% tested positive for gonorrhea, and 18% tested positive for at least one of the three infections studied.

By age, the rate of trichomoniasis ranged from 8.3% among those aged 20-24 years to 11.5% among 25- to 29-year-olds. And by race, it ranged from 0% among Asian women to 13.2% among black women.

In a multivariate analysis, women were more likely to have trichomoniasis if they were black compared with white, Asian, or other race/ethnicity (odds ratio, 2.69); did not have health insurance (OR, 1.57); did not have a bachelor’s degree (OR, 5.53); had 2-15, or 16 or more partners in the past year vs. none or a single partner (OR, 1.60 and 3.51); were bisexual (OR, 2.00); did not always use a condom (3.04); or had a partner who had an STI (OR, 1.71).

Age, having had trichomoniasis previously, and having had any STI in the past were not independent risk factors for trichomoniasis, according to Dr. Gaydos.

Participants reported hearing about the program in a variety of ways. "About 30% say that they found it surfing the Internet, and about 28% say they heard about it on the radio, which is how we advertise the presence of the kit in our local areas most of the time," Dr. Gaydos said. Additionally, small proportions reported learning about the program from friends, fliers, and partners.

"Interestingly enough, when we queried the men, a much higher percentage answer on their questionnaire that they were told by their partner," she commented. "So the men are not telling their female partners to get tested, but the females are telling their male partners to get tested."

The study had its limitations, Dr. Gaydos acknowledged. "Obviously, it is biased because it’s selecting people who are empowered to think about their own sexual health. They are interested in finding out if they are infected, and they do report high [levels of] risk factors, which are similar to those that we see in STD clinics," she said.

Dr. Gaydos reported that she has received free diagnostic kits from Gen-Probe Inc.

SEATTLE – Both a high rate of trichomoniasis among sexually active teenage and adult women who seek self-testing and the elevated rate of adverse reproductive health outcomes in infected women raise the question of whether trichomoniasis should be a reportable infection in the United States, Charlotte A. Gaydos said.

Some 10% of the more than 1,500 women who were recruited through the Internet and offered free self-testing, and who then submitted vaginal samples, were positive for this sexually transmitted infection (STI) in an observational study reported at the annual meeting of the Society for Adolescent Health and Medicine. Rates were highest among those aged 25-29 years and among blacks.

These findings, coupled with the adverse health effects of trichomoniasis, may have implications for tracking the infection in the population, according to lead investigator Charlotte A. Gaydos, Dr.P.H., a professor in the division of infectious diseases at Johns Hopkins University in Baltimore.

Trichomoniasis is currently not reportable to the Centers for Disease Control and Prevention, she noted. But study estimates from the CDC suggest that there are 7-8 million new cases every year in the United States.

Infected men and – in particular – women have elevated rates of adverse reproductive health outcomes, including pelvic inflammatory disease, low infant birth weight, and premature delivery. Furthermore, this STI has been increasingly implicated as a risk factor for HIV transmission, she said.

"My question to the proponents of adolescent health and health for women in general is, should we start to do surveillance for Trichomonas [vaginalis] in the United States, so that we can have good data?" Dr. Gaydos asked. "I think more studies are needed."

Additionally, "should we make this a reportable infection in the future?" she inquired, given the many negative outcomes associated with trichomoniasis and the fact that it can be asymptomatic.

The investigators studied women who were recruited through IWantTheKit.org, an educational Internet program on STIs that offers free self-testing to sexually active individuals aged 14 years or older in Denver, Philadelphia, Alaska, Maryland, West Virginia, selected counties in Illinois, and Washington, D.C.

"We know that submission of self-collected samples at home can remove some barriers for adolescents and other women in testing for sexually transmitted diseases," Dr. Gaydos commented. "We have shown in the past that an Internet-recruited population can do this for Chlamydia and gonorrhea."

Starting in mid-2006, the program added testing for trichomoniasis to its existing testing for Chlamydia and gonorrhea. Women ordered the kit online and sent self-collected vaginal samples by U.S. mail to the testing lab. They also completed questionnaires on demographics and risk factors.

The lab tested for trichomoniasis using a nucleic acid amplification test, which has a sensitivity of about 90%, compared with roughly 50% for wet prep and 70% for culture, according to Dr. Gaydos.

The women were instructed to call for their test results in 1-2 weeks, and – should they forget to call – to indicate their preferred method of notification (e-mail, cell phone, letter, or text message).

A total of 1,525 women requested and returned self-collected vaginal swab kits in 2006-2010.

Overall, 10% of women tested positive for trichomoniasis, Dr. Gaydos reported. In addition, 10% tested positive for Chlamydia, 1% tested positive for gonorrhea, and 18% tested positive for at least one of the three infections studied.

By age, the rate of trichomoniasis ranged from 8.3% among those aged 20-24 years to 11.5% among 25- to 29-year-olds. And by race, it ranged from 0% among Asian women to 13.2% among black women.

In a multivariate analysis, women were more likely to have trichomoniasis if they were black compared with white, Asian, or other race/ethnicity (odds ratio, 2.69); did not have health insurance (OR, 1.57); did not have a bachelor’s degree (OR, 5.53); had 2-15, or 16 or more partners in the past year vs. none or a single partner (OR, 1.60 and 3.51); were bisexual (OR, 2.00); did not always use a condom (3.04); or had a partner who had an STI (OR, 1.71).

Age, having had trichomoniasis previously, and having had any STI in the past were not independent risk factors for trichomoniasis, according to Dr. Gaydos.

Participants reported hearing about the program in a variety of ways. "About 30% say that they found it surfing the Internet, and about 28% say they heard about it on the radio, which is how we advertise the presence of the kit in our local areas most of the time," Dr. Gaydos said. Additionally, small proportions reported learning about the program from friends, fliers, and partners.

"Interestingly enough, when we queried the men, a much higher percentage answer on their questionnaire that they were told by their partner," she commented. "So the men are not telling their female partners to get tested, but the females are telling their male partners to get tested."

The study had its limitations, Dr. Gaydos acknowledged. "Obviously, it is biased because it’s selecting people who are empowered to think about their own sexual health. They are interested in finding out if they are infected, and they do report high [levels of] risk factors, which are similar to those that we see in STD clinics," she said.

Dr. Gaydos reported that she has received free diagnostic kits from Gen-Probe Inc.

SEATTLE – Both a high rate of trichomoniasis among sexually active teenage and adult women who seek self-testing and the elevated rate of adverse reproductive health outcomes in infected women raise the question of whether trichomoniasis should be a reportable infection in the United States, Charlotte A. Gaydos said.

Some 10% of the more than 1,500 women who were recruited through the Internet and offered free self-testing, and who then submitted vaginal samples, were positive for this sexually transmitted infection (STI) in an observational study reported at the annual meeting of the Society for Adolescent Health and Medicine. Rates were highest among those aged 25-29 years and among blacks.

These findings, coupled with the adverse health effects of trichomoniasis, may have implications for tracking the infection in the population, according to lead investigator Charlotte A. Gaydos, Dr.P.H., a professor in the division of infectious diseases at Johns Hopkins University in Baltimore.

Trichomoniasis is currently not reportable to the Centers for Disease Control and Prevention, she noted. But study estimates from the CDC suggest that there are 7-8 million new cases every year in the United States.

Infected men and – in particular – women have elevated rates of adverse reproductive health outcomes, including pelvic inflammatory disease, low infant birth weight, and premature delivery. Furthermore, this STI has been increasingly implicated as a risk factor for HIV transmission, she said.

"My question to the proponents of adolescent health and health for women in general is, should we start to do surveillance for Trichomonas [vaginalis] in the United States, so that we can have good data?" Dr. Gaydos asked. "I think more studies are needed."

Additionally, "should we make this a reportable infection in the future?" she inquired, given the many negative outcomes associated with trichomoniasis and the fact that it can be asymptomatic.

The investigators studied women who were recruited through IWantTheKit.org, an educational Internet program on STIs that offers free self-testing to sexually active individuals aged 14 years or older in Denver, Philadelphia, Alaska, Maryland, West Virginia, selected counties in Illinois, and Washington, D.C.

"We know that submission of self-collected samples at home can remove some barriers for adolescents and other women in testing for sexually transmitted diseases," Dr. Gaydos commented. "We have shown in the past that an Internet-recruited population can do this for Chlamydia and gonorrhea."

Starting in mid-2006, the program added testing for trichomoniasis to its existing testing for Chlamydia and gonorrhea. Women ordered the kit online and sent self-collected vaginal samples by U.S. mail to the testing lab. They also completed questionnaires on demographics and risk factors.

The lab tested for trichomoniasis using a nucleic acid amplification test, which has a sensitivity of about 90%, compared with roughly 50% for wet prep and 70% for culture, according to Dr. Gaydos.

The women were instructed to call for their test results in 1-2 weeks, and – should they forget to call – to indicate their preferred method of notification (e-mail, cell phone, letter, or text message).

A total of 1,525 women requested and returned self-collected vaginal swab kits in 2006-2010.

Overall, 10% of women tested positive for trichomoniasis, Dr. Gaydos reported. In addition, 10% tested positive for Chlamydia, 1% tested positive for gonorrhea, and 18% tested positive for at least one of the three infections studied.

By age, the rate of trichomoniasis ranged from 8.3% among those aged 20-24 years to 11.5% among 25- to 29-year-olds. And by race, it ranged from 0% among Asian women to 13.2% among black women.

In a multivariate analysis, women were more likely to have trichomoniasis if they were black compared with white, Asian, or other race/ethnicity (odds ratio, 2.69); did not have health insurance (OR, 1.57); did not have a bachelor’s degree (OR, 5.53); had 2-15, or 16 or more partners in the past year vs. none or a single partner (OR, 1.60 and 3.51); were bisexual (OR, 2.00); did not always use a condom (3.04); or had a partner who had an STI (OR, 1.71).

Age, having had trichomoniasis previously, and having had any STI in the past were not independent risk factors for trichomoniasis, according to Dr. Gaydos.

Participants reported hearing about the program in a variety of ways. "About 30% say that they found it surfing the Internet, and about 28% say they heard about it on the radio, which is how we advertise the presence of the kit in our local areas most of the time," Dr. Gaydos said. Additionally, small proportions reported learning about the program from friends, fliers, and partners.

"Interestingly enough, when we queried the men, a much higher percentage answer on their questionnaire that they were told by their partner," she commented. "So the men are not telling their female partners to get tested, but the females are telling their male partners to get tested."

The study had its limitations, Dr. Gaydos acknowledged. "Obviously, it is biased because it’s selecting people who are empowered to think about their own sexual health. They are interested in finding out if they are infected, and they do report high [levels of] risk factors, which are similar to those that we see in STD clinics," she said.

Dr. Gaydos reported that she has received free diagnostic kits from Gen-Probe Inc.

SEATTLE – Both a high rate of trichomoniasis among sexually active teenage and adult women who seek self-testing and the elevated rate of adverse reproductive health outcomes in infected women raise the question of whether trichomoniasis should be a reportable infection in the United States, Charlotte A. Gaydos said.

Some 10% of the more than 1,500 women who were recruited through the Internet and offered free self-testing, and who then submitted vaginal samples, were positive for this sexually transmitted infection (STI) in an observational study reported at the annual meeting of the Society for Adolescent Health and Medicine. Rates were highest among those aged 25-29 years and among blacks.

These findings, coupled with the adverse health effects of trichomoniasis, may have implications for tracking the infection in the population, according to lead investigator Charlotte A. Gaydos, Dr.P.H., a professor in the division of infectious diseases at Johns Hopkins University in Baltimore.

Trichomoniasis is currently not reportable to the Centers for Disease Control and Prevention, she noted. But study estimates from the CDC suggest that there are 7-8 million new cases every year in the United States.

Infected men and – in particular – women have elevated rates of adverse reproductive health outcomes, including pelvic inflammatory disease, low infant birth weight, and premature delivery. Furthermore, this STI has been increasingly implicated as a risk factor for HIV transmission, she said.

"My question to the proponents of adolescent health and health for women in general is, should we start to do surveillance for Trichomonas [vaginalis] in the United States, so that we can have good data?" Dr. Gaydos asked. "I think more studies are needed."

Additionally, "should we make this a reportable infection in the future?" she inquired, given the many negative outcomes associated with trichomoniasis and the fact that it can be asymptomatic.

The investigators studied women who were recruited through IWantTheKit.org, an educational Internet program on STIs that offers free self-testing to sexually active individuals aged 14 years or older in Denver, Philadelphia, Alaska, Maryland, West Virginia, selected counties in Illinois, and Washington, D.C.

"We know that submission of self-collected samples at home can remove some barriers for adolescents and other women in testing for sexually transmitted diseases," Dr. Gaydos commented. "We have shown in the past that an Internet-recruited population can do this for Chlamydia and gonorrhea."

Starting in mid-2006, the program added testing for trichomoniasis to its existing testing for Chlamydia and gonorrhea. Women ordered the kit online and sent self-collected vaginal samples by U.S. mail to the testing lab. They also completed questionnaires on demographics and risk factors.

The lab tested for trichomoniasis using a nucleic acid amplification test, which has a sensitivity of about 90%, compared with roughly 50% for wet prep and 70% for culture, according to Dr. Gaydos.

The women were instructed to call for their test results in 1-2 weeks, and – should they forget to call – to indicate their preferred method of notification (e-mail, cell phone, letter, or text message).

A total of 1,525 women requested and returned self-collected vaginal swab kits in 2006-2010.

Overall, 10% of women tested positive for trichomoniasis, Dr. Gaydos reported. In addition, 10% tested positive for Chlamydia, 1% tested positive for gonorrhea, and 18% tested positive for at least one of the three infections studied.

By age, the rate of trichomoniasis ranged from 8.3% among those aged 20-24 years to 11.5% among 25- to 29-year-olds. And by race, it ranged from 0% among Asian women to 13.2% among black women.

In a multivariate analysis, women were more likely to have trichomoniasis if they were black compared with white, Asian, or other race/ethnicity (odds ratio, 2.69); did not have health insurance (OR, 1.57); did not have a bachelor’s degree (OR, 5.53); had 2-15, or 16 or more partners in the past year vs. none or a single partner (OR, 1.60 and 3.51); were bisexual (OR, 2.00); did not always use a condom (3.04); or had a partner who had an STI (OR, 1.71).

Age, having had trichomoniasis previously, and having had any STI in the past were not independent risk factors for trichomoniasis, according to Dr. Gaydos.

Participants reported hearing about the program in a variety of ways. "About 30% say that they found it surfing the Internet, and about 28% say they heard about it on the radio, which is how we advertise the presence of the kit in our local areas most of the time," Dr. Gaydos said. Additionally, small proportions reported learning about the program from friends, fliers, and partners.

"Interestingly enough, when we queried the men, a much higher percentage answer on their questionnaire that they were told by their partner," she commented. "So the men are not telling their female partners to get tested, but the females are telling their male partners to get tested."

The study had its limitations, Dr. Gaydos acknowledged. "Obviously, it is biased because it’s selecting people who are empowered to think about their own sexual health. They are interested in finding out if they are infected, and they do report high [levels of] risk factors, which are similar to those that we see in STD clinics," she said.

Dr. Gaydos reported that she has received free diagnostic kits from Gen-Probe Inc.

SEATTLE – Both a high rate of trichomoniasis among sexually active teenage and adult women who seek self-testing and the elevated rate of adverse reproductive health outcomes in infected women raise the question of whether trichomoniasis should be a reportable infection in the United States, Charlotte A. Gaydos said.

Some 10% of the more than 1,500 women who were recruited through the Internet and offered free self-testing, and who then submitted vaginal samples, were positive for this sexually transmitted infection (STI) in an observational study reported at the annual meeting of the Society for Adolescent Health and Medicine. Rates were highest among those aged 25-29 years and among blacks.

These findings, coupled with the adverse health effects of trichomoniasis, may have implications for tracking the infection in the population, according to lead investigator Charlotte A. Gaydos, Dr.P.H., a professor in the division of infectious diseases at Johns Hopkins University in Baltimore.

Trichomoniasis is currently not reportable to the Centers for Disease Control and Prevention, she noted. But study estimates from the CDC suggest that there are 7-8 million new cases every year in the United States.

Infected men and – in particular – women have elevated rates of adverse reproductive health outcomes, including pelvic inflammatory disease, low infant birth weight, and premature delivery. Furthermore, this STI has been increasingly implicated as a risk factor for HIV transmission, she said.

"My question to the proponents of adolescent health and health for women in general is, should we start to do surveillance for Trichomonas [vaginalis] in the United States, so that we can have good data?" Dr. Gaydos asked. "I think more studies are needed."

Additionally, "should we make this a reportable infection in the future?" she inquired, given the many negative outcomes associated with trichomoniasis and the fact that it can be asymptomatic.

The investigators studied women who were recruited through IWantTheKit.org, an educational Internet program on STIs that offers free self-testing to sexually active individuals aged 14 years or older in Denver, Philadelphia, Alaska, Maryland, West Virginia, selected counties in Illinois, and Washington, D.C.

"We know that submission of self-collected samples at home can remove some barriers for adolescents and other women in testing for sexually transmitted diseases," Dr. Gaydos commented. "We have shown in the past that an Internet-recruited population can do this for Chlamydia and gonorrhea."

Starting in mid-2006, the program added testing for trichomoniasis to its existing testing for Chlamydia and gonorrhea. Women ordered the kit online and sent self-collected vaginal samples by U.S. mail to the testing lab. They also completed questionnaires on demographics and risk factors.

The lab tested for trichomoniasis using a nucleic acid amplification test, which has a sensitivity of about 90%, compared with roughly 50% for wet prep and 70% for culture, according to Dr. Gaydos.

The women were instructed to call for their test results in 1-2 weeks, and – should they forget to call – to indicate their preferred method of notification (e-mail, cell phone, letter, or text message).

A total of 1,525 women requested and returned self-collected vaginal swab kits in 2006-2010.

Overall, 10% of women tested positive for trichomoniasis, Dr. Gaydos reported. In addition, 10% tested positive for Chlamydia, 1% tested positive for gonorrhea, and 18% tested positive for at least one of the three infections studied.

By age, the rate of trichomoniasis ranged from 8.3% among those aged 20-24 years to 11.5% among 25- to 29-year-olds. And by race, it ranged from 0% among Asian women to 13.2% among black women.

In a multivariate analysis, women were more likely to have trichomoniasis if they were black compared with white, Asian, or other race/ethnicity (odds ratio, 2.69); did not have health insurance (OR, 1.57); did not have a bachelor’s degree (OR, 5.53); had 2-15, or 16 or more partners in the past year vs. none or a single partner (OR, 1.60 and 3.51); were bisexual (OR, 2.00); did not always use a condom (3.04); or had a partner who had an STI (OR, 1.71).

Age, having had trichomoniasis previously, and having had any STI in the past were not independent risk factors for trichomoniasis, according to Dr. Gaydos.

Participants reported hearing about the program in a variety of ways. "About 30% say that they found it surfing the Internet, and about 28% say they heard about it on the radio, which is how we advertise the presence of the kit in our local areas most of the time," Dr. Gaydos said. Additionally, small proportions reported learning about the program from friends, fliers, and partners.

"Interestingly enough, when we queried the men, a much higher percentage answer on their questionnaire that they were told by their partner," she commented. "So the men are not telling their female partners to get tested, but the females are telling their male partners to get tested."

The study had its limitations, Dr. Gaydos acknowledged. "Obviously, it is biased because it’s selecting people who are empowered to think about their own sexual health. They are interested in finding out if they are infected, and they do report high [levels of] risk factors, which are similar to those that we see in STD clinics," she said.

Dr. Gaydos reported that she has received free diagnostic kits from Gen-Probe Inc.

SEATTLE – Both a high rate of trichomoniasis among sexually active teenage and adult women who seek self-testing and the elevated rate of adverse reproductive health outcomes in infected women raise the question of whether trichomoniasis should be a reportable infection in the United States, Charlotte A. Gaydos said.

Some 10% of the more than 1,500 women who were recruited through the Internet and offered free self-testing, and who then submitted vaginal samples, were positive for this sexually transmitted infection (STI) in an observational study reported at the annual meeting of the Society for Adolescent Health and Medicine. Rates were highest among those aged 25-29 years and among blacks.

These findings, coupled with the adverse health effects of trichomoniasis, may have implications for tracking the infection in the population, according to lead investigator Charlotte A. Gaydos, Dr.P.H., a professor in the division of infectious diseases at Johns Hopkins University in Baltimore.

Trichomoniasis is currently not reportable to the Centers for Disease Control and Prevention, she noted. But study estimates from the CDC suggest that there are 7-8 million new cases every year in the United States.

Infected men and – in particular – women have elevated rates of adverse reproductive health outcomes, including pelvic inflammatory disease, low infant birth weight, and premature delivery. Furthermore, this STI has been increasingly implicated as a risk factor for HIV transmission, she said.

"My question to the proponents of adolescent health and health for women in general is, should we start to do surveillance for Trichomonas [vaginalis] in the United States, so that we can have good data?" Dr. Gaydos asked. "I think more studies are needed."

Additionally, "should we make this a reportable infection in the future?" she inquired, given the many negative outcomes associated with trichomoniasis and the fact that it can be asymptomatic.

The investigators studied women who were recruited through IWantTheKit.org, an educational Internet program on STIs that offers free self-testing to sexually active individuals aged 14 years or older in Denver, Philadelphia, Alaska, Maryland, West Virginia, selected counties in Illinois, and Washington, D.C.

"We know that submission of self-collected samples at home can remove some barriers for adolescents and other women in testing for sexually transmitted diseases," Dr. Gaydos commented. "We have shown in the past that an Internet-recruited population can do this for Chlamydia and gonorrhea."

Starting in mid-2006, the program added testing for trichomoniasis to its existing testing for Chlamydia and gonorrhea. Women ordered the kit online and sent self-collected vaginal samples by U.S. mail to the testing lab. They also completed questionnaires on demographics and risk factors.

The lab tested for trichomoniasis using a nucleic acid amplification test, which has a sensitivity of about 90%, compared with roughly 50% for wet prep and 70% for culture, according to Dr. Gaydos.

The women were instructed to call for their test results in 1-2 weeks, and – should they forget to call – to indicate their preferred method of notification (e-mail, cell phone, letter, or text message).

A total of 1,525 women requested and returned self-collected vaginal swab kits in 2006-2010.

Overall, 10% of women tested positive for trichomoniasis, Dr. Gaydos reported. In addition, 10% tested positive for Chlamydia, 1% tested positive for gonorrhea, and 18% tested positive for at least one of the three infections studied.

By age, the rate of trichomoniasis ranged from 8.3% among those aged 20-24 years to 11.5% among 25- to 29-year-olds. And by race, it ranged from 0% among Asian women to 13.2% among black women.

In a multivariate analysis, women were more likely to have trichomoniasis if they were black compared with white, Asian, or other race/ethnicity (odds ratio, 2.69); did not have health insurance (OR, 1.57); did not have a bachelor’s degree (OR, 5.53); had 2-15, or 16 or more partners in the past year vs. none or a single partner (OR, 1.60 and 3.51); were bisexual (OR, 2.00); did not always use a condom (3.04); or had a partner who had an STI (OR, 1.71).

Age, having had trichomoniasis previously, and having had any STI in the past were not independent risk factors for trichomoniasis, according to Dr. Gaydos.

Participants reported hearing about the program in a variety of ways. "About 30% say that they found it surfing the Internet, and about 28% say they heard about it on the radio, which is how we advertise the presence of the kit in our local areas most of the time," Dr. Gaydos said. Additionally, small proportions reported learning about the program from friends, fliers, and partners.

"Interestingly enough, when we queried the men, a much higher percentage answer on their questionnaire that they were told by their partner," she commented. "So the men are not telling their female partners to get tested, but the females are telling their male partners to get tested."

The study had its limitations, Dr. Gaydos acknowledged. "Obviously, it is biased because it’s selecting people who are empowered to think about their own sexual health. They are interested in finding out if they are infected, and they do report high [levels of] risk factors, which are similar to those that we see in STD clinics," she said.

Dr. Gaydos reported that she has received free diagnostic kits from Gen-Probe Inc.

SEATTLE – Vaccinating girls against human papillomavirus at age 11 or 12 years, as is currently recommended, appears to be most appropriate for preventing infection, but barriers persist, according to two studies presented at the annual meeting of the Society for Adolescent Health and Medicine.

In a study among girls as young as age 13 years, one in eight who reported that they had never had sexual intercourse nonetheless had vaginal infection with human papillomavirus (HPV). And more than two-thirds of those who had had sex were infected.

In another study among girls aged 14-17 years and their mothers, the most commonly cited reasons for not vaccinating were fear of side effects, perceived danger of the vaccine, and lack of a recommendation to vaccinate from their health care provider.

Prevalence of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that HPV vaccine be targeted to girls aged 11-12 years, with catch-up vaccination in girls and young women aged 13-26 years, noted Dr. Jessica A. Kahn, an associate professor of pediatrics at the University of Cincinnati.

But there is some reluctance among clinicians and parents alike to vaccinate at age 11 or 12, she said. "This is concerning, as HPV is commonly acquired during the teen years, and HPV vaccines are not effective at preventing infections with vaccine types of HPV in young women who are already infected with those types at the time of vaccination."

Data on the prevalence of type-specific HPV infection in girls initiating HPV vaccination are generally lacking, according to Dr. Kahn. "These data are needed in order to estimate the public health impact of HPV vaccination in the catch-up age group, and to guide educational and public health interventions designed to maximize the effectiveness of HPV vaccination."

She and her colleagues studied 259 girls aged 13-21 years who were receiving their first dose of HPV vaccine in a hospital-based adolescent clinic. Clinicians or the girls themselves collected vaginal samples that were tested for 37 HPV types. The girls and their mothers completed questionnaires about factors potentially related to HPV acquisition.

Overall, 27% of the girls were sexually inexperienced, reporting that they had never had vaginal or anal sex. But 13% of this group had had sexual contact, reporting genital skin-to-skin contact only.

The percentage of girls testing positive for any HPV type was 70% in the sexually experienced group and much lower, though not zero, at 12% in the sexually inexperienced group (P less than .001).

The sexually experienced group was also more likely than the inexperienced group to test positive for at least one of the high-risk HPV types in the quadrivalent vaccine – types 6, 11, 16, and 18 (31% vs. 4%, P less than .001) – and for at least one of those in the bivalent vaccine – types 16 and 18 (21% vs. 3%, P less than .001).

In a multivariate analysis of the sexually experienced group, these girls were significantly more likely to be HPV positive if they had had two to five, or six or more lifetime male partners, compared with one partner (odds ratios 6.2 and 10.3) and if their mother reported not having communicated with them about the HPV vaccine (OR 4.0).

In contrast, in the sexually inexperienced group, none of a variety of factors, including reported sexual contact, were independently associated with the odds of being HPV positive.

"Clinicians and parents should be strongly encouraged to vaccinate 11- to 12-year-old girls and not procrastinate," Dr. Kahn asserted. "It’s difficult to predict the age of sexual initiation, and thus, these recommendations by the ACIP minimize the probability that girls will be infected at the time of vaccination."

The findings also support the recommendation for catch-up vaccination in older girls, she added, as a majority of the sexually active group were still negative for high-risk types of the virus covered by the vaccines.

"I think it’s probably helpful for clinicians to develop some brief talking points for use with parents in terms of HPV vaccination," said Dr. Kahn. "Those would include the fact that HPV is acquired very rapidly after sexual initiation, that the vast majority of people will acquire HPV at some point in their lives, and that the vaccine is only effective in preventing vaccine-type HPVs if given before exposure."

"I think it’s really important for us to get those messages out, and I think it can be done in a pretty concise way," she concluded.

Barriers to HPV vaccination. Understanding barriers to HPV vaccination is important not only for promoting uptake, but also possibly for efforts to address disproportionately high rates of HPV infection in certain population groups, according to Dr. Laura M. Kester, a pediatrician at Indiana University in Indianapolis.

"Positive maternal attitudes toward vaccination have been shown to be associated with higher rates of HPV vaccination," she noted.

Dr. Kester and her colleagues studied a national sample of 501 girls aged 14-17 years and their mothers recruited to an online-based survey in 2010. The mothers and daughters completed surveys asking about number of doses of HPV vaccine the daughter had received, sociodemographic factors, insurance status, and maternal experiences related to HPV infection. The mothers of unvaccinated daughters were asked why they had not had their girls vaccinated. Survey results showed that the mothers were 45 years old on average. The majority were white (76%) and college educated (81%).

According to maternal report, 50% of the daughters had initiated HPV vaccination, defined as having received at least one dose, and 38% had completed vaccination, defined as having received all three doses in the series.

These rates suggest improvement from 2009, Dr. Kester noted, when data from the Centers for Disease Control and Prevention showed an initiation rate of 44% and a completion rate of 27%.

The rate of initiation did not vary significantly with the daughter’s insurance status or according to a variety of maternal factors, such as race/ethnicity, education level, relationship status, geographic location, employment status, or exposure to negative experiences related to HPV (having had an abnormal Pap smear, a colposcopy, or a friend or family member with cervical cancer).

In contrast, the rate of completion differed significantly by maternal race/ethnicity, with about 40% of the daughters of white mothers having completed the series, compared with 25% of daughters of black mothers and 25% of daughters of Hispanic mothers (P less than .001).

Mothers’ most commonly reported reasons for not initiating HPV vaccination for their daughter were concern about vaccine side effects (cited by 36%), fear that it was dangerous (36%), and lack of a recommendation by their provider (34%).

They also cited a belief that the vaccine did not work (13%), not having seen a provider in a long time (12%), concern about eligibility for or cost of the vaccine (11%), and concern that vaccinating would encourage their daughter to have sex (8%).

"There is no evidence from our data that demographic or socioeconomic disparities played a role in vaccination initiation," commented Dr. Kester. "However, we do see that black and Hispanic populations were less likely to complete vaccination."

Taken together, the findings "suggest there is continued need to encourage vaccine uptake as well as need for further educational interventions, at the level of the patient, the provider, and the parent on vaccine benefit, efficacy, and safety," she said. "In addition, this data reminds us that there is a continuing need to evaluate barriers to vaccination initiation and completion, looking at reasons for racial discrepancy of vaccine completion."

Dr. Kahn reported that she is co-principal investigator on two trials in which Merck is providing the vaccine and immunogenicity testing. Dr. Kester reported that some of her coinvestigators are investigators for or receive research funding from Merck.

SEATTLE – Vaccinating girls against human papillomavirus at age 11 or 12 years, as is currently recommended, appears to be most appropriate for preventing infection, but barriers persist, according to two studies presented at the annual meeting of the Society for Adolescent Health and Medicine.

In a study among girls as young as age 13 years, one in eight who reported that they had never had sexual intercourse nonetheless had vaginal infection with human papillomavirus (HPV). And more than two-thirds of those who had had sex were infected.

In another study among girls aged 14-17 years and their mothers, the most commonly cited reasons for not vaccinating were fear of side effects, perceived danger of the vaccine, and lack of a recommendation to vaccinate from their health care provider.

Prevalence of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that HPV vaccine be targeted to girls aged 11-12 years, with catch-up vaccination in girls and young women aged 13-26 years, noted Dr. Jessica A. Kahn, an associate professor of pediatrics at the University of Cincinnati.

But there is some reluctance among clinicians and parents alike to vaccinate at age 11 or 12, she said. "This is concerning, as HPV is commonly acquired during the teen years, and HPV vaccines are not effective at preventing infections with vaccine types of HPV in young women who are already infected with those types at the time of vaccination."

Data on the prevalence of type-specific HPV infection in girls initiating HPV vaccination are generally lacking, according to Dr. Kahn. "These data are needed in order to estimate the public health impact of HPV vaccination in the catch-up age group, and to guide educational and public health interventions designed to maximize the effectiveness of HPV vaccination."

She and her colleagues studied 259 girls aged 13-21 years who were receiving their first dose of HPV vaccine in a hospital-based adolescent clinic. Clinicians or the girls themselves collected vaginal samples that were tested for 37 HPV types. The girls and their mothers completed questionnaires about factors potentially related to HPV acquisition.

Overall, 27% of the girls were sexually inexperienced, reporting that they had never had vaginal or anal sex. But 13% of this group had had sexual contact, reporting genital skin-to-skin contact only.

The percentage of girls testing positive for any HPV type was 70% in the sexually experienced group and much lower, though not zero, at 12% in the sexually inexperienced group (P less than .001).

The sexually experienced group was also more likely than the inexperienced group to test positive for at least one of the high-risk HPV types in the quadrivalent vaccine – types 6, 11, 16, and 18 (31% vs. 4%, P less than .001) – and for at least one of those in the bivalent vaccine – types 16 and 18 (21% vs. 3%, P less than .001).

In a multivariate analysis of the sexually experienced group, these girls were significantly more likely to be HPV positive if they had had two to five, or six or more lifetime male partners, compared with one partner (odds ratios 6.2 and 10.3) and if their mother reported not having communicated with them about the HPV vaccine (OR 4.0).

In contrast, in the sexually inexperienced group, none of a variety of factors, including reported sexual contact, were independently associated with the odds of being HPV positive.

"Clinicians and parents should be strongly encouraged to vaccinate 11- to 12-year-old girls and not procrastinate," Dr. Kahn asserted. "It’s difficult to predict the age of sexual initiation, and thus, these recommendations by the ACIP minimize the probability that girls will be infected at the time of vaccination."

The findings also support the recommendation for catch-up vaccination in older girls, she added, as a majority of the sexually active group were still negative for high-risk types of the virus covered by the vaccines.

"I think it’s probably helpful for clinicians to develop some brief talking points for use with parents in terms of HPV vaccination," said Dr. Kahn. "Those would include the fact that HPV is acquired very rapidly after sexual initiation, that the vast majority of people will acquire HPV at some point in their lives, and that the vaccine is only effective in preventing vaccine-type HPVs if given before exposure."

"I think it’s really important for us to get those messages out, and I think it can be done in a pretty concise way," she concluded.

Barriers to HPV vaccination. Understanding barriers to HPV vaccination is important not only for promoting uptake, but also possibly for efforts to address disproportionately high rates of HPV infection in certain population groups, according to Dr. Laura M. Kester, a pediatrician at Indiana University in Indianapolis.

"Positive maternal attitudes toward vaccination have been shown to be associated with higher rates of HPV vaccination," she noted.

Dr. Kester and her colleagues studied a national sample of 501 girls aged 14-17 years and their mothers recruited to an online-based survey in 2010. The mothers and daughters completed surveys asking about number of doses of HPV vaccine the daughter had received, sociodemographic factors, insurance status, and maternal experiences related to HPV infection. The mothers of unvaccinated daughters were asked why they had not had their girls vaccinated. Survey results showed that the mothers were 45 years old on average. The majority were white (76%) and college educated (81%).

According to maternal report, 50% of the daughters had initiated HPV vaccination, defined as having received at least one dose, and 38% had completed vaccination, defined as having received all three doses in the series.

These rates suggest improvement from 2009, Dr. Kester noted, when data from the Centers for Disease Control and Prevention showed an initiation rate of 44% and a completion rate of 27%.

The rate of initiation did not vary significantly with the daughter’s insurance status or according to a variety of maternal factors, such as race/ethnicity, education level, relationship status, geographic location, employment status, or exposure to negative experiences related to HPV (having had an abnormal Pap smear, a colposcopy, or a friend or family member with cervical cancer).

In contrast, the rate of completion differed significantly by maternal race/ethnicity, with about 40% of the daughters of white mothers having completed the series, compared with 25% of daughters of black mothers and 25% of daughters of Hispanic mothers (P less than .001).

Mothers’ most commonly reported reasons for not initiating HPV vaccination for their daughter were concern about vaccine side effects (cited by 36%), fear that it was dangerous (36%), and lack of a recommendation by their provider (34%).

They also cited a belief that the vaccine did not work (13%), not having seen a provider in a long time (12%), concern about eligibility for or cost of the vaccine (11%), and concern that vaccinating would encourage their daughter to have sex (8%).

"There is no evidence from our data that demographic or socioeconomic disparities played a role in vaccination initiation," commented Dr. Kester. "However, we do see that black and Hispanic populations were less likely to complete vaccination."

Taken together, the findings "suggest there is continued need to encourage vaccine uptake as well as need for further educational interventions, at the level of the patient, the provider, and the parent on vaccine benefit, efficacy, and safety," she said. "In addition, this data reminds us that there is a continuing need to evaluate barriers to vaccination initiation and completion, looking at reasons for racial discrepancy of vaccine completion."

Dr. Kahn reported that she is co-principal investigator on two trials in which Merck is providing the vaccine and immunogenicity testing. Dr. Kester reported that some of her coinvestigators are investigators for or receive research funding from Merck.

SEATTLE – Vaccinating girls against human papillomavirus at age 11 or 12 years, as is currently recommended, appears to be most appropriate for preventing infection, but barriers persist, according to two studies presented at the annual meeting of the Society for Adolescent Health and Medicine.

In a study among girls as young as age 13 years, one in eight who reported that they had never had sexual intercourse nonetheless had vaginal infection with human papillomavirus (HPV). And more than two-thirds of those who had had sex were infected.

In another study among girls aged 14-17 years and their mothers, the most commonly cited reasons for not vaccinating were fear of side effects, perceived danger of the vaccine, and lack of a recommendation to vaccinate from their health care provider.

Prevalence of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that HPV vaccine be targeted to girls aged 11-12 years, with catch-up vaccination in girls and young women aged 13-26 years, noted Dr. Jessica A. Kahn, an associate professor of pediatrics at the University of Cincinnati.

But there is some reluctance among clinicians and parents alike to vaccinate at age 11 or 12, she said. "This is concerning, as HPV is commonly acquired during the teen years, and HPV vaccines are not effective at preventing infections with vaccine types of HPV in young women who are already infected with those types at the time of vaccination."

Data on the prevalence of type-specific HPV infection in girls initiating HPV vaccination are generally lacking, according to Dr. Kahn. "These data are needed in order to estimate the public health impact of HPV vaccination in the catch-up age group, and to guide educational and public health interventions designed to maximize the effectiveness of HPV vaccination."

She and her colleagues studied 259 girls aged 13-21 years who were receiving their first dose of HPV vaccine in a hospital-based adolescent clinic. Clinicians or the girls themselves collected vaginal samples that were tested for 37 HPV types. The girls and their mothers completed questionnaires about factors potentially related to HPV acquisition.

Overall, 27% of the girls were sexually inexperienced, reporting that they had never had vaginal or anal sex. But 13% of this group had had sexual contact, reporting genital skin-to-skin contact only.

The percentage of girls testing positive for any HPV type was 70% in the sexually experienced group and much lower, though not zero, at 12% in the sexually inexperienced group (P less than .001).

The sexually experienced group was also more likely than the inexperienced group to test positive for at least one of the high-risk HPV types in the quadrivalent vaccine – types 6, 11, 16, and 18 (31% vs. 4%, P less than .001) – and for at least one of those in the bivalent vaccine – types 16 and 18 (21% vs. 3%, P less than .001).

In a multivariate analysis of the sexually experienced group, these girls were significantly more likely to be HPV positive if they had had two to five, or six or more lifetime male partners, compared with one partner (odds ratios 6.2 and 10.3) and if their mother reported not having communicated with them about the HPV vaccine (OR 4.0).

In contrast, in the sexually inexperienced group, none of a variety of factors, including reported sexual contact, were independently associated with the odds of being HPV positive.

"Clinicians and parents should be strongly encouraged to vaccinate 11- to 12-year-old girls and not procrastinate," Dr. Kahn asserted. "It’s difficult to predict the age of sexual initiation, and thus, these recommendations by the ACIP minimize the probability that girls will be infected at the time of vaccination."

The findings also support the recommendation for catch-up vaccination in older girls, she added, as a majority of the sexually active group were still negative for high-risk types of the virus covered by the vaccines.

"I think it’s probably helpful for clinicians to develop some brief talking points for use with parents in terms of HPV vaccination," said Dr. Kahn. "Those would include the fact that HPV is acquired very rapidly after sexual initiation, that the vast majority of people will acquire HPV at some point in their lives, and that the vaccine is only effective in preventing vaccine-type HPVs if given before exposure."

"I think it’s really important for us to get those messages out, and I think it can be done in a pretty concise way," she concluded.

Barriers to HPV vaccination. Understanding barriers to HPV vaccination is important not only for promoting uptake, but also possibly for efforts to address disproportionately high rates of HPV infection in certain population groups, according to Dr. Laura M. Kester, a pediatrician at Indiana University in Indianapolis.

"Positive maternal attitudes toward vaccination have been shown to be associated with higher rates of HPV vaccination," she noted.

Dr. Kester and her colleagues studied a national sample of 501 girls aged 14-17 years and their mothers recruited to an online-based survey in 2010. The mothers and daughters completed surveys asking about number of doses of HPV vaccine the daughter had received, sociodemographic factors, insurance status, and maternal experiences related to HPV infection. The mothers of unvaccinated daughters were asked why they had not had their girls vaccinated. Survey results showed that the mothers were 45 years old on average. The majority were white (76%) and college educated (81%).

According to maternal report, 50% of the daughters had initiated HPV vaccination, defined as having received at least one dose, and 38% had completed vaccination, defined as having received all three doses in the series.

These rates suggest improvement from 2009, Dr. Kester noted, when data from the Centers for Disease Control and Prevention showed an initiation rate of 44% and a completion rate of 27%.

The rate of initiation did not vary significantly with the daughter’s insurance status or according to a variety of maternal factors, such as race/ethnicity, education level, relationship status, geographic location, employment status, or exposure to negative experiences related to HPV (having had an abnormal Pap smear, a colposcopy, or a friend or family member with cervical cancer).

In contrast, the rate of completion differed significantly by maternal race/ethnicity, with about 40% of the daughters of white mothers having completed the series, compared with 25% of daughters of black mothers and 25% of daughters of Hispanic mothers (P less than .001).

Mothers’ most commonly reported reasons for not initiating HPV vaccination for their daughter were concern about vaccine side effects (cited by 36%), fear that it was dangerous (36%), and lack of a recommendation by their provider (34%).

They also cited a belief that the vaccine did not work (13%), not having seen a provider in a long time (12%), concern about eligibility for or cost of the vaccine (11%), and concern that vaccinating would encourage their daughter to have sex (8%).

"There is no evidence from our data that demographic or socioeconomic disparities played a role in vaccination initiation," commented Dr. Kester. "However, we do see that black and Hispanic populations were less likely to complete vaccination."

Taken together, the findings "suggest there is continued need to encourage vaccine uptake as well as need for further educational interventions, at the level of the patient, the provider, and the parent on vaccine benefit, efficacy, and safety," she said. "In addition, this data reminds us that there is a continuing need to evaluate barriers to vaccination initiation and completion, looking at reasons for racial discrepancy of vaccine completion."

Dr. Kahn reported that she is co-principal investigator on two trials in which Merck is providing the vaccine and immunogenicity testing. Dr. Kester reported that some of her coinvestigators are investigators for or receive research funding from Merck.

SEATTLE – Vaccinating girls against human papillomavirus at age 11 or 12 years, as is currently recommended, appears to be most appropriate for preventing infection, but barriers persist, according to two studies presented at the annual meeting of the Society for Adolescent Health and Medicine.

In a study among girls as young as age 13 years, one in eight who reported that they had never had sexual intercourse nonetheless had vaginal infection with human papillomavirus (HPV). And more than two-thirds of those who had had sex were infected.

In another study among girls aged 14-17 years and their mothers, the most commonly cited reasons for not vaccinating were fear of side effects, perceived danger of the vaccine, and lack of a recommendation to vaccinate from their health care provider.

Prevalence of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that HPV vaccine be targeted to girls aged 11-12 years, with catch-up vaccination in girls and young women aged 13-26 years, noted Dr. Jessica A. Kahn, an associate professor of pediatrics at the University of Cincinnati.

But there is some reluctance among clinicians and parents alike to vaccinate at age 11 or 12, she said. "This is concerning, as HPV is commonly acquired during the teen years, and HPV vaccines are not effective at preventing infections with vaccine types of HPV in young women who are already infected with those types at the time of vaccination."

Data on the prevalence of type-specific HPV infection in girls initiating HPV vaccination are generally lacking, according to Dr. Kahn. "These data are needed in order to estimate the public health impact of HPV vaccination in the catch-up age group, and to guide educational and public health interventions designed to maximize the effectiveness of HPV vaccination."

She and her colleagues studied 259 girls aged 13-21 years who were receiving their first dose of HPV vaccine in a hospital-based adolescent clinic. Clinicians or the girls themselves collected vaginal samples that were tested for 37 HPV types. The girls and their mothers completed questionnaires about factors potentially related to HPV acquisition.

Overall, 27% of the girls were sexually inexperienced, reporting that they had never had vaginal or anal sex. But 13% of this group had had sexual contact, reporting genital skin-to-skin contact only.

The percentage of girls testing positive for any HPV type was 70% in the sexually experienced group and much lower, though not zero, at 12% in the sexually inexperienced group (P less than .001).

The sexually experienced group was also more likely than the inexperienced group to test positive for at least one of the high-risk HPV types in the quadrivalent vaccine – types 6, 11, 16, and 18 (31% vs. 4%, P less than .001) – and for at least one of those in the bivalent vaccine – types 16 and 18 (21% vs. 3%, P less than .001).

In a multivariate analysis of the sexually experienced group, these girls were significantly more likely to be HPV positive if they had had two to five, or six or more lifetime male partners, compared with one partner (odds ratios 6.2 and 10.3) and if their mother reported not having communicated with them about the HPV vaccine (OR 4.0).

In contrast, in the sexually inexperienced group, none of a variety of factors, including reported sexual contact, were independently associated with the odds of being HPV positive.

"Clinicians and parents should be strongly encouraged to vaccinate 11- to 12-year-old girls and not procrastinate," Dr. Kahn asserted. "It’s difficult to predict the age of sexual initiation, and thus, these recommendations by the ACIP minimize the probability that girls will be infected at the time of vaccination."

The findings also support the recommendation for catch-up vaccination in older girls, she added, as a majority of the sexually active group were still negative for high-risk types of the virus covered by the vaccines.

"I think it’s probably helpful for clinicians to develop some brief talking points for use with parents in terms of HPV vaccination," said Dr. Kahn. "Those would include the fact that HPV is acquired very rapidly after sexual initiation, that the vast majority of people will acquire HPV at some point in their lives, and that the vaccine is only effective in preventing vaccine-type HPVs if given before exposure."

"I think it’s really important for us to get those messages out, and I think it can be done in a pretty concise way," she concluded.

Barriers to HPV vaccination. Understanding barriers to HPV vaccination is important not only for promoting uptake, but also possibly for efforts to address disproportionately high rates of HPV infection in certain population groups, according to Dr. Laura M. Kester, a pediatrician at Indiana University in Indianapolis.

"Positive maternal attitudes toward vaccination have been shown to be associated with higher rates of HPV vaccination," she noted.

Dr. Kester and her colleagues studied a national sample of 501 girls aged 14-17 years and their mothers recruited to an online-based survey in 2010. The mothers and daughters completed surveys asking about number of doses of HPV vaccine the daughter had received, sociodemographic factors, insurance status, and maternal experiences related to HPV infection. The mothers of unvaccinated daughters were asked why they had not had their girls vaccinated. Survey results showed that the mothers were 45 years old on average. The majority were white (76%) and college educated (81%).

According to maternal report, 50% of the daughters had initiated HPV vaccination, defined as having received at least one dose, and 38% had completed vaccination, defined as having received all three doses in the series.

These rates suggest improvement from 2009, Dr. Kester noted, when data from the Centers for Disease Control and Prevention showed an initiation rate of 44% and a completion rate of 27%.

The rate of initiation did not vary significantly with the daughter’s insurance status or according to a variety of maternal factors, such as race/ethnicity, education level, relationship status, geographic location, employment status, or exposure to negative experiences related to HPV (having had an abnormal Pap smear, a colposcopy, or a friend or family member with cervical cancer).

In contrast, the rate of completion differed significantly by maternal race/ethnicity, with about 40% of the daughters of white mothers having completed the series, compared with 25% of daughters of black mothers and 25% of daughters of Hispanic mothers (P less than .001).

Mothers’ most commonly reported reasons for not initiating HPV vaccination for their daughter were concern about vaccine side effects (cited by 36%), fear that it was dangerous (36%), and lack of a recommendation by their provider (34%).

They also cited a belief that the vaccine did not work (13%), not having seen a provider in a long time (12%), concern about eligibility for or cost of the vaccine (11%), and concern that vaccinating would encourage their daughter to have sex (8%).

"There is no evidence from our data that demographic or socioeconomic disparities played a role in vaccination initiation," commented Dr. Kester. "However, we do see that black and Hispanic populations were less likely to complete vaccination."

Taken together, the findings "suggest there is continued need to encourage vaccine uptake as well as need for further educational interventions, at the level of the patient, the provider, and the parent on vaccine benefit, efficacy, and safety," she said. "In addition, this data reminds us that there is a continuing need to evaluate barriers to vaccination initiation and completion, looking at reasons for racial discrepancy of vaccine completion."

Dr. Kahn reported that she is co-principal investigator on two trials in which Merck is providing the vaccine and immunogenicity testing. Dr. Kester reported that some of her coinvestigators are investigators for or receive research funding from Merck.

SEATTLE – Vaccinating girls against human papillomavirus at age 11 or 12 years, as is currently recommended, appears to be most appropriate for preventing infection, but barriers persist, according to two studies presented at the annual meeting of the Society for Adolescent Health and Medicine.

In a study among girls as young as age 13 years, one in eight who reported that they had never had sexual intercourse nonetheless had vaginal infection with human papillomavirus (HPV). And more than two-thirds of those who had had sex were infected.

In another study among girls aged 14-17 years and their mothers, the most commonly cited reasons for not vaccinating were fear of side effects, perceived danger of the vaccine, and lack of a recommendation to vaccinate from their health care provider.

Prevalence of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that HPV vaccine be targeted to girls aged 11-12 years, with catch-up vaccination in girls and young women aged 13-26 years, noted Dr. Jessica A. Kahn, an associate professor of pediatrics at the University of Cincinnati.

But there is some reluctance among clinicians and parents alike to vaccinate at age 11 or 12, she said. "This is concerning, as HPV is commonly acquired during the teen years, and HPV vaccines are not effective at preventing infections with vaccine types of HPV in young women who are already infected with those types at the time of vaccination."

Data on the prevalence of type-specific HPV infection in girls initiating HPV vaccination are generally lacking, according to Dr. Kahn. "These data are needed in order to estimate the public health impact of HPV vaccination in the catch-up age group, and to guide educational and public health interventions designed to maximize the effectiveness of HPV vaccination."

She and her colleagues studied 259 girls aged 13-21 years who were receiving their first dose of HPV vaccine in a hospital-based adolescent clinic. Clinicians or the girls themselves collected vaginal samples that were tested for 37 HPV types. The girls and their mothers completed questionnaires about factors potentially related to HPV acquisition.

Overall, 27% of the girls were sexually inexperienced, reporting that they had never had vaginal or anal sex. But 13% of this group had had sexual contact, reporting genital skin-to-skin contact only.

The percentage of girls testing positive for any HPV type was 70% in the sexually experienced group and much lower, though not zero, at 12% in the sexually inexperienced group (P less than .001).

The sexually experienced group was also more likely than the inexperienced group to test positive for at least one of the high-risk HPV types in the quadrivalent vaccine – types 6, 11, 16, and 18 (31% vs. 4%, P less than .001) – and for at least one of those in the bivalent vaccine – types 16 and 18 (21% vs. 3%, P less than .001).

In a multivariate analysis of the sexually experienced group, these girls were significantly more likely to be HPV positive if they had had two to five, or six or more lifetime male partners, compared with one partner (odds ratios 6.2 and 10.3) and if their mother reported not having communicated with them about the HPV vaccine (OR 4.0).

In contrast, in the sexually inexperienced group, none of a variety of factors, including reported sexual contact, were independently associated with the odds of being HPV positive.

"Clinicians and parents should be strongly encouraged to vaccinate 11- to 12-year-old girls and not procrastinate," Dr. Kahn asserted. "It’s difficult to predict the age of sexual initiation, and thus, these recommendations by the ACIP minimize the probability that girls will be infected at the time of vaccination."

The findings also support the recommendation for catch-up vaccination in older girls, she added, as a majority of the sexually active group were still negative for high-risk types of the virus covered by the vaccines.

"I think it’s probably helpful for clinicians to develop some brief talking points for use with parents in terms of HPV vaccination," said Dr. Kahn. "Those would include the fact that HPV is acquired very rapidly after sexual initiation, that the vast majority of people will acquire HPV at some point in their lives, and that the vaccine is only effective in preventing vaccine-type HPVs if given before exposure."

"I think it’s really important for us to get those messages out, and I think it can be done in a pretty concise way," she concluded.

Barriers to HPV vaccination. Understanding barriers to HPV vaccination is important not only for promoting uptake, but also possibly for efforts to address disproportionately high rates of HPV infection in certain population groups, according to Dr. Laura M. Kester, a pediatrician at Indiana University in Indianapolis.

"Positive maternal attitudes toward vaccination have been shown to be associated with higher rates of HPV vaccination," she noted.

Dr. Kester and her colleagues studied a national sample of 501 girls aged 14-17 years and their mothers recruited to an online-based survey in 2010. The mothers and daughters completed surveys asking about number of doses of HPV vaccine the daughter had received, sociodemographic factors, insurance status, and maternal experiences related to HPV infection. The mothers of unvaccinated daughters were asked why they had not had their girls vaccinated. Survey results showed that the mothers were 45 years old on average. The majority were white (76%) and college educated (81%).

According to maternal report, 50% of the daughters had initiated HPV vaccination, defined as having received at least one dose, and 38% had completed vaccination, defined as having received all three doses in the series.

These rates suggest improvement from 2009, Dr. Kester noted, when data from the Centers for Disease Control and Prevention showed an initiation rate of 44% and a completion rate of 27%.

The rate of initiation did not vary significantly with the daughter’s insurance status or according to a variety of maternal factors, such as race/ethnicity, education level, relationship status, geographic location, employment status, or exposure to negative experiences related to HPV (having had an abnormal Pap smear, a colposcopy, or a friend or family member with cervical cancer).

In contrast, the rate of completion differed significantly by maternal race/ethnicity, with about 40% of the daughters of white mothers having completed the series, compared with 25% of daughters of black mothers and 25% of daughters of Hispanic mothers (P less than .001).

Mothers’ most commonly reported reasons for not initiating HPV vaccination for their daughter were concern about vaccine side effects (cited by 36%), fear that it was dangerous (36%), and lack of a recommendation by their provider (34%).

They also cited a belief that the vaccine did not work (13%), not having seen a provider in a long time (12%), concern about eligibility for or cost of the vaccine (11%), and concern that vaccinating would encourage their daughter to have sex (8%).

"There is no evidence from our data that demographic or socioeconomic disparities played a role in vaccination initiation," commented Dr. Kester. "However, we do see that black and Hispanic populations were less likely to complete vaccination."

Taken together, the findings "suggest there is continued need to encourage vaccine uptake as well as need for further educational interventions, at the level of the patient, the provider, and the parent on vaccine benefit, efficacy, and safety," she said. "In addition, this data reminds us that there is a continuing need to evaluate barriers to vaccination initiation and completion, looking at reasons for racial discrepancy of vaccine completion."

Dr. Kahn reported that she is co-principal investigator on two trials in which Merck is providing the vaccine and immunogenicity testing. Dr. Kester reported that some of her coinvestigators are investigators for or receive research funding from Merck.

SEATTLE – Vaccinating girls against human papillomavirus at age 11 or 12 years, as is currently recommended, appears to be most appropriate for preventing infection, but barriers persist, according to two studies presented at the annual meeting of the Society for Adolescent Health and Medicine.

In a study among girls as young as age 13 years, one in eight who reported that they had never had sexual intercourse nonetheless had vaginal infection with human papillomavirus (HPV). And more than two-thirds of those who had had sex were infected.

In another study among girls aged 14-17 years and their mothers, the most commonly cited reasons for not vaccinating were fear of side effects, perceived danger of the vaccine, and lack of a recommendation to vaccinate from their health care provider.

Prevalence of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends that HPV vaccine be targeted to girls aged 11-12 years, with catch-up vaccination in girls and young women aged 13-26 years, noted Dr. Jessica A. Kahn, an associate professor of pediatrics at the University of Cincinnati.

But there is some reluctance among clinicians and parents alike to vaccinate at age 11 or 12, she said. "This is concerning, as HPV is commonly acquired during the teen years, and HPV vaccines are not effective at preventing infections with vaccine types of HPV in young women who are already infected with those types at the time of vaccination."

Data on the prevalence of type-specific HPV infection in girls initiating HPV vaccination are generally lacking, according to Dr. Kahn. "These data are needed in order to estimate the public health impact of HPV vaccination in the catch-up age group, and to guide educational and public health interventions designed to maximize the effectiveness of HPV vaccination."

She and her colleagues studied 259 girls aged 13-21 years who were receiving their first dose of HPV vaccine in a hospital-based adolescent clinic. Clinicians or the girls themselves collected vaginal samples that were tested for 37 HPV types. The girls and their mothers completed questionnaires about factors potentially related to HPV acquisition.

Overall, 27% of the girls were sexually inexperienced, reporting that they had never had vaginal or anal sex. But 13% of this group had had sexual contact, reporting genital skin-to-skin contact only.

The percentage of girls testing positive for any HPV type was 70% in the sexually experienced group and much lower, though not zero, at 12% in the sexually inexperienced group (P less than .001).

The sexually experienced group was also more likely than the inexperienced group to test positive for at least one of the high-risk HPV types in the quadrivalent vaccine – types 6, 11, 16, and 18 (31% vs. 4%, P less than .001) – and for at least one of those in the bivalent vaccine – types 16 and 18 (21% vs. 3%, P less than .001).

In a multivariate analysis of the sexually experienced group, these girls were significantly more likely to be HPV positive if they had had two to five, or six or more lifetime male partners, compared with one partner (odds ratios 6.2 and 10.3) and if their mother reported not having communicated with them about the HPV vaccine (OR 4.0).

In contrast, in the sexually inexperienced group, none of a variety of factors, including reported sexual contact, were independently associated with the odds of being HPV positive.

"Clinicians and parents should be strongly encouraged to vaccinate 11- to 12-year-old girls and not procrastinate," Dr. Kahn asserted. "It’s difficult to predict the age of sexual initiation, and thus, these recommendations by the ACIP minimize the probability that girls will be infected at the time of vaccination."

The findings also support the recommendation for catch-up vaccination in older girls, she added, as a majority of the sexually active group were still negative for high-risk types of the virus covered by the vaccines.

"I think it’s probably helpful for clinicians to develop some brief talking points for use with parents in terms of HPV vaccination," said Dr. Kahn. "Those would include the fact that HPV is acquired very rapidly after sexual initiation, that the vast majority of people will acquire HPV at some point in their lives, and that the vaccine is only effective in preventing vaccine-type HPVs if given before exposure."

"I think it’s really important for us to get those messages out, and I think it can be done in a pretty concise way," she concluded.

Barriers to HPV vaccination. Understanding barriers to HPV vaccination is important not only for promoting uptake, but also possibly for efforts to address disproportionately high rates of HPV infection in certain population groups, according to Dr. Laura M. Kester, a pediatrician at Indiana University in Indianapolis.

"Positive maternal attitudes toward vaccination have been shown to be associated with higher rates of HPV vaccination," she noted.

Dr. Kester and her colleagues studied a national sample of 501 girls aged 14-17 years and their mothers recruited to an online-based survey in 2010. The mothers and daughters completed surveys asking about number of doses of HPV vaccine the daughter had received, sociodemographic factors, insurance status, and maternal experiences related to HPV infection. The mothers of unvaccinated daughters were asked why they had not had their girls vaccinated. Survey results showed that the mothers were 45 years old on average. The majority were white (76%) and college educated (81%).

According to maternal report, 50% of the daughters had initiated HPV vaccination, defined as having received at least one dose, and 38% had completed vaccination, defined as having received all three doses in the series.

These rates suggest improvement from 2009, Dr. Kester noted, when data from the Centers for Disease Control and Prevention showed an initiation rate of 44% and a completion rate of 27%.

The rate of initiation did not vary significantly with the daughter’s insurance status or according to a variety of maternal factors, such as race/ethnicity, education level, relationship status, geographic location, employment status, or exposure to negative experiences related to HPV (having had an abnormal Pap smear, a colposcopy, or a friend or family member with cervical cancer).

In contrast, the rate of completion differed significantly by maternal race/ethnicity, with about 40% of the daughters of white mothers having completed the series, compared with 25% of daughters of black mothers and 25% of daughters of Hispanic mothers (P less than .001).

Mothers’ most commonly reported reasons for not initiating HPV vaccination for their daughter were concern about vaccine side effects (cited by 36%), fear that it was dangerous (36%), and lack of a recommendation by their provider (34%).

They also cited a belief that the vaccine did not work (13%), not having seen a provider in a long time (12%), concern about eligibility for or cost of the vaccine (11%), and concern that vaccinating would encourage their daughter to have sex (8%).

"There is no evidence from our data that demographic or socioeconomic disparities played a role in vaccination initiation," commented Dr. Kester. "However, we do see that black and Hispanic populations were less likely to complete vaccination."

Taken together, the findings "suggest there is continued need to encourage vaccine uptake as well as need for further educational interventions, at the level of the patient, the provider, and the parent on vaccine benefit, efficacy, and safety," she said. "In addition, this data reminds us that there is a continuing need to evaluate barriers to vaccination initiation and completion, looking at reasons for racial discrepancy of vaccine completion."

Dr. Kahn reported that she is co-principal investigator on two trials in which Merck is providing the vaccine and immunogenicity testing. Dr. Kester reported that some of her coinvestigators are investigators for or receive research funding from Merck.

SEATTLE – Efforts to promote vaccination of boys against human papillomavirus may be more successful if they de-emphasize infection-related outcomes that make parents uncomfortable because of their sexual associations, according to a study of 158 parents of boys.

Surveyed parents were less likely to intend to vaccinate their son if they ranked anal cancer or oropharyngeal cancer as the most severe possible outcome of human papillomavirus (HPV) infection, investigators reported at the annual meeting of the Society for Adolescent Health and Medicine.

Comments made in focus groups suggested that these cancers elicited negative emotions: stigma in the case of anal cancer because it was associated with anal sex and homosexuality, and anxiety in the case of oropharyngeal cancer because it was associated with oral sex.

"Parents seemed to dwell on the sexual transmission of HPV," commented lead investigator Abigail C. Lees, a research assistant in the pediatrics department at the University of North Carolina, Chapel Hill.

"HPV awareness campaigns should decrease emphasis on outcomes that elicited either stigma associated with anal cancer or increased anxiety associated with oral cancer, and instead focus on prevalence," she recommended. "Furthermore, the parental preoccupation with the sexual transmission of HPV could be entirely avoided by vaccinating children at younger ages, when parents are less likely to associate stigmas or anxiety with their child's behavior and the vaccine."

A quarter of the HPV-associated cancers that occurred in 2009 were in males, according to Ms. Lees. The quadrivalent HPV vaccine is now licensed for prevention of genital warts and anal cancer in both males and females, as well as for prevention of cervical, vulvar, and vaginal cancer in females.

To assess parental knowledge about male HPV outcomes and attitudes about vaccinating sons, the investigators recruited to their study parents of boys aged 11-17 years from a pediatric clinic, university listservs, craigslist, and other venues.

They completed surveys asking about perceived susceptibility (at least a 40% chance) of their son experiencing HPV infection and its outcomes, and perceived severity of the outcomes. They also participated in single-sex focus groups, conducted separately in English and Spanish.

The majority of the parents, 72%, were the boy's mother. By race/ethnicity, 54% were white, 23% were black, 15% were Hispanic, and the rest were other. About a third had a high school diploma or less education. Slightly more than half were currently married. And 61% also had a daughter.

"Overall, parents believed their sons to have a low susceptibility to HPV infection and its outcomes," Ms. Lees reported. Just 22% thought their son was susceptible to infection. And smaller proportions thought he was susceptible to genital warts (18%), oropharyngeal cancer (11%), anal cancer (9%), and penile cancer (9%).

However, 82% of parents believed the consequence of HPV infection in their son would be severe; of these, 31% ranked penile cancer as the most severe possible outcome, 30% oropharyngeal cancer, 23% anal cancer, and 16% genital warts.

Eighty-three percent of parents indicated that they intended to vaccinate their sons against HPV. In a multivariate analysis, parents were more likely to intend to do so if they were older (odds ratio 1.14) and believed that the consequences of HPV infection could be severe (OR 9.94).

On the other hand, they were less likely to intend to vaccinate if they were more educated (OR 0.62). And there were trends whereby they were less likely to intend to do so if they ranked anal cancer or oropharyngeal cancer as the most severe possible outcome (OR 0.25 and 0.67, respectively).

"The most striking finding from our focus groups was that parents had very limited knowledge of HPV infection in males, despite an awareness of HPV in females," commented Ms. Lees. For example, parents were often unaware that HPV infection pertained to boys.

Their comments also provided some insight into why high rankings of certain HPV-related outcomes might have been associated with lower odds of intending to vaccinate. "Parents responded to the sexual nature of transmission, in particular, in focus groups, which revealed parental stigmatization of anal cancer by association with homosexuality among males," she noted.

In addition, "parents expressed an anxiety associated with oral sex practices they perceived youth to be engaging in," Ms. Lees elaborated. "Parents alluded to the frequency of oral sex among youth" and expressed "concerns that youth believe oral sex can be used to avoid infidelity, is safer than intercourse, and preserves their virginity."

Taken together, the study’s findings should help to inform provider and public health efforts to increase uptake of the HPV vaccine among boys, she concluded.

Ms. Lees reported that the investigators received grant support from Merck to conduct the study.

SEATTLE – Efforts to promote vaccination of boys against human papillomavirus may be more successful if they de-emphasize infection-related outcomes that make parents uncomfortable because of their sexual associations, according to a study of 158 parents of boys.

Surveyed parents were less likely to intend to vaccinate their son if they ranked anal cancer or oropharyngeal cancer as the most severe possible outcome of human papillomavirus (HPV) infection, investigators reported at the annual meeting of the Society for Adolescent Health and Medicine.

Comments made in focus groups suggested that these cancers elicited negative emotions: stigma in the case of anal cancer because it was associated with anal sex and homosexuality, and anxiety in the case of oropharyngeal cancer because it was associated with oral sex.

"Parents seemed to dwell on the sexual transmission of HPV," commented lead investigator Abigail C. Lees, a research assistant in the pediatrics department at the University of North Carolina, Chapel Hill.

"HPV awareness campaigns should decrease emphasis on outcomes that elicited either stigma associated with anal cancer or increased anxiety associated with oral cancer, and instead focus on prevalence," she recommended. "Furthermore, the parental preoccupation with the sexual transmission of HPV could be entirely avoided by vaccinating children at younger ages, when parents are less likely to associate stigmas or anxiety with their child's behavior and the vaccine."

A quarter of the HPV-associated cancers that occurred in 2009 were in males, according to Ms. Lees. The quadrivalent HPV vaccine is now licensed for prevention of genital warts and anal cancer in both males and females, as well as for prevention of cervical, vulvar, and vaginal cancer in females.

To assess parental knowledge about male HPV outcomes and attitudes about vaccinating sons, the investigators recruited to their study parents of boys aged 11-17 years from a pediatric clinic, university listservs, craigslist, and other venues.

They completed surveys asking about perceived susceptibility (at least a 40% chance) of their son experiencing HPV infection and its outcomes, and perceived severity of the outcomes. They also participated in single-sex focus groups, conducted separately in English and Spanish.

The majority of the parents, 72%, were the boy's mother. By race/ethnicity, 54% were white, 23% were black, 15% were Hispanic, and the rest were other. About a third had a high school diploma or less education. Slightly more than half were currently married. And 61% also had a daughter.

"Overall, parents believed their sons to have a low susceptibility to HPV infection and its outcomes," Ms. Lees reported. Just 22% thought their son was susceptible to infection. And smaller proportions thought he was susceptible to genital warts (18%), oropharyngeal cancer (11%), anal cancer (9%), and penile cancer (9%).

However, 82% of parents believed the consequence of HPV infection in their son would be severe; of these, 31% ranked penile cancer as the most severe possible outcome, 30% oropharyngeal cancer, 23% anal cancer, and 16% genital warts.

Eighty-three percent of parents indicated that they intended to vaccinate their sons against HPV. In a multivariate analysis, parents were more likely to intend to do so if they were older (odds ratio 1.14) and believed that the consequences of HPV infection could be severe (OR 9.94).

On the other hand, they were less likely to intend to vaccinate if they were more educated (OR 0.62). And there were trends whereby they were less likely to intend to do so if they ranked anal cancer or oropharyngeal cancer as the most severe possible outcome (OR 0.25 and 0.67, respectively).

"The most striking finding from our focus groups was that parents had very limited knowledge of HPV infection in males, despite an awareness of HPV in females," commented Ms. Lees. For example, parents were often unaware that HPV infection pertained to boys.

Their comments also provided some insight into why high rankings of certain HPV-related outcomes might have been associated with lower odds of intending to vaccinate. "Parents responded to the sexual nature of transmission, in particular, in focus groups, which revealed parental stigmatization of anal cancer by association with homosexuality among males," she noted.

In addition, "parents expressed an anxiety associated with oral sex practices they perceived youth to be engaging in," Ms. Lees elaborated. "Parents alluded to the frequency of oral sex among youth" and expressed "concerns that youth believe oral sex can be used to avoid infidelity, is safer than intercourse, and preserves their virginity."

Taken together, the study’s findings should help to inform provider and public health efforts to increase uptake of the HPV vaccine among boys, she concluded.

Ms. Lees reported that the investigators received grant support from Merck to conduct the study.

SEATTLE – Efforts to promote vaccination of boys against human papillomavirus may be more successful if they de-emphasize infection-related outcomes that make parents uncomfortable because of their sexual associations, according to a study of 158 parents of boys.

Surveyed parents were less likely to intend to vaccinate their son if they ranked anal cancer or oropharyngeal cancer as the most severe possible outcome of human papillomavirus (HPV) infection, investigators reported at the annual meeting of the Society for Adolescent Health and Medicine.

Comments made in focus groups suggested that these cancers elicited negative emotions: stigma in the case of anal cancer because it was associated with anal sex and homosexuality, and anxiety in the case of oropharyngeal cancer because it was associated with oral sex.

"Parents seemed to dwell on the sexual transmission of HPV," commented lead investigator Abigail C. Lees, a research assistant in the pediatrics department at the University of North Carolina, Chapel Hill.

"HPV awareness campaigns should decrease emphasis on outcomes that elicited either stigma associated with anal cancer or increased anxiety associated with oral cancer, and instead focus on prevalence," she recommended. "Furthermore, the parental preoccupation with the sexual transmission of HPV could be entirely avoided by vaccinating children at younger ages, when parents are less likely to associate stigmas or anxiety with their child's behavior and the vaccine."

A quarter of the HPV-associated cancers that occurred in 2009 were in males, according to Ms. Lees. The quadrivalent HPV vaccine is now licensed for prevention of genital warts and anal cancer in both males and females, as well as for prevention of cervical, vulvar, and vaginal cancer in females.

To assess parental knowledge about male HPV outcomes and attitudes about vaccinating sons, the investigators recruited to their study parents of boys aged 11-17 years from a pediatric clinic, university listservs, craigslist, and other venues.

They completed surveys asking about perceived susceptibility (at least a 40% chance) of their son experiencing HPV infection and its outcomes, and perceived severity of the outcomes. They also participated in single-sex focus groups, conducted separately in English and Spanish.

The majority of the parents, 72%, were the boy's mother. By race/ethnicity, 54% were white, 23% were black, 15% were Hispanic, and the rest were other. About a third had a high school diploma or less education. Slightly more than half were currently married. And 61% also had a daughter.

"Overall, parents believed their sons to have a low susceptibility to HPV infection and its outcomes," Ms. Lees reported. Just 22% thought their son was susceptible to infection. And smaller proportions thought he was susceptible to genital warts (18%), oropharyngeal cancer (11%), anal cancer (9%), and penile cancer (9%).

However, 82% of parents believed the consequence of HPV infection in their son would be severe; of these, 31% ranked penile cancer as the most severe possible outcome, 30% oropharyngeal cancer, 23% anal cancer, and 16% genital warts.

Eighty-three percent of parents indicated that they intended to vaccinate their sons against HPV. In a multivariate analysis, parents were more likely to intend to do so if they were older (odds ratio 1.14) and believed that the consequences of HPV infection could be severe (OR 9.94).

On the other hand, they were less likely to intend to vaccinate if they were more educated (OR 0.62). And there were trends whereby they were less likely to intend to do so if they ranked anal cancer or oropharyngeal cancer as the most severe possible outcome (OR 0.25 and 0.67, respectively).

"The most striking finding from our focus groups was that parents had very limited knowledge of HPV infection in males, despite an awareness of HPV in females," commented Ms. Lees. For example, parents were often unaware that HPV infection pertained to boys.

Their comments also provided some insight into why high rankings of certain HPV-related outcomes might have been associated with lower odds of intending to vaccinate. "Parents responded to the sexual nature of transmission, in particular, in focus groups, which revealed parental stigmatization of anal cancer by association with homosexuality among males," she noted.

In addition, "parents expressed an anxiety associated with oral sex practices they perceived youth to be engaging in," Ms. Lees elaborated. "Parents alluded to the frequency of oral sex among youth" and expressed "concerns that youth believe oral sex can be used to avoid infidelity, is safer than intercourse, and preserves their virginity."

Taken together, the study’s findings should help to inform provider and public health efforts to increase uptake of the HPV vaccine among boys, she concluded.

Ms. Lees reported that the investigators received grant support from Merck to conduct the study.

SEATTLE – Awareness is not enough when it comes to promoting uptake of the meningococcal vaccine among adolescents, suggest results of a recent North Carolina survey.

Two-thirds of the more than 1,000 parents of adolescents polled had heard of the vaccine, which the Advisory Committee on Immunization Practices (ACIP) recommends be given at the age of 11-12 years and, because of waning immunity, again as a booster at the age of 16 years.

But just 44% of these parents had had their adolescent vaccinated, lead investigator Dr. Tamera Coyne-Beasley reported at the annual meeting of the Society for Adolescent Health and Medicine. In addition, 39% of the parents of unvaccinated adolescents indicated that they probably or definitely would not vaccinate them in the next year.

The leading reason parents cited for nonvaccination was that their health care provider had not mentioned or recommended the vaccine. Some also gave as a reason not having seen their doctor recently.

"Interventions are urgently needed to increase the uptake of meningococcal conjugate vaccine, particularly in light of the new recommendation for a booster dose, and the substantial proportion of parents ... who reported that they still definitely or probably will not get the vaccine," Dr. Coyne-Beasley said. "Strategies such as increasing provider recommendations and increasing regular preventive visits may be important."

"One of the things I would like to explore is what are those issues [behind nonvaccination] and how can we overcome them," she commented. Some people "may have just an inherent philosophy that we may not understand about why they don’t want to get vaccines. But I do think that there are things we can work with, with families."

The investigators analyzed data from the 2008 Child Health Assessment and Monitoring Program (CHAMP) telephone survey conducted in North Carolina, a state that does not mandate receipt of the meningococcal vaccine for school entry. The survey involved households from a larger, random, population-based survey that had at least one child under age 18.

The individual in the household most knowledgeable about the child’s health was read a list of possible names of the meningococcal vaccine (meningitis shot, meningococcal shot, Menactra) and asked whether they had heard of it, and if they had, whether the child had received it.

Data from parents of adolescents aged 11-17 years were weighted to provide population-based estimates, according to Dr. Coyne-Beasley, who is an associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill.

In all, 1,281 parents completed the survey. Some 48% were 40-49 years old, and two-thirds were female. Some 74% were married or cohabiting with a partner, and 71% were employed.

On average, the adolescents were 14.1 years old. They were equally split by sex. Some 63% were white, 23% were black, 9% were Hispanic, and 5% were of other races/ethnicities.

The majority of the adolescents attended public school (88%), had health insurance (93%), had a regular health care provider (83%), and had had a preventive checkup in the past 12 months (78%).

Fully 65% of the surveyed parents were aware of the meningococcal vaccine, according to Dr. Coyne-Beasley. She noted that the state did not have any meningitis outbreaks during the survey year, which usually increase awareness.

In multivariate analyses, parents were significantly more likely to be aware of the vaccine if their child was aged 16-17 years compared with 11-12 years (odds ratio 1.82), attended private school compared with public school (OR 1.95), and had health insurance (OR 1.90).

On the other hand, parents were significantly less likely to be aware of the vaccine if their child was Hispanic compared with white (OR 0.50).

Just 44% of the parents who were aware of the meningococcal vaccine had had their adolescent vaccinated.

In multivariate analyses, adolescents were significantly more likely to have been vaccinated if they were black versus white (OR 2.17), had had a preventive health checkup in the past 12 months (OR 3.03), and lived in a household having two or more children under age 18 (OR 1.83).

Among the parents who had not had their adolescent vaccinated, the single most common reason, cited by 25%, was that their health care provider did not mention or recommend the vaccine, Dr. Coyne-Beasley reported. Other reasons cited included believing that their adolescent did not need the vaccine (14%), wanting to wait until he or she was older (10%), concerns about vaccine safety (9%), and not having been to a doctor recently (8%).

More than half of these parents of unvaccinated children said that in the next year, they definitely would (21%) or probably would (33%) have them vaccinated, and a small minority (8%) were unsure.

However, sizable proportions said they probably would not (29%) or definitely would not (10%) have their child vaccinated in the next year.

"Awareness of a vaccine doesn’t necessarily mean that one will get it," Dr. Coyne-Beasley concluded, and it will be important to ascertain the reasons for the observed disconnect between awareness and uptake of the meningococcal vaccine among adolescents.

The study had its limitations, she acknowledged. They included the self-reported nature of the data, potential limited generalizability, inclusion of only households having a landline telephone, and availability of just a single meningococcal conjugate vaccine at the time of the survey.

Dr. Coyne-Beasley reported that she did not have any relevant financial disclosures.

SEATTLE – Awareness is not enough when it comes to promoting uptake of the meningococcal vaccine among adolescents, suggest results of a recent North Carolina survey.

Two-thirds of the more than 1,000 parents of adolescents polled had heard of the vaccine, which the Advisory Committee on Immunization Practices (ACIP) recommends be given at the age of 11-12 years and, because of waning immunity, again as a booster at the age of 16 years.

But just 44% of these parents had had their adolescent vaccinated, lead investigator Dr. Tamera Coyne-Beasley reported at the annual meeting of the Society for Adolescent Health and Medicine. In addition, 39% of the parents of unvaccinated adolescents indicated that they probably or definitely would not vaccinate them in the next year.

The leading reason parents cited for nonvaccination was that their health care provider had not mentioned or recommended the vaccine. Some also gave as a reason not having seen their doctor recently.

"Interventions are urgently needed to increase the uptake of meningococcal conjugate vaccine, particularly in light of the new recommendation for a booster dose, and the substantial proportion of parents ... who reported that they still definitely or probably will not get the vaccine," Dr. Coyne-Beasley said. "Strategies such as increasing provider recommendations and increasing regular preventive visits may be important."

"One of the things I would like to explore is what are those issues [behind nonvaccination] and how can we overcome them," she commented. Some people "may have just an inherent philosophy that we may not understand about why they don’t want to get vaccines. But I do think that there are things we can work with, with families."

The investigators analyzed data from the 2008 Child Health Assessment and Monitoring Program (CHAMP) telephone survey conducted in North Carolina, a state that does not mandate receipt of the meningococcal vaccine for school entry. The survey involved households from a larger, random, population-based survey that had at least one child under age 18.

The individual in the household most knowledgeable about the child’s health was read a list of possible names of the meningococcal vaccine (meningitis shot, meningococcal shot, Menactra) and asked whether they had heard of it, and if they had, whether the child had received it.

Data from parents of adolescents aged 11-17 years were weighted to provide population-based estimates, according to Dr. Coyne-Beasley, who is an associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill.

In all, 1,281 parents completed the survey. Some 48% were 40-49 years old, and two-thirds were female. Some 74% were married or cohabiting with a partner, and 71% were employed.

On average, the adolescents were 14.1 years old. They were equally split by sex. Some 63% were white, 23% were black, 9% were Hispanic, and 5% were of other races/ethnicities.

The majority of the adolescents attended public school (88%), had health insurance (93%), had a regular health care provider (83%), and had had a preventive checkup in the past 12 months (78%).

Fully 65% of the surveyed parents were aware of the meningococcal vaccine, according to Dr. Coyne-Beasley. She noted that the state did not have any meningitis outbreaks during the survey year, which usually increase awareness.

In multivariate analyses, parents were significantly more likely to be aware of the vaccine if their child was aged 16-17 years compared with 11-12 years (odds ratio 1.82), attended private school compared with public school (OR 1.95), and had health insurance (OR 1.90).

On the other hand, parents were significantly less likely to be aware of the vaccine if their child was Hispanic compared with white (OR 0.50).

Just 44% of the parents who were aware of the meningococcal vaccine had had their adolescent vaccinated.

In multivariate analyses, adolescents were significantly more likely to have been vaccinated if they were black versus white (OR 2.17), had had a preventive health checkup in the past 12 months (OR 3.03), and lived in a household having two or more children under age 18 (OR 1.83).

Among the parents who had not had their adolescent vaccinated, the single most common reason, cited by 25%, was that their health care provider did not mention or recommend the vaccine, Dr. Coyne-Beasley reported. Other reasons cited included believing that their adolescent did not need the vaccine (14%), wanting to wait until he or she was older (10%), concerns about vaccine safety (9%), and not having been to a doctor recently (8%).

More than half of these parents of unvaccinated children said that in the next year, they definitely would (21%) or probably would (33%) have them vaccinated, and a small minority (8%) were unsure.

However, sizable proportions said they probably would not (29%) or definitely would not (10%) have their child vaccinated in the next year.

"Awareness of a vaccine doesn’t necessarily mean that one will get it," Dr. Coyne-Beasley concluded, and it will be important to ascertain the reasons for the observed disconnect between awareness and uptake of the meningococcal vaccine among adolescents.

The study had its limitations, she acknowledged. They included the self-reported nature of the data, potential limited generalizability, inclusion of only households having a landline telephone, and availability of just a single meningococcal conjugate vaccine at the time of the survey.

Dr. Coyne-Beasley reported that she did not have any relevant financial disclosures.

SEATTLE – Awareness is not enough when it comes to promoting uptake of the meningococcal vaccine among adolescents, suggest results of a recent North Carolina survey.

Two-thirds of the more than 1,000 parents of adolescents polled had heard of the vaccine, which the Advisory Committee on Immunization Practices (ACIP) recommends be given at the age of 11-12 years and, because of waning immunity, again as a booster at the age of 16 years.

But just 44% of these parents had had their adolescent vaccinated, lead investigator Dr. Tamera Coyne-Beasley reported at the annual meeting of the Society for Adolescent Health and Medicine. In addition, 39% of the parents of unvaccinated adolescents indicated that they probably or definitely would not vaccinate them in the next year.

The leading reason parents cited for nonvaccination was that their health care provider had not mentioned or recommended the vaccine. Some also gave as a reason not having seen their doctor recently.

"Interventions are urgently needed to increase the uptake of meningococcal conjugate vaccine, particularly in light of the new recommendation for a booster dose, and the substantial proportion of parents ... who reported that they still definitely or probably will not get the vaccine," Dr. Coyne-Beasley said. "Strategies such as increasing provider recommendations and increasing regular preventive visits may be important."

"One of the things I would like to explore is what are those issues [behind nonvaccination] and how can we overcome them," she commented. Some people "may have just an inherent philosophy that we may not understand about why they don’t want to get vaccines. But I do think that there are things we can work with, with families."

The investigators analyzed data from the 2008 Child Health Assessment and Monitoring Program (CHAMP) telephone survey conducted in North Carolina, a state that does not mandate receipt of the meningococcal vaccine for school entry. The survey involved households from a larger, random, population-based survey that had at least one child under age 18.

The individual in the household most knowledgeable about the child’s health was read a list of possible names of the meningococcal vaccine (meningitis shot, meningococcal shot, Menactra) and asked whether they had heard of it, and if they had, whether the child had received it.

Data from parents of adolescents aged 11-17 years were weighted to provide population-based estimates, according to Dr. Coyne-Beasley, who is an associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill.

In all, 1,281 parents completed the survey. Some 48% were 40-49 years old, and two-thirds were female. Some 74% were married or cohabiting with a partner, and 71% were employed.

On average, the adolescents were 14.1 years old. They were equally split by sex. Some 63% were white, 23% were black, 9% were Hispanic, and 5% were of other races/ethnicities.

The majority of the adolescents attended public school (88%), had health insurance (93%), had a regular health care provider (83%), and had had a preventive checkup in the past 12 months (78%).

Fully 65% of the surveyed parents were aware of the meningococcal vaccine, according to Dr. Coyne-Beasley. She noted that the state did not have any meningitis outbreaks during the survey year, which usually increase awareness.

In multivariate analyses, parents were significantly more likely to be aware of the vaccine if their child was aged 16-17 years compared with 11-12 years (odds ratio 1.82), attended private school compared with public school (OR 1.95), and had health insurance (OR 1.90).

On the other hand, parents were significantly less likely to be aware of the vaccine if their child was Hispanic compared with white (OR 0.50).

Just 44% of the parents who were aware of the meningococcal vaccine had had their adolescent vaccinated.

In multivariate analyses, adolescents were significantly more likely to have been vaccinated if they were black versus white (OR 2.17), had had a preventive health checkup in the past 12 months (OR 3.03), and lived in a household having two or more children under age 18 (OR 1.83).

Among the parents who had not had their adolescent vaccinated, the single most common reason, cited by 25%, was that their health care provider did not mention or recommend the vaccine, Dr. Coyne-Beasley reported. Other reasons cited included believing that their adolescent did not need the vaccine (14%), wanting to wait until he or she was older (10%), concerns about vaccine safety (9%), and not having been to a doctor recently (8%).

More than half of these parents of unvaccinated children said that in the next year, they definitely would (21%) or probably would (33%) have them vaccinated, and a small minority (8%) were unsure.

However, sizable proportions said they probably would not (29%) or definitely would not (10%) have their child vaccinated in the next year.

"Awareness of a vaccine doesn’t necessarily mean that one will get it," Dr. Coyne-Beasley concluded, and it will be important to ascertain the reasons for the observed disconnect between awareness and uptake of the meningococcal vaccine among adolescents.

The study had its limitations, she acknowledged. They included the self-reported nature of the data, potential limited generalizability, inclusion of only households having a landline telephone, and availability of just a single meningococcal conjugate vaccine at the time of the survey.

Dr. Coyne-Beasley reported that she did not have any relevant financial disclosures.

SEATTLE – Awareness is not enough when it comes to promoting uptake of the meningococcal vaccine among adolescents, suggest results of a recent North Carolina survey.

Two-thirds of the more than 1,000 parents of adolescents polled had heard of the vaccine, which the Advisory Committee on Immunization Practices (ACIP) recommends be given at the age of 11-12 years and, because of waning immunity, again as a booster at the age of 16 years.

But just 44% of these parents had had their adolescent vaccinated, lead investigator Dr. Tamera Coyne-Beasley reported at the annual meeting of the Society for Adolescent Health and Medicine. In addition, 39% of the parents of unvaccinated adolescents indicated that they probably or definitely would not vaccinate them in the next year.

The leading reason parents cited for nonvaccination was that their health care provider had not mentioned or recommended the vaccine. Some also gave as a reason not having seen their doctor recently.

"Interventions are urgently needed to increase the uptake of meningococcal conjugate vaccine, particularly in light of the new recommendation for a booster dose, and the substantial proportion of parents ... who reported that they still definitely or probably will not get the vaccine," Dr. Coyne-Beasley said. "Strategies such as increasing provider recommendations and increasing regular preventive visits may be important."

"One of the things I would like to explore is what are those issues [behind nonvaccination] and how can we overcome them," she commented. Some people "may have just an inherent philosophy that we may not understand about why they don’t want to get vaccines. But I do think that there are things we can work with, with families."

The investigators analyzed data from the 2008 Child Health Assessment and Monitoring Program (CHAMP) telephone survey conducted in North Carolina, a state that does not mandate receipt of the meningococcal vaccine for school entry. The survey involved households from a larger, random, population-based survey that had at least one child under age 18.

The individual in the household most knowledgeable about the child’s health was read a list of possible names of the meningococcal vaccine (meningitis shot, meningococcal shot, Menactra) and asked whether they had heard of it, and if they had, whether the child had received it.

Data from parents of adolescents aged 11-17 years were weighted to provide population-based estimates, according to Dr. Coyne-Beasley, who is an associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill.

In all, 1,281 parents completed the survey. Some 48% were 40-49 years old, and two-thirds were female. Some 74% were married or cohabiting with a partner, and 71% were employed.

On average, the adolescents were 14.1 years old. They were equally split by sex. Some 63% were white, 23% were black, 9% were Hispanic, and 5% were of other races/ethnicities.

The majority of the adolescents attended public school (88%), had health insurance (93%), had a regular health care provider (83%), and had had a preventive checkup in the past 12 months (78%).

Fully 65% of the surveyed parents were aware of the meningococcal vaccine, according to Dr. Coyne-Beasley. She noted that the state did not have any meningitis outbreaks during the survey year, which usually increase awareness.

In multivariate analyses, parents were significantly more likely to be aware of the vaccine if their child was aged 16-17 years compared with 11-12 years (odds ratio 1.82), attended private school compared with public school (OR 1.95), and had health insurance (OR 1.90).

On the other hand, parents were significantly less likely to be aware of the vaccine if their child was Hispanic compared with white (OR 0.50).

Just 44% of the parents who were aware of the meningococcal vaccine had had their adolescent vaccinated.

In multivariate analyses, adolescents were significantly more likely to have been vaccinated if they were black versus white (OR 2.17), had had a preventive health checkup in the past 12 months (OR 3.03), and lived in a household having two or more children under age 18 (OR 1.83).

Among the parents who had not had their adolescent vaccinated, the single most common reason, cited by 25%, was that their health care provider did not mention or recommend the vaccine, Dr. Coyne-Beasley reported. Other reasons cited included believing that their adolescent did not need the vaccine (14%), wanting to wait until he or she was older (10%), concerns about vaccine safety (9%), and not having been to a doctor recently (8%).

More than half of these parents of unvaccinated children said that in the next year, they definitely would (21%) or probably would (33%) have them vaccinated, and a small minority (8%) were unsure.

However, sizable proportions said they probably would not (29%) or definitely would not (10%) have their child vaccinated in the next year.

"Awareness of a vaccine doesn’t necessarily mean that one will get it," Dr. Coyne-Beasley concluded, and it will be important to ascertain the reasons for the observed disconnect between awareness and uptake of the meningococcal vaccine among adolescents.

The study had its limitations, she acknowledged. They included the self-reported nature of the data, potential limited generalizability, inclusion of only households having a landline telephone, and availability of just a single meningococcal conjugate vaccine at the time of the survey.

Dr. Coyne-Beasley reported that she did not have any relevant financial disclosures.

SEATTLE – Awareness is not enough when it comes to promoting uptake of the meningococcal vaccine among adolescents, suggest results of a recent North Carolina survey.

Two-thirds of the more than 1,000 parents of adolescents polled had heard of the vaccine, which the Advisory Committee on Immunization Practices (ACIP) recommends be given at the age of 11-12 years and, because of waning immunity, again as a booster at the age of 16 years.

But just 44% of these parents had had their adolescent vaccinated, lead investigator Dr. Tamera Coyne-Beasley reported at the annual meeting of the Society for Adolescent Health and Medicine. In addition, 39% of the parents of unvaccinated adolescents indicated that they probably or definitely would not vaccinate them in the next year.

The leading reason parents cited for nonvaccination was that their health care provider had not mentioned or recommended the vaccine. Some also gave as a reason not having seen their doctor recently.

"Interventions are urgently needed to increase the uptake of meningococcal conjugate vaccine, particularly in light of the new recommendation for a booster dose, and the substantial proportion of parents ... who reported that they still definitely or probably will not get the vaccine," Dr. Coyne-Beasley said. "Strategies such as increasing provider recommendations and increasing regular preventive visits may be important."

"One of the things I would like to explore is what are those issues [behind nonvaccination] and how can we overcome them," she commented. Some people "may have just an inherent philosophy that we may not understand about why they don’t want to get vaccines. But I do think that there are things we can work with, with families."

The investigators analyzed data from the 2008 Child Health Assessment and Monitoring Program (CHAMP) telephone survey conducted in North Carolina, a state that does not mandate receipt of the meningococcal vaccine for school entry. The survey involved households from a larger, random, population-based survey that had at least one child under age 18.

The individual in the household most knowledgeable about the child’s health was read a list of possible names of the meningococcal vaccine (meningitis shot, meningococcal shot, Menactra) and asked whether they had heard of it, and if they had, whether the child had received it.

Data from parents of adolescents aged 11-17 years were weighted to provide population-based estimates, according to Dr. Coyne-Beasley, who is an associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill.

In all, 1,281 parents completed the survey. Some 48% were 40-49 years old, and two-thirds were female. Some 74% were married or cohabiting with a partner, and 71% were employed.

On average, the adolescents were 14.1 years old. They were equally split by sex. Some 63% were white, 23% were black, 9% were Hispanic, and 5% were of other races/ethnicities.

The majority of the adolescents attended public school (88%), had health insurance (93%), had a regular health care provider (83%), and had had a preventive checkup in the past 12 months (78%).

Fully 65% of the surveyed parents were aware of the meningococcal vaccine, according to Dr. Coyne-Beasley. She noted that the state did not have any meningitis outbreaks during the survey year, which usually increase awareness.

In multivariate analyses, parents were significantly more likely to be aware of the vaccine if their child was aged 16-17 years compared with 11-12 years (odds ratio 1.82), attended private school compared with public school (OR 1.95), and had health insurance (OR 1.90).

On the other hand, parents were significantly less likely to be aware of the vaccine if their child was Hispanic compared with white (OR 0.50).

Just 44% of the parents who were aware of the meningococcal vaccine had had their adolescent vaccinated.

In multivariate analyses, adolescents were significantly more likely to have been vaccinated if they were black versus white (OR 2.17), had had a preventive health checkup in the past 12 months (OR 3.03), and lived in a household having two or more children under age 18 (OR 1.83).

Among the parents who had not had their adolescent vaccinated, the single most common reason, cited by 25%, was that their health care provider did not mention or recommend the vaccine, Dr. Coyne-Beasley reported. Other reasons cited included believing that their adolescent did not need the vaccine (14%), wanting to wait until he or she was older (10%), concerns about vaccine safety (9%), and not having been to a doctor recently (8%).

More than half of these parents of unvaccinated children said that in the next year, they definitely would (21%) or probably would (33%) have them vaccinated, and a small minority (8%) were unsure.

However, sizable proportions said they probably would not (29%) or definitely would not (10%) have their child vaccinated in the next year.

"Awareness of a vaccine doesn’t necessarily mean that one will get it," Dr. Coyne-Beasley concluded, and it will be important to ascertain the reasons for the observed disconnect between awareness and uptake of the meningococcal vaccine among adolescents.

The study had its limitations, she acknowledged. They included the self-reported nature of the data, potential limited generalizability, inclusion of only households having a landline telephone, and availability of just a single meningococcal conjugate vaccine at the time of the survey.

Dr. Coyne-Beasley reported that she did not have any relevant financial disclosures.

SEATTLE – Awareness is not enough when it comes to promoting uptake of the meningococcal vaccine among adolescents, suggest results of a recent North Carolina survey.

Two-thirds of the more than 1,000 parents of adolescents polled had heard of the vaccine, which the Advisory Committee on Immunization Practices (ACIP) recommends be given at the age of 11-12 years and, because of waning immunity, again as a booster at the age of 16 years.

But just 44% of these parents had had their adolescent vaccinated, lead investigator Dr. Tamera Coyne-Beasley reported at the annual meeting of the Society for Adolescent Health and Medicine. In addition, 39% of the parents of unvaccinated adolescents indicated that they probably or definitely would not vaccinate them in the next year.

The leading reason parents cited for nonvaccination was that their health care provider had not mentioned or recommended the vaccine. Some also gave as a reason not having seen their doctor recently.

"Interventions are urgently needed to increase the uptake of meningococcal conjugate vaccine, particularly in light of the new recommendation for a booster dose, and the substantial proportion of parents ... who reported that they still definitely or probably will not get the vaccine," Dr. Coyne-Beasley said. "Strategies such as increasing provider recommendations and increasing regular preventive visits may be important."

"One of the things I would like to explore is what are those issues [behind nonvaccination] and how can we overcome them," she commented. Some people "may have just an inherent philosophy that we may not understand about why they don’t want to get vaccines. But I do think that there are things we can work with, with families."

The investigators analyzed data from the 2008 Child Health Assessment and Monitoring Program (CHAMP) telephone survey conducted in North Carolina, a state that does not mandate receipt of the meningococcal vaccine for school entry. The survey involved households from a larger, random, population-based survey that had at least one child under age 18.

The individual in the household most knowledgeable about the child’s health was read a list of possible names of the meningococcal vaccine (meningitis shot, meningococcal shot, Menactra) and asked whether they had heard of it, and if they had, whether the child had received it.

Data from parents of adolescents aged 11-17 years were weighted to provide population-based estimates, according to Dr. Coyne-Beasley, who is an associate professor of pediatrics and internal medicine at the University of North Carolina, Chapel Hill.

In all, 1,281 parents completed the survey. Some 48% were 40-49 years old, and two-thirds were female. Some 74% were married or cohabiting with a partner, and 71% were employed.

On average, the adolescents were 14.1 years old. They were equally split by sex. Some 63% were white, 23% were black, 9% were Hispanic, and 5% were of other races/ethnicities.

The majority of the adolescents attended public school (88%), had health insurance (93%), had a regular health care provider (83%), and had had a preventive checkup in the past 12 months (78%).

Fully 65% of the surveyed parents were aware of the meningococcal vaccine, according to Dr. Coyne-Beasley. She noted that the state did not have any meningitis outbreaks during the survey year, which usually increase awareness.

In multivariate analyses, parents were significantly more likely to be aware of the vaccine if their child was aged 16-17 years compared with 11-12 years (odds ratio 1.82), attended private school compared with public school (OR 1.95), and had health insurance (OR 1.90).

On the other hand, parents were significantly less likely to be aware of the vaccine if their child was Hispanic compared with white (OR 0.50).

Just 44% of the parents who were aware of the meningococcal vaccine had had their adolescent vaccinated.

In multivariate analyses, adolescents were significantly more likely to have been vaccinated if they were black versus white (OR 2.17), had had a preventive health checkup in the past 12 months (OR 3.03), and lived in a household having two or more children under age 18 (OR 1.83).

Among the parents who had not had their adolescent vaccinated, the single most common reason, cited by 25%, was that their health care provider did not mention or recommend the vaccine, Dr. Coyne-Beasley reported. Other reasons cited included believing that their adolescent did not need the vaccine (14%), wanting to wait until he or she was older (10%), concerns about vaccine safety (9%), and not having been to a doctor recently (8%).

More than half of these parents of unvaccinated children said that in the next year, they definitely would (21%) or probably would (33%) have them vaccinated, and a small minority (8%) were unsure.

However, sizable proportions said they probably would not (29%) or definitely would not (10%) have their child vaccinated in the next year.

"Awareness of a vaccine doesn’t necessarily mean that one will get it," Dr. Coyne-Beasley concluded, and it will be important to ascertain the reasons for the observed disconnect between awareness and uptake of the meningococcal vaccine among adolescents.

The study had its limitations, she acknowledged. They included the self-reported nature of the data, potential limited generalizability, inclusion of only households having a landline telephone, and availability of just a single meningococcal conjugate vaccine at the time of the survey.

Dr. Coyne-Beasley reported that she did not have any relevant financial disclosures.

SEATTLE – A new index that captures the multiple and complex aspects of media use among today’s youth helps identify those at high risk for drinking, new data show.

In a cross-sectional study among 126 middle school students, relative to their peers having a media involvement index (MII) in the bottom tertile, those having an MII in the top tertile had four- to fivefold higher odds of being current drinkers after potential confounders were taken into account.

Students with a top-tertile MII also had similarly elevated odds of having alcohol risk factors in general, such as planning to drink in the next year, principal investigator Craig S. Ross reported at the annual meeting of the Society for Adolescent Health and Medicine.

In contrast, measures that have traditionally been used to assess media use among adolescents, such as time spent watching television, showed little or no association with these outcomes.

"Adolescents are really avid experimenters, and the new media environment provides inexpensive and powerful tools to facilitate experimentation," he said. "We need new measures in public health to reflect the changing media environment, and the MII shows promise as one such new measure."

The observed associations have several possible explanations, according to Mr. Ross, who is a doctoral student in the epidemiology department at the Boston University School of Public Health.

"Heavy media use may be a marker for sensation seeking or self-medication, or a need to belong among these young adolescents," he speculated. "It may expose them to more normalizing portrayals of alcohol use, and it may enable them to share potentially unhealthful messages with their peers."

Past studies have linked traditional measures of media use to both initiation and frequency of drinking among adolescents, Mr. Ross noted. "The key challenge we face today is that the media environment is rapidly changing, and adolescents really are at the vanguard of this change."

"In this changing media environment, we set out to determine which traditional measures of media use would be associated with alcohol risk factors among young adolescents, and whether we could identify new measures that capture the ubiquity of media access and multitasking behaviors," he explained.

The investigators studied 126 middle school students aged 13-15 years from a small New England city who were participants in the Measuring Youth Media Exposure Study. All were recruited from school and community settings.

Analyses were based on students’ self-reported data from computer-assisted interviews conducted at baseline between January and November 2009. Overall, 53% of the students were boys, 37% were black or Hispanic, and 44% lived with a single mother.

The MII captured multiple facets of media access and activity among the youth, including the presence of media in their bedroom, possession of portable media, media multitasking behaviors (such as using the phone while watching television), use of media while traveling, and home background media (such as having the television on while nobody is watching). Possible scores ranged from 0 to 23 points.

In terms of alcohol outcomes, 18% of the students fell into a general alcohol risk group because they were current drinkers, had positive attitudes about alcohol, and/or intended to drink within a year. Some 10% specifically were current drinkers.

Traditional measures of media use showed only limited associations with these outcomes, according to Mr. Ross. Time spent listening to music was associated with both having alcohol risk factors (P = .01) and being a current drinker (P = .01). And overall time spent using nonprint media was associated with the latter (P = .03).

But a variety of other individual measures – television time, video game time, cell phone time, and e-mail/chat time, among others – were not significantly associated with alcohol outcomes. "These isolated measures of time spent with different media really don’t reflect the modern media environment," he commented.

The students had MIIs ranging from 4 to 19, with an average of 10. When they were split into tertiles by MII, the bottom tertile had values of 4-7, and the top tertile had values of 12-19.

"Just to give you a sense of what these kids might look like from a media perspective, a typical participant in the upper tertile has a full complement of bedroom media, including a television hooked up to premium cable, a video game console, and a computer hooked up to the Internet. They will have a cell phone and a notebook computer, and they are going to be multitasking with these devices frequently," Mr. Ross explained.

"On the other end of the scale, a typical participant in the lower tertile may have a television in their bedroom, but it’s not hooked up to premium cable. They do not have a computer in their bedroom, and only half have a cell phone. Very few will have a notebook computer, and in this group, media multitasking is infrequent," he said.

Compared with their counterparts in the bottom tertile of MII, students in the top tertile were significantly more likely to fall into the alcohol risk group in unadjusted analysis (odds ratio 6.01) and also in analyses that adjusted for age (OR 4.9) and for race (OR 5.2).

Similarly, students with a top-tertile MII were significantly more likely to fall into the current drinker group in unadjusted analysis (OR 6.6) and in analyses adjusting for age (OR 4.6), time with friends (OR 4.6), parental media monitoring (OR 4.9), and minutes spent listening to music (OR 4.3).

Additional analyses showed that potential confounders that might influence both media use and alcohol use, such as anxiety disorders, did not explain the observed associations, according to Mr. Ross.

Might it be possible, a person in attendance asked, that adolescents spending more time using media also are spending less time developing social skills and building supportive family relationships that could be protective in this context?

"The simple answer is, this is a very complex, changing dynamic right now," Mr. Ross replied. "What we are hypothesizing is that kids are getting a chance to experiment much more rapidly and get feedback much more rapidly on different kinds of identities through these media, and that can lead to higher-risk behaviors and an acceleration of a lot of other factors.

"We hope to explore prospective associations between the MII and a number of outcomes in future research," he concluded, including sexual activity, use of tobacco and other substances, and personal injury from high-risk activities.

Mr. Ross reported that he had no relevant conflicts of interest.

SEATTLE – A new index that captures the multiple and complex aspects of media use among today’s youth helps identify those at high risk for drinking, new data show.

In a cross-sectional study among 126 middle school students, relative to their peers having a media involvement index (MII) in the bottom tertile, those having an MII in the top tertile had four- to fivefold higher odds of being current drinkers after potential confounders were taken into account.

Students with a top-tertile MII also had similarly elevated odds of having alcohol risk factors in general, such as planning to drink in the next year, principal investigator Craig S. Ross reported at the annual meeting of the Society for Adolescent Health and Medicine.

In contrast, measures that have traditionally been used to assess media use among adolescents, such as time spent watching television, showed little or no association with these outcomes.

"Adolescents are really avid experimenters, and the new media environment provides inexpensive and powerful tools to facilitate experimentation," he said. "We need new measures in public health to reflect the changing media environment, and the MII shows promise as one such new measure."

The observed associations have several possible explanations, according to Mr. Ross, who is a doctoral student in the epidemiology department at the Boston University School of Public Health.

"Heavy media use may be a marker for sensation seeking or self-medication, or a need to belong among these young adolescents," he speculated. "It may expose them to more normalizing portrayals of alcohol use, and it may enable them to share potentially unhealthful messages with their peers."

Past studies have linked traditional measures of media use to both initiation and frequency of drinking among adolescents, Mr. Ross noted. "The key challenge we face today is that the media environment is rapidly changing, and adolescents really are at the vanguard of this change."

"In this changing media environment, we set out to determine which traditional measures of media use would be associated with alcohol risk factors among young adolescents, and whether we could identify new measures that capture the ubiquity of media access and multitasking behaviors," he explained.

The investigators studied 126 middle school students aged 13-15 years from a small New England city who were participants in the Measuring Youth Media Exposure Study. All were recruited from school and community settings.

Analyses were based on students’ self-reported data from computer-assisted interviews conducted at baseline between January and November 2009. Overall, 53% of the students were boys, 37% were black or Hispanic, and 44% lived with a single mother.

The MII captured multiple facets of media access and activity among the youth, including the presence of media in their bedroom, possession of portable media, media multitasking behaviors (such as using the phone while watching television), use of media while traveling, and home background media (such as having the television on while nobody is watching). Possible scores ranged from 0 to 23 points.

In terms of alcohol outcomes, 18% of the students fell into a general alcohol risk group because they were current drinkers, had positive attitudes about alcohol, and/or intended to drink within a year. Some 10% specifically were current drinkers.

Traditional measures of media use showed only limited associations with these outcomes, according to Mr. Ross. Time spent listening to music was associated with both having alcohol risk factors (P = .01) and being a current drinker (P = .01). And overall time spent using nonprint media was associated with the latter (P = .03).

But a variety of other individual measures – television time, video game time, cell phone time, and e-mail/chat time, among others – were not significantly associated with alcohol outcomes. "These isolated measures of time spent with different media really don’t reflect the modern media environment," he commented.

The students had MIIs ranging from 4 to 19, with an average of 10. When they were split into tertiles by MII, the bottom tertile had values of 4-7, and the top tertile had values of 12-19.

"Just to give you a sense of what these kids might look like from a media perspective, a typical participant in the upper tertile has a full complement of bedroom media, including a television hooked up to premium cable, a video game console, and a computer hooked up to the Internet. They will have a cell phone and a notebook computer, and they are going to be multitasking with these devices frequently," Mr. Ross explained.

"On the other end of the scale, a typical participant in the lower tertile may have a television in their bedroom, but it’s not hooked up to premium cable. They do not have a computer in their bedroom, and only half have a cell phone. Very few will have a notebook computer, and in this group, media multitasking is infrequent," he said.

Compared with their counterparts in the bottom tertile of MII, students in the top tertile were significantly more likely to fall into the alcohol risk group in unadjusted analysis (odds ratio 6.01) and also in analyses that adjusted for age (OR 4.9) and for race (OR 5.2).

Similarly, students with a top-tertile MII were significantly more likely to fall into the current drinker group in unadjusted analysis (OR 6.6) and in analyses adjusting for age (OR 4.6), time with friends (OR 4.6), parental media monitoring (OR 4.9), and minutes spent listening to music (OR 4.3).

Additional analyses showed that potential confounders that might influence both media use and alcohol use, such as anxiety disorders, did not explain the observed associations, according to Mr. Ross.

Might it be possible, a person in attendance asked, that adolescents spending more time using media also are spending less time developing social skills and building supportive family relationships that could be protective in this context?

"The simple answer is, this is a very complex, changing dynamic right now," Mr. Ross replied. "What we are hypothesizing is that kids are getting a chance to experiment much more rapidly and get feedback much more rapidly on different kinds of identities through these media, and that can lead to higher-risk behaviors and an acceleration of a lot of other factors.

"We hope to explore prospective associations between the MII and a number of outcomes in future research," he concluded, including sexual activity, use of tobacco and other substances, and personal injury from high-risk activities.

Mr. Ross reported that he had no relevant conflicts of interest.

SEATTLE – A new index that captures the multiple and complex aspects of media use among today’s youth helps identify those at high risk for drinking, new data show.

In a cross-sectional study among 126 middle school students, relative to their peers having a media involvement index (MII) in the bottom tertile, those having an MII in the top tertile had four- to fivefold higher odds of being current drinkers after potential confounders were taken into account.

Students with a top-tertile MII also had similarly elevated odds of having alcohol risk factors in general, such as planning to drink in the next year, principal investigator Craig S. Ross reported at the annual meeting of the Society for Adolescent Health and Medicine.

In contrast, measures that have traditionally been used to assess media use among adolescents, such as time spent watching television, showed little or no association with these outcomes.

"Adolescents are really avid experimenters, and the new media environment provides inexpensive and powerful tools to facilitate experimentation," he said. "We need new measures in public health to reflect the changing media environment, and the MII shows promise as one such new measure."

The observed associations have several possible explanations, according to Mr. Ross, who is a doctoral student in the epidemiology department at the Boston University School of Public Health.

"Heavy media use may be a marker for sensation seeking or self-medication, or a need to belong among these young adolescents," he speculated. "It may expose them to more normalizing portrayals of alcohol use, and it may enable them to share potentially unhealthful messages with their peers."

Past studies have linked traditional measures of media use to both initiation and frequency of drinking among adolescents, Mr. Ross noted. "The key challenge we face today is that the media environment is rapidly changing, and adolescents really are at the vanguard of this change."

"In this changing media environment, we set out to determine which traditional measures of media use would be associated with alcohol risk factors among young adolescents, and whether we could identify new measures that capture the ubiquity of media access and multitasking behaviors," he explained.

The investigators studied 126 middle school students aged 13-15 years from a small New England city who were participants in the Measuring Youth Media Exposure Study. All were recruited from school and community settings.

Analyses were based on students’ self-reported data from computer-assisted interviews conducted at baseline between January and November 2009. Overall, 53% of the students were boys, 37% were black or Hispanic, and 44% lived with a single mother.

The MII captured multiple facets of media access and activity among the youth, including the presence of media in their bedroom, possession of portable media, media multitasking behaviors (such as using the phone while watching television), use of media while traveling, and home background media (such as having the television on while nobody is watching). Possible scores ranged from 0 to 23 points.

In terms of alcohol outcomes, 18% of the students fell into a general alcohol risk group because they were current drinkers, had positive attitudes about alcohol, and/or intended to drink within a year. Some 10% specifically were current drinkers.

Traditional measures of media use showed only limited associations with these outcomes, according to Mr. Ross. Time spent listening to music was associated with both having alcohol risk factors (P = .01) and being a current drinker (P = .01). And overall time spent using nonprint media was associated with the latter (P = .03).

But a variety of other individual measures – television time, video game time, cell phone time, and e-mail/chat time, among others – were not significantly associated with alcohol outcomes. "These isolated measures of time spent with different media really don’t reflect the modern media environment," he commented.

The students had MIIs ranging from 4 to 19, with an average of 10. When they were split into tertiles by MII, the bottom tertile had values of 4-7, and the top tertile had values of 12-19.

"Just to give you a sense of what these kids might look like from a media perspective, a typical participant in the upper tertile has a full complement of bedroom media, including a television hooked up to premium cable, a video game console, and a computer hooked up to the Internet. They will have a cell phone and a notebook computer, and they are going to be multitasking with these devices frequently," Mr. Ross explained.

"On the other end of the scale, a typical participant in the lower tertile may have a television in their bedroom, but it’s not hooked up to premium cable. They do not have a computer in their bedroom, and only half have a cell phone. Very few will have a notebook computer, and in this group, media multitasking is infrequent," he said.

Compared with their counterparts in the bottom tertile of MII, students in the top tertile were significantly more likely to fall into the alcohol risk group in unadjusted analysis (odds ratio 6.01) and also in analyses that adjusted for age (OR 4.9) and for race (OR 5.2).

Similarly, students with a top-tertile MII were significantly more likely to fall into the current drinker group in unadjusted analysis (OR 6.6) and in analyses adjusting for age (OR 4.6), time with friends (OR 4.6), parental media monitoring (OR 4.9), and minutes spent listening to music (OR 4.3).

Additional analyses showed that potential confounders that might influence both media use and alcohol use, such as anxiety disorders, did not explain the observed associations, according to Mr. Ross.

Might it be possible, a person in attendance asked, that adolescents spending more time using media also are spending less time developing social skills and building supportive family relationships that could be protective in this context?

"The simple answer is, this is a very complex, changing dynamic right now," Mr. Ross replied. "What we are hypothesizing is that kids are getting a chance to experiment much more rapidly and get feedback much more rapidly on different kinds of identities through these media, and that can lead to higher-risk behaviors and an acceleration of a lot of other factors.

"We hope to explore prospective associations between the MII and a number of outcomes in future research," he concluded, including sexual activity, use of tobacco and other substances, and personal injury from high-risk activities.

Mr. Ross reported that he had no relevant conflicts of interest.

SEATTLE – A new index that captures the multiple and complex aspects of media use among today’s youth helps identify those at high risk for drinking, new data show.

In a cross-sectional study among 126 middle school students, relative to their peers having a media involvement index (MII) in the bottom tertile, those having an MII in the top tertile had four- to fivefold higher odds of being current drinkers after potential confounders were taken into account.

Students with a top-tertile MII also had similarly elevated odds of having alcohol risk factors in general, such as planning to drink in the next year, principal investigator Craig S. Ross reported at the annual meeting of the Society for Adolescent Health and Medicine.

In contrast, measures that have traditionally been used to assess media use among adolescents, such as time spent watching television, showed little or no association with these outcomes.

"Adolescents are really avid experimenters, and the new media environment provides inexpensive and powerful tools to facilitate experimentation," he said. "We need new measures in public health to reflect the changing media environment, and the MII shows promise as one such new measure."

The observed associations have several possible explanations, according to Mr. Ross, who is a doctoral student in the epidemiology department at the Boston University School of Public Health.

"Heavy media use may be a marker for sensation seeking or self-medication, or a need to belong among these young adolescents," he speculated. "It may expose them to more normalizing portrayals of alcohol use, and it may enable them to share potentially unhealthful messages with their peers."

Past studies have linked traditional measures of media use to both initiation and frequency of drinking among adolescents, Mr. Ross noted. "The key challenge we face today is that the media environment is rapidly changing, and adolescents really are at the vanguard of this change."

"In this changing media environment, we set out to determine which traditional measures of media use would be associated with alcohol risk factors among young adolescents, and whether we could identify new measures that capture the ubiquity of media access and multitasking behaviors," he explained.

The investigators studied 126 middle school students aged 13-15 years from a small New England city who were participants in the Measuring Youth Media Exposure Study. All were recruited from school and community settings.

Analyses were based on students’ self-reported data from computer-assisted interviews conducted at baseline between January and November 2009. Overall, 53% of the students were boys, 37% were black or Hispanic, and 44% lived with a single mother.

The MII captured multiple facets of media access and activity among the youth, including the presence of media in their bedroom, possession of portable media, media multitasking behaviors (such as using the phone while watching television), use of media while traveling, and home background media (such as having the television on while nobody is watching). Possible scores ranged from 0 to 23 points.

In terms of alcohol outcomes, 18% of the students fell into a general alcohol risk group because they were current drinkers, had positive attitudes about alcohol, and/or intended to drink within a year. Some 10% specifically were current drinkers.

Traditional measures of media use showed only limited associations with these outcomes, according to Mr. Ross. Time spent listening to music was associated with both having alcohol risk factors (P = .01) and being a current drinker (P = .01). And overall time spent using nonprint media was associated with the latter (P = .03).

But a variety of other individual measures – television time, video game time, cell phone time, and e-mail/chat time, among others – were not significantly associated with alcohol outcomes. "These isolated measures of time spent with different media really don’t reflect the modern media environment," he commented.

The students had MIIs ranging from 4 to 19, with an average of 10. When they were split into tertiles by MII, the bottom tertile had values of 4-7, and the top tertile had values of 12-19.

"Just to give you a sense of what these kids might look like from a media perspective, a typical participant in the upper tertile has a full complement of bedroom media, including a television hooked up to premium cable, a video game console, and a computer hooked up to the Internet. They will have a cell phone and a notebook computer, and they are going to be multitasking with these devices frequently," Mr. Ross explained.

"On the other end of the scale, a typical participant in the lower tertile may have a television in their bedroom, but it’s not hooked up to premium cable. They do not have a computer in their bedroom, and only half have a cell phone. Very few will have a notebook computer, and in this group, media multitasking is infrequent," he said.

Compared with their counterparts in the bottom tertile of MII, students in the top tertile were significantly more likely to fall into the alcohol risk group in unadjusted analysis (odds ratio 6.01) and also in analyses that adjusted for age (OR 4.9) and for race (OR 5.2).

Similarly, students with a top-tertile MII were significantly more likely to fall into the current drinker group in unadjusted analysis (OR 6.6) and in analyses adjusting for age (OR 4.6), time with friends (OR 4.6), parental media monitoring (OR 4.9), and minutes spent listening to music (OR 4.3).

Additional analyses showed that potential confounders that might influence both media use and alcohol use, such as anxiety disorders, did not explain the observed associations, according to Mr. Ross.

Might it be possible, a person in attendance asked, that adolescents spending more time using media also are spending less time developing social skills and building supportive family relationships that could be protective in this context?

"The simple answer is, this is a very complex, changing dynamic right now," Mr. Ross replied. "What we are hypothesizing is that kids are getting a chance to experiment much more rapidly and get feedback much more rapidly on different kinds of identities through these media, and that can lead to higher-risk behaviors and an acceleration of a lot of other factors.

"We hope to explore prospective associations between the MII and a number of outcomes in future research," he concluded, including sexual activity, use of tobacco and other substances, and personal injury from high-risk activities.

Mr. Ross reported that he had no relevant conflicts of interest.

SEATTLE – A new index that captures the multiple and complex aspects of media use among today’s youth helps identify those at high risk for drinking, new data show.

In a cross-sectional study among 126 middle school students, relative to their peers having a media involvement index (MII) in the bottom tertile, those having an MII in the top tertile had four- to fivefold higher odds of being current drinkers after potential confounders were taken into account.

Students with a top-tertile MII also had similarly elevated odds of having alcohol risk factors in general, such as planning to drink in the next year, principal investigator Craig S. Ross reported at the annual meeting of the Society for Adolescent Health and Medicine.

In contrast, measures that have traditionally been used to assess media use among adolescents, such as time spent watching television, showed little or no association with these outcomes.

"Adolescents are really avid experimenters, and the new media environment provides inexpensive and powerful tools to facilitate experimentation," he said. "We need new measures in public health to reflect the changing media environment, and the MII shows promise as one such new measure."

The observed associations have several possible explanations, according to Mr. Ross, who is a doctoral student in the epidemiology department at the Boston University School of Public Health.

"Heavy media use may be a marker for sensation seeking or self-medication, or a need to belong among these young adolescents," he speculated. "It may expose them to more normalizing portrayals of alcohol use, and it may enable them to share potentially unhealthful messages with their peers."

Past studies have linked traditional measures of media use to both initiation and frequency of drinking among adolescents, Mr. Ross noted. "The key challenge we face today is that the media environment is rapidly changing, and adolescents really are at the vanguard of this change."

"In this changing media environment, we set out to determine which traditional measures of media use would be associated with alcohol risk factors among young adolescents, and whether we could identify new measures that capture the ubiquity of media access and multitasking behaviors," he explained.

The investigators studied 126 middle school students aged 13-15 years from a small New England city who were participants in the Measuring Youth Media Exposure Study. All were recruited from school and community settings.

Analyses were based on students’ self-reported data from computer-assisted interviews conducted at baseline between January and November 2009. Overall, 53% of the students were boys, 37% were black or Hispanic, and 44% lived with a single mother.

The MII captured multiple facets of media access and activity among the youth, including the presence of media in their bedroom, possession of portable media, media multitasking behaviors (such as using the phone while watching television), use of media while traveling, and home background media (such as having the television on while nobody is watching). Possible scores ranged from 0 to 23 points.

In terms of alcohol outcomes, 18% of the students fell into a general alcohol risk group because they were current drinkers, had positive attitudes about alcohol, and/or intended to drink within a year. Some 10% specifically were current drinkers.

Traditional measures of media use showed only limited associations with these outcomes, according to Mr. Ross. Time spent listening to music was associated with both having alcohol risk factors (P = .01) and being a current drinker (P = .01). And overall time spent using nonprint media was associated with the latter (P = .03).

But a variety of other individual measures – television time, video game time, cell phone time, and e-mail/chat time, among others – were not significantly associated with alcohol outcomes. "These isolated measures of time spent with different media really don’t reflect the modern media environment," he commented.

The students had MIIs ranging from 4 to 19, with an average of 10. When they were split into tertiles by MII, the bottom tertile had values of 4-7, and the top tertile had values of 12-19.

"Just to give you a sense of what these kids might look like from a media perspective, a typical participant in the upper tertile has a full complement of bedroom media, including a television hooked up to premium cable, a video game console, and a computer hooked up to the Internet. They will have a cell phone and a notebook computer, and they are going to be multitasking with these devices frequently," Mr. Ross explained.

"On the other end of the scale, a typical participant in the lower tertile may have a television in their bedroom, but it’s not hooked up to premium cable. They do not have a computer in their bedroom, and only half have a cell phone. Very few will have a notebook computer, and in this group, media multitasking is infrequent," he said.

Compared with their counterparts in the bottom tertile of MII, students in the top tertile were significantly more likely to fall into the alcohol risk group in unadjusted analysis (odds ratio 6.01) and also in analyses that adjusted for age (OR 4.9) and for race (OR 5.2).

Similarly, students with a top-tertile MII were significantly more likely to fall into the current drinker group in unadjusted analysis (OR 6.6) and in analyses adjusting for age (OR 4.6), time with friends (OR 4.6), parental media monitoring (OR 4.9), and minutes spent listening to music (OR 4.3).

Additional analyses showed that potential confounders that might influence both media use and alcohol use, such as anxiety disorders, did not explain the observed associations, according to Mr. Ross.

Might it be possible, a person in attendance asked, that adolescents spending more time using media also are spending less time developing social skills and building supportive family relationships that could be protective in this context?

"The simple answer is, this is a very complex, changing dynamic right now," Mr. Ross replied. "What we are hypothesizing is that kids are getting a chance to experiment much more rapidly and get feedback much more rapidly on different kinds of identities through these media, and that can lead to higher-risk behaviors and an acceleration of a lot of other factors.

"We hope to explore prospective associations between the MII and a number of outcomes in future research," he concluded, including sexual activity, use of tobacco and other substances, and personal injury from high-risk activities.

Mr. Ross reported that he had no relevant conflicts of interest.

SEATTLE – A new index that captures the multiple and complex aspects of media use among today’s youth helps identify those at high risk for drinking, new data show.

In a cross-sectional study among 126 middle school students, relative to their peers having a media involvement index (MII) in the bottom tertile, those having an MII in the top tertile had four- to fivefold higher odds of being current drinkers after potential confounders were taken into account.

Students with a top-tertile MII also had similarly elevated odds of having alcohol risk factors in general, such as planning to drink in the next year, principal investigator Craig S. Ross reported at the annual meeting of the Society for Adolescent Health and Medicine.

In contrast, measures that have traditionally been used to assess media use among adolescents, such as time spent watching television, showed little or no association with these outcomes.

"Adolescents are really avid experimenters, and the new media environment provides inexpensive and powerful tools to facilitate experimentation," he said. "We need new measures in public health to reflect the changing media environment, and the MII shows promise as one such new measure."

The observed associations have several possible explanations, according to Mr. Ross, who is a doctoral student in the epidemiology department at the Boston University School of Public Health.

"Heavy media use may be a marker for sensation seeking or self-medication, or a need to belong among these young adolescents," he speculated. "It may expose them to more normalizing portrayals of alcohol use, and it may enable them to share potentially unhealthful messages with their peers."

Past studies have linked traditional measures of media use to both initiation and frequency of drinking among adolescents, Mr. Ross noted. "The key challenge we face today is that the media environment is rapidly changing, and adolescents really are at the vanguard of this change."

"In this changing media environment, we set out to determine which traditional measures of media use would be associated with alcohol risk factors among young adolescents, and whether we could identify new measures that capture the ubiquity of media access and multitasking behaviors," he explained.

The investigators studied 126 middle school students aged 13-15 years from a small New England city who were participants in the Measuring Youth Media Exposure Study. All were recruited from school and community settings.

Analyses were based on students’ self-reported data from computer-assisted interviews conducted at baseline between January and November 2009. Overall, 53% of the students were boys, 37% were black or Hispanic, and 44% lived with a single mother.

The MII captured multiple facets of media access and activity among the youth, including the presence of media in their bedroom, possession of portable media, media multitasking behaviors (such as using the phone while watching television), use of media while traveling, and home background media (such as having the television on while nobody is watching). Possible scores ranged from 0 to 23 points.

In terms of alcohol outcomes, 18% of the students fell into a general alcohol risk group because they were current drinkers, had positive attitudes about alcohol, and/or intended to drink within a year. Some 10% specifically were current drinkers.

Traditional measures of media use showed only limited associations with these outcomes, according to Mr. Ross. Time spent listening to music was associated with both having alcohol risk factors (P = .01) and being a current drinker (P = .01). And overall time spent using nonprint media was associated with the latter (P = .03).

But a variety of other individual measures – television time, video game time, cell phone time, and e-mail/chat time, among others – were not significantly associated with alcohol outcomes. "These isolated measures of time spent with different media really don’t reflect the modern media environment," he commented.

The students had MIIs ranging from 4 to 19, with an average of 10. When they were split into tertiles by MII, the bottom tertile had values of 4-7, and the top tertile had values of 12-19.

"Just to give you a sense of what these kids might look like from a media perspective, a typical participant in the upper tertile has a full complement of bedroom media, including a television hooked up to premium cable, a video game console, and a computer hooked up to the Internet. They will have a cell phone and a notebook computer, and they are going to be multitasking with these devices frequently," Mr. Ross explained.

"On the other end of the scale, a typical participant in the lower tertile may have a television in their bedroom, but it’s not hooked up to premium cable. They do not have a computer in their bedroom, and only half have a cell phone. Very few will have a notebook computer, and in this group, media multitasking is infrequent," he said.

Compared with their counterparts in the bottom tertile of MII, students in the top tertile were significantly more likely to fall into the alcohol risk group in unadjusted analysis (odds ratio 6.01) and also in analyses that adjusted for age (OR 4.9) and for race (OR 5.2).

Similarly, students with a top-tertile MII were significantly more likely to fall into the current drinker group in unadjusted analysis (OR 6.6) and in analyses adjusting for age (OR 4.6), time with friends (OR 4.6), parental media monitoring (OR 4.9), and minutes spent listening to music (OR 4.3).

Additional analyses showed that potential confounders that might influence both media use and alcohol use, such as anxiety disorders, did not explain the observed associations, according to Mr. Ross.

Might it be possible, a person in attendance asked, that adolescents spending more time using media also are spending less time developing social skills and building supportive family relationships that could be protective in this context?

"The simple answer is, this is a very complex, changing dynamic right now," Mr. Ross replied. "What we are hypothesizing is that kids are getting a chance to experiment much more rapidly and get feedback much more rapidly on different kinds of identities through these media, and that can lead to higher-risk behaviors and an acceleration of a lot of other factors.

"We hope to explore prospective associations between the MII and a number of outcomes in future research," he concluded, including sexual activity, use of tobacco and other substances, and personal injury from high-risk activities.

Mr. Ross reported that he had no relevant conflicts of interest.