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FightHPV: Design and Evaluation of a Mobile Game to Raise Awareness About Human Papillomavirus and Nudge People to Take Action Against Cervical Cancer

Authors:
Tomás Ruiz-López
Tomás Ruiz-López
Tomás Ruiz-López
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Sagar Sen at SINTEF
Sagar Sen
Elisabeth Jakobsen at Cancer Registry of Norway
Elisabeth Jakobsen
Ameli Tropé at Akershus universitetssykehus
Ameli Tropé
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Abstract

Background Human papillomavirus (HPV) is the most common sexually transmitted infection globally. High-risk HPV types can cause cervical cancer, other anogenital cancer, and oropharyngeal cancer; low-risk HPV types can cause genital warts. Cervical cancer is highly preventable through HPV vaccination and screening; however, a lack of awareness and knowledge of HPV and these preventive strategies represents an important barrier to reducing the burden of the disease. The rapid development and widespread use of mobile technologies in the last few years present an opportunity to overcome this lack of knowledge and create new, effective, and modern health communication strategies. Objective This study aimed to describe the development of a mobile app called FightHPV, a game-based learning tool that educates mobile technology users about HPV, the disease risks associated with HPV infection, and existing preventive methods. Methods The first version of FightHPV was improved in a design-development-evaluation loop, which incorporated feedback from a beta testing study of 40 participants, a first focus group of 6 participants aged between 40 and 50 years and a second focus group of 23 participants aged between 16 and 18 years. Gameplay data from the beta testing study were collected using Google Analytics (Google), whereas feedback from focus groups was evaluated qualitatively. Of the 29 focus group participants, 26 returned self-administered questionnaires. HPV knowledge before and after playing the game was evaluated in the 22 participants from the second focus group who returned a questionnaire. Results FightHPV communicates concepts about HPV, associated diseases and their prevention by representing relationships among 14 characters in 6 episodes of 10 levels each, with each level being represented by a puzzle. Main concepts were reinforced with text explanations. Beta testing revealed that many players either failed or had to retry several times before succeeding at the more difficult levels in the game. It also revealed that players gave up at around level 47 of 60, which prompted the redesign of FightHPV to increase accessibility to all episodes. Focus group discussions led to several improvements in the user experience and dissemination of health information in the game, such as making all episodes available from the beginning of the game and rewriting the information in a more appealing way. Among the 26 focus group participants who returned a questionnaire, all stated that FightHPV is an appealing educational tool, 69% (18/26) reported that they liked the game, and 81% (21/26) stated that the game was challenging. We observed an increase in HPV knowledge after playing the game (P=.001). Conclusions FightHPV was easy to access, use, and it increased awareness about HPV infection, its consequences, and preventive measures. FightHPV can be used to educate people to take action against HPV and cervical cancer.
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The player can change characters’ location on the board by selecting the character and (a)
rotating it along the ring of hexagons; the rest of the characters in the rotating ring remain in
the same relative position to each other; (b) dragging it to one of the three main diagonals of
the hexagonal board. To prevent characters being pushed off the board, the diagonals are
circular; when a character goes off the board, it re-enters the diagonal from the opposite side.
Character interactions and their effects appear when the player places characters beside each
other (c). Moving Low-Risk HPV next to an Epithelial Cell, causes the latter to turn into a Wart.
This effect is determined by the pre-defined game rules, which mimic clinical outcomes
following infection with low-risk HPV. The game is considered over if the player cannot solve
the puzzle, i.e., cannot collect all the Epithelial Cells that were present on the board. At next
try, the player has learned that s/he must avoid moves that place Epithelial Cell and Low-Risk
HPV in neighbouring positions on the board, in order to complete this puzzle.
(c)
... Moreover, there was insufficient information on the validity and reliability of the instruments used for outcome assessment (Cates et al., 2020;Darville et al., 2018;Epstein et al., 2021;Fadda et al., 2017). These were complemented by three quasi-experimental studies, providing Level III evidence (Bertozzi et al., 2013;Mitchell et al., 2021;Venigalla et al., 2021), and four mixed-methods approaches, which were assigned Level II or III evidence based on whether randomization was included (Eley et al., 2019;Frick et al., 2023;Occa et al., 2022;Ruiz-López et al., 2019). ...
... Geographically diverse, the studies were conducted across seven countries, with sample sizes ranging from 12 to 3,087 participants, including specific demographics such as parent-preteen dyads (Cates et al., 2020), parents of young children (Fadda et al., 2017), school-aged children (Bertozzi et al., 2013;Eley et al., 2019;Epstein et al., 2021;Occa et al., 2022), high school (Ruiz-López et al., 2019), and university students (Darville et al., 2018;Mitchell et al., 2021;Venigalla et al., 2021), as well as young adults (Frick et al., 2023). One study only included male participants (Darville et al., 2018); no other studies reported limiting participation by gender. ...
... Type of Game Platforms. Most of the games were digitalbased games, such as having the game installed on mobile devices and using desktop, smartphone, or tablet-based applications or accessing through web applications for playing (Bertozzi et al., 2013;Cates et al., 2020;Darville et al., 2018;Eley et al., 2019;Fadda et al., 2017;Frick et al., 2023;Mitchell et al., 2021;Occa et al., 2022;Ruiz-López et al., 2019;Venigalla et al., 2021). Instead, Epstein et al. (2021) used collectible vaccine card packs as the gamification intervention in the study. ...
Using Gaming to Promote Vaccination Among Youth: A Systematic Review
Article
Full-text available
  • May 2024
Introduction While vaccines are crucial for disease prevention, disparities in vaccination coverage persist among youths aged 10 to 29 years, including within the United States. Serious games are emerging as a new strategy to address vaccine hesitancy. This systematic review aimed to aggregate and assess the current evidence on game-based interventions to improve youth vaccination rates, evaluating their impact and identifying factors influencing their effectiveness. Methods This systematic review was conducted through a meticulous search and evaluation of literature from databases including PubMed, Cumulative Index to Nursing and Allied Health Literature database, ProQuest platform, Cochrane Library, and Google Scholar. Studies were included if they (a) were designed with the purpose of improving youth vaccination rates; (b) were published in English; (c) were published between January 2011 and June 2023; and (d) evaluated the effect of game-based interventions. Search terms included Medical Subject Headings terms and keywords of the eligible articles. Results Out of 269 studies, 11 were included in the final analysis of this review. The earliest study dated back to 2013, with 5 being randomized controlled trial and 6 studies incorporating theoretical models in their design or outcome measures. The findings indicated a generally positive effect of game-based interventions on vaccine-related knowledge. However, the impact on actual vaccine uptake was limited. In-game avatar customization and collaboration games were found as effective tools for player engagement. Conclusion The review findings indicated that serious games boost vaccine knowledge but lack strong evidence for influencing youth vaccine uptake. More rigorous research and tailored game designs are needed to determine the effectiveness of game-based interventions and effectively address the diverse needs of youth in vaccine decision-making.
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... Tailoring of interventions to cancer patients' needs has been argued to be a prerequisite for their successful rehabilitation [12]. Virtually, the needs management intervention approaches have mainly focused on face-to-face counseling, telephone follow-up, web-based intervention, or the combination of the three and are typically offered by health care professionals [6,13]. Such approaches, although promising, have encountered problems in effectively motivating individual self-management and difficulties in functioning as a navigation instrument for personalized supportive care [14]. ...
... Regarding content design, the application specifically focused on supportive care needs for patients with cervical cancer who were undergoing surgery. On the basis of our previous literature review, 13 of 16 (81%) applications were mainly developed for symptom management, negative emotion management and QoL improvement related to various cancer types, and neither cervical cancer inpatients nor supportive care needs were addressed. Regarding the platform management and function settings, the application was designed to promote online communication or interaction between health care professionals and patients. ...
Development of a supportive care needs eHealth application for patients with cervical cancer undergoing surgery: a feasibility study
Article
Full-text available
  • Jan 2024
  • BMC HEALTH SERV RES
Purpose To inform the development of an eHealth application for patients with cervical cancer for monitoring supportive care needs, perceived care supply and quality of life. Methods A mixed-method design was used. The 19-month process involved five phases: (1) a literature review to screen the components of applications, (2) a cross-sectional needs assessment for patients with cervical cancer to define the needs and application program frame, (3) expert consultation to refine the draft, (4) software development, and (5) pilot testing and user comment collection. Patients in the intervention group received a 7-day application intervention combined with usual care. Supportive care needs, perceived care supply, quality of life and user’s additional comments were collected. Results The literature review results in phase 1 revealed the importance of full preparation, especially a supportive care needs assessment, before application development. Subsequent supportive care needs investigation in phase 2 revealed that the most urgent needs were informational needs and privacy protection. In phase 3, 43 expert recommendations for application improvement were refined. The new application contained the patient and the health care professional portal in phase 4. Then, on Day 7, there existed score changes of the outcome measures in both intervention and control group. Users had a positive experience with the application. Conclusions This study demonstrates the feasibility of applications targeting access to supportive care, which may be effective for improving the outcome measures but needed to be evaluated in future studies.
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... Strategies include system-level changes to electronic health records to routinize provider prompts to recommend HPV vaccination and audit and feedback strategies [22], provider-level interventions to promote effective provider communication (including presumptive, bundled, and/or unqualified provider recommendations) [23], and patient reminders [24] and parent education [25] aimed at parent determinants. There is also modest evidence for the implementation of parent-and patient-focused apps to promote HPV education and vaccination [26][27][28]. ...
Effect of an HPV Vaccination Multi-Level, Multi-Component Program on HPV Vaccination Initiation and Completion in a Pediatric Clinic Network
Article
Full-text available
  • May 2024
Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study’s purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP’s effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11–17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.
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... [24][25][26][27]29,38] Electronic health can be used to increase women's awareness of cancer and increase participation in cervical cancer screening and HPV 1 vaccination. [22,39] Since increasing women's awareness of cervical cancer has been associated with the success of cervical cancer programs, [40,41] applications have been increasingly used to increase cancer information. On the other hand, this tool has been proposed as a method for educational interventions to improve people's health. ...
Development of mobile application for cervical cancer screening in women: Protocol of a multi-phase study
Article
Full-text available
  • Feb 2024
BACKGROUND Cervical cancer is one of the most common cancers in women. It is considered preventable due to the possibility of screening. The common barriers to cervical cancer screening include lack of knowledge, lack of time, and wrong beliefs. The use of e-Health technologies is one of the approaches for health promotion. The present study is aimed to the development of a mobile application for cervical cancer screening in women. MATERIALS AND METHOD This is a multi-phase study. In the first step, a literature review will be conducted to examine factors related to cervical cancer screening and existing applications related to cervical cancer and its screening. Then, in the second step, a cross-sectional study will be conducted to investigate the factors related to cervical cancer screening in 246 women referred to comprehensive health centers and women’s clinics in teaching hospitals in Isfahan, Iran. The comprehensive health centers and women’s clinics in teaching hospitals will be randomly selected using a lottery method. Using convenience sampling, women who meet the inclusion criteria will be included in the study, provided they provide informed consent. The data will be collected using a questionnaire, and then the descriptive and inferential statistical tests and SPSS18 software will be used to analyze the data. In the third step, specialists (gynecologists, reproductive health specialists, and midwives) will prioritize the application content by filling out a questionnaire. Then, the research team will compile the application content draft, and this draft will be reviewed and approved by experts on the expert panel. The prototype of the application will be prepared, and experts will evaluate it in the fifth step. DISCUSSION The results of this study will result in the development of applications for cervical cancer screening. The use of mobile applications can be useful in lifting some of the barriers to screening. Therefore, developing such applications may help improve cervical cancer screening.
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... In the context of environmental factors as external factors that shape character, education becomes very important. This is in line with what was stated by Ki Hajar Dewantara (1962) as an Indonesian education figure that the essence of education is an effort to advance the growth of character (inner strength, character), mind (intellect), and the child's body in the framework of the perfection of life and harmony in his world (Bonnett, 2017;Infante-Moro, 2020;Ruiz-López, 2019). Education aims to form human beings who are virtuous, intelligent-minded and healthy-bodied. ...
The Implementation of Character Education in Madrasah
Article
Full-text available
  • Mar 2023
This paper aims to describe the strengthening of character education in madrasas. Character education is an essential theme in efforts to overcome social problems that often plague this nation. Character education is an alternative solution considered the most appropriate and must be applied in everyday life, including in madrasas. Madrasahs are seen as an influential place in efforts to form a child's positive personality after the family. Strengthening character education is a process of forming, transmitting, transforming and developing students' abilities to think, behave, and behave according to Pancasila values. Character education in madrasas has the function of selecting and sorting Indonesian culture and foreign cultures that are more civilized and respectable. As a manifestation of the National Movement for Mental Revolution (GNRM), namely changing patterns of thinking (mindset), attitude, and better behavior, religious, nationalist, independent, mutual cooperation and high integrity we must instill it through strengthening character education, especially in madrasas so that all students know, understand, and apply to all aspects of life whenever and wherever they are. All of this can be realized if all stakeholders are involved in overseeing, running, supervising and evaluating all of these processes so that it becomes a positive culture in madrasas.
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... Similar to the results from our study, multiple studies of electronic game-based learning have shown high appeal and satisfaction with the game format [15][16][17]. While many reviews of mHealth studies to increase preventative health behavior have shown positive results, these studies combine multiple interventions, predominantly SMS text messaging, telephone calls, and social media messaging, with a smaller number of studies evaluating mHealth apps [7,18]. ...
Usability and Satisfaction Testing of Game-Based Learning Avatar-Navigated Mobile (GLAm), an App for Cervical Cancer Screening: Mixed Methods Study
Article
Full-text available
  • Aug 2023
Background: Barriers to cervical cancer screening in young adults include a lack of knowledge and negative perceptions of testing. Evidence shows that mobile technology reduces these barriers; thus, we developed a web app, Game-based Learning Avatar-navigated mobile (GLAm), to educate and motivate cervical cancer screening using the Fogg Behavioral Model as a theoretic guide. Users create avatars to navigate the app, answer short quizzes with education about cervical cancer and screening, watch videos of the screening process, and earn digital trophies. Objective: We tested ease of use, usefulness, and satisfaction with the GLAm app among young adults. Methods: This mixed methods study comprised a qualitative think-aloud play interview session and a quantitative survey study. Participants were cervical cancer screening-eligible US residents aged 21 to 29 years recruited through social media. Qualitative study participants explored the app in a think-aloud play session conducted through videoconference. Data were analyzed using directed content analysis to identify themes of ease of use, usefulness, and content satisfaction. Qualitative study participants and additional participants then used the app independently for 1 week and completed a web-based survey (the quantitative study). Ease of use, usefulness, and satisfaction were assessed using the validated Technology Acceptance Model and Computer System Usability Questionnaire adapted to use of an app. Mean (SD) scores (range 1-7) are presented. Results: A total of 23 individuals participated in one or both study components. The mean age was 25.6 years. A majority were cisgender women (21/23, 91%) and White (18/23, 78%), and 83% (19/23) had at least some secondary education. Nine participants completed the think-aloud play session. Direct content analysis showed desire for content that is concise, eases anxiety around screenings, and uses game features (avatars and rewards). Twenty-three individuals completed the quantitative survey study. Mean scores showed the app was perceived to be easy to use (mean score 6.17, SD 0.27) and moderately useful to increase cervical cancer screening knowledge and uptake (mean score 4.94, SD 0.27). Participants were highly satisfied with the app (mean score 6.21, SD 1.20). Conclusions: Survey results showed participants were satisfied with the app format and found it easy to use. The app was perceived to be moderately useful to inform and motivate cervical cancer screening; notably, the screening reminder function was not tested in this study. Qualitative study results demonstrated the app's ability to ease anxiety about screening through demonstration of the screening process, and brevity of app components was favored. Interpretation of results is limited by the predominantly cisgender, White, and educated study population; additional testing in populations which historically have lower cervical cancer screening uptake is needed. A modified version of the app is undergoing efficacy testing in a randomized clinical trial.
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Digital Gamification Tools to Enhance Vaccine Uptake: A Scoping Review (Preprint)
Article
Full-text available
  • Mar 2023
Background Gamification has been used successfully to promote various desired health behaviors. Previous studies have used gamification to achieve desired health behaviors or facilitate their learning about health. Objective In this scoping review, we aimed to describe digital gamified tools that have been implemented or evaluated across various populations to encourage vaccination, as well as any reported effects of identified tools. Methods We searched Medline, Embase, CINAHL, the Web of Science Core Collection, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Academic Search Premier, PsycInfo, Global Health, and ERIC for peer-reviewed papers describing digital gamified tools with or without evaluations. We also conducted web searches with Google to identify digital gamified tools lacking associated publications. We consulted 12 experts in the field of gamification and health behavior to identify any papers or tools we might have missed. We extracted data about the target population of the tools, the interventions themselves (eg, type of digital gamified tool platform, type of disease/vaccine, type and design of study), and any effects of evaluated tools, and we synthesized data narratively. Results Of 1402 records, we included 28 (2%) peer-reviewed papers and 10 digital gamified tools lacking associated publications. The experts added 1 digital gamified tool that met the inclusion criteria. Our final data set therefore included 28 peer-reviewed papers and 11 digital gamified tools. Of the 28 peer-reviewed papers, 7 (25%) explained the development of the tool, 16 (57%) described evaluation, and 2 (7%) reported both development and evaluation of the tool. The 28 peer-reviewed papers reported on 25 different tools. Of these 25 digital gamified tools, 11 (44%) were web-based tools, 8 (32%) mobile (native mobile or mobile-enabled web) apps, and 6 (24%) virtual reality tools. Overall, tools that were evaluated showed increases in knowledge and intentions to receive vaccines, mixed effects on attitudes, and positive effects on beliefs. We did not observe discernible advantages of one type of digital gamified tool (web based, mobile, virtual reality) over the others. However, a few studies were randomized controlled trials, and publication bias may have led to such positive effects having a higher likelihood of appearing in the peer-reviewed literature. Conclusions Digital gamified tools appear to have potential for improving vaccine uptake by fostering positive beliefs and increasing vaccine-related knowledge and intentions. Encouraging comparative studies of different features or different types of digital gamified tools could advance the field by identifying features or types of tools that yield more positive effects across populations and contexts. Further work in this area should seek to inform the implementation of gamification for vaccine acceptance and promote effective health communication, thus yielding meaningful health and social impacts.
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Digital health interventions for cervical cancer care: A systematic review and future research opportunities
Article
Full-text available
Background Cervical cancer is a malignancy among women worldwide, which is responsible for innumerable deaths every year. The primary objective of this review study is to offer a comprehensive and synthesized overview of the existing literature concerning digital interventions in cervical cancer care. As such, we aim to uncover prevalent research gaps and highlight prospective avenues for future investigations. Methods This study adopted a Systematic Literature Review (SLR) methodology where a total of 26 articles were reviewed from an initial set of 1110 articles following an inclusion-exclusion criterion. Results The review highlights a deficiency in existing studies that address awareness dissemination, screening facilitation, and treatment provision for cervical cancer. The review also reveals future research opportunities like explore innovative approaches using emerging technologies to enhance awareness campaigns and treatment accessibility, consider diverse study contexts, develop sophisticated machine learning models for screening, incorporate additional features in machine learning research, investigate the impact of treatments across different stages of cervical cancer, and create more user-friendly applications for cervical cancer care. Conclusions The findings of this study can contribute to mitigating the adverse effects of cervical cancer and improving patient outcomes. It also highlights the untapped potential of Artificial Intelligence and Machine Learning, which could significantly impact our society.
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Medidas favorecedoras da adesão ao exame de rastreamento de Câncer de Colo de Útero: revisão integrativa
Article
Full-text available
  • Oct 2023
O câncer de colo de útero (CCU) é caracterizado por alterações celulares malignas causadas, na maioria das vezes, pela infecção do Papilomavírus Humano, através de transmissão sexual. Embora existam medidas de prevenção primária e secundária efetivas para o bom prognóstico da enfermidade referida, a adesão ao exame preventivo é baixa, no Brasil e no mundo. Dessa forma, objetivou-se revisar, na literatura científica, medidas favorecedoras da adesão ao rastreamento de CCU no mundo. Para isso, foi feita revisão integrativa da literatura, com as estratégias de busca “Women's Health AND Secondary Prevention ", “Uterine Cervical Neoplasms AND Secondary Prevention", “Women's Health AND Humanization of Assistance” e “Uterine Cervical Neoplasms AND Secondary Prevention AND health education” de artigos publicados entre 2018 e 2023, na base de dados on-line National Library Medicine. Os resultados de 13 estudos incluídos indicam que as mulheres com menor poder aquisitivo e grau de instrução são as que compõem a maior parcela da população que não adere às medidas preventivas do CCU. Por isso, a adoção de ações de ES, para os profissionais de saúde e para a sociedade, que conscientizem as mulheres a realizarem o exame de rastreamento, conforme preconizado por diretrizes do Ministério da Saúde, deve orientar o processo de trabalho em saúde pública, uma vez que pode evitar prognósticos ruins no CCU.
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Cervical Cancer Screening Barriers and Risk Factor Knowledge Among Uninsured Women
Article
Full-text available
  • Aug 2017
  • J COMMUN HEALTH
A steady decline in cervical cancer incidence and mortality in the United States has been attributed to increased uptake of cervical cancer screening tests such as Papanicolau (Pap) tests. However, disparities in Pap test compliance exist, and may be due in part to perceived barriers or lack of knowledge about risk factors for cervical cancer. This study aimed to assess correlates of cervical cancer risk factor knowledge and examine socio-demographic predictors of self-reported barriers to screening among a group of low-income uninsured women. Survey and procedure data from 433 women, who received grant-funded cervical cancer screenings over a span of 33 months, were examined for this project. Data included demographics, knowledge of risk factors, and agreement on potential barriers to screening. Descriptive analysis showed significant correlation between educational attainment and knowledge of risk factors (r = 0.1381, P < 0.01). Multivariate analyses revealed that compared to Whites, Hispanics had increased odds of identifying fear of finding cancer (OR 1.56, 95% CI 1.00–2.43), language barriers (OR 4.72, 95% CI 2.62–8.50), and male physicians (OR 2.16, 95% CI 1.32–3.55) as barriers. Hispanics (OR 1.99, 95% CI 1.16–3.44) and Blacks (OR 2.06, 95% CI 1.15–3.68) had a two-fold increase in odds of agreeing that lack of knowledge was a barrier. Identified barriers varied with age, marital status and previous screening. Programs aimed at conducting free or subsidized screenings for medically underserved women should include culturally relevant education and patient care in order to reduce barriers and improve screening compliance for safety-net populations.
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The Low-Risk Papillomaviruses
Article
Full-text available
  • Dec 2016
Human Papillomavirus (HPV) research has been dominated by the study of a subset of Alpha papillomaviruses that together cause almost 5% of human cancers worldwide, with the focus being on the two most prominent of these (HPV16 and 18). These viruses are referred to as ‘high-risk’ (hrHPV), to distinguish them from the over 200 prevalent HPV types that more commonly cause only benign epithelial lesions. The ‘low-risk’ (lrHPV) term used to describe this group belies their cumulative morbidity. Persistent laryngeal papillomas, which occur rarely in children and adults, requires regular surgical de-bulking to allow breathing. Such infections are not curable, and despite being caused by the HPV11 (a lrHPV) are associated with 1-3% risk of cancer progression if not resolved. Similarly, the ubiquitous Beta HPV types, which commonly cause asymptomatic infections at cutaneous sites, can sometimes cause debilitating papillomatosis with associated cancer risk. Recalcitrant genital warts, which affect 1 in 200 young adults in the general population, and even the ubiquitous common warts and verrucas that most of us at some time experience, cannot be reliably eradicated, with treatment strategies advancing little over the last 100 years. The review highlights molecular similarities between high and low-risk HPV types, but focuses on the different pathways that the two groups use to ensure persistent infection and adequate virus shedding from the epithelial surface. Understanding the normal patterns of viral gene expression that underlie lesion formation, and which also prevent loss of the infected basal cells in established lesions are particularly important when considering new treatment options. Finally, the common requirement for deregulated viral gene expression and genome persistence in development of cancers, unites both high and low-risk HPV types, and when considered alongside viral protein functions, provides us with a working understanding of the mechanisms that underlie HPV-associated pathology.
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Using probabilistic record linkage methods to identify Australian Indigenous women on the Queensland Pap Smear Register: the National Indigenous Cervical Screening Project
Article
Full-text available
  • Feb 2016
Objective To evaluate the feasibility and reliability of record linkage of existing population-based data sets to determine Indigenous status among women receiving Pap smears. This method may allow for the first ever population measure of Australian Indigenous women's cervical screening participation rates. Setting/participants A linked data set of women aged 20–69 in the Queensland Pap Smear Register (PSR; 1999–2011) and Queensland Cancer Registry (QCR; 1997–2010) formed the Initial Study Cohort. Two extracts (1995–2011) were taken from Queensland public hospitals data (Queensland Hospital Admitted Patient Data Collection, QHAPDC) for women, aged 20–69, who had ever been identified as Indigenous (extract 1) and had a diagnosis or procedure code relating to cervical cancer (extract 2). The Initial Study Cohort was linked to extract 1, and women with cervical cancer in the initial cohort were linked to extract 2. Outcome measures The proportion of women in the Initial Cohort who linked with the extracts (true -pairs) is reported, as well as the proportion of potential pairs that required clerical review. After assigning Indigenous status from QHAPDC to the PSR, the proportion of women identified as Indigenous was calculated using 4 algorithms, and compared. Results There were 28 872 women (2.1%) from the Initial Study Cohort who matched to an ever Indigenous record in extract 1 (n=76 831). Women with cervical cancer in the Initial Study Cohort linked to 1385 (71%) records in extract 2. The proportion of Indigenous women ranged from 2.00% to 2.08% when using different algorithms to define Indigenous status. The Final Study Cohort included 1 372 823 women (PSR n=1 374 401; QCR n=1955), and 5 062 118 records. Conclusions Indigenous status in Queensland cervical screening data was successfully ascertained through record linkage, allowing for the crucial assessment of the current cervical screening programme for Indigenous women. Our study highlights the need to include Indigenous status on Pap smear request and report forms in any renewed and redesigned cervical screening programme in Australia.
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Translating Evidence Into Practice via Social Media: A Mixed-Methods Study
Article
Full-text available
  • Oct 2015
  • J MED INTERNET RES
Background: Approximately 80% of research evidence relevant to clinical practice never reaches the clinicians delivering patient care. A key barrier for the translation of evidence into practice is the limited time and skills clinicians have to find and appraise emerging evidence. Social media may provide a bridge between health researchers and health service providers. Objective: The aim of this study was to determine the efficacy of social media as an educational medium to effectively translate emerging research evidence into clinical practice. Methods: The study used a mixed-methods approach. Evidence-based practice points were delivered via social media platforms. The primary outcomes of attitude, knowledge, and behavior change were assessed using a preintervention/postintervention evaluation, with qualitative data gathered to contextualize the findings. Results: Data were obtained from 317 clinicians from multiple health disciplines, predominantly from the United Kingdom, Australia, the United States, India, and Malaysia. The participants reported an overall improvement in attitudes toward social media for professional development (P<.001). The knowledge evaluation demonstrated a significant increase in knowledge after the training (P<.001). The majority of respondents (136/194, 70.1%) indicated that the education they had received via social media had changed the way they practice, or intended to practice. Similarly, a large proportion of respondents (135/193, 69.9%) indicated that the education they had received via social media had increased their use of research evidence within their clinical practice. Conclusions: Social media may be an effective educational medium for improving knowledge of health professionals, fostering their use of research evidence, and changing their clinical behaviors by translating new research evidence into clinical practice.
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Improving the Ergonomics of Cognitive Assessment with Serious Games
Article
Full-text available
  • Jun 2015
Current cognitive testing methods in the elderly rely on clinical assessments, which are time consuming, costly, and require highly trained staff (Kueider, Parisi, Gross, & Rebok, 2012). We are developing a serious game with the goal of improving the ergonomics of cognition assessment. Instead of pencil and paper, or a computer, we are using touch-based tablets in order to provide a highly mobile and usable form of cognitive assessment. We are currently conducting usability studies on elderly adults in different healthcare environments to evaluate the technology. This paper presents work on customizing the game for use by elderly adults in a hospital emergency department (ED) and it will discuss some of the results obtained thus far, focusing on the usability of the game for this clinical population. In addition to usability results we will also report on the validity of the game in terms of how well it agrees with existing methods of cognitive assessment that are used in the ED.
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Advancing the evaluation of cervical cancer screening: development and application of a longitudinal adherence metric
Article
  • Dec 2017
  • EUR J PUBLIC HEALTH
Background: Attendance to routine cancer screening at repeated intervals is essential for reducing morbidity and mortality of targeted cancers, yet currently defined quality-assurance metrics evaluate coverage within a defined period of time (e.g. 3.5 years). Methods: We developed a longitudinal adherence metric that captures attendance to cancer screening at repeated intervals, and applied the metric to population-based data from the Cancer Registry of Norway that captures two decades of organised cervical cancer screening, including all screening tests and cervical cancer diagnoses for women living in Norway at any time during years 1992-2013 and eligible for at least two screening rounds (1 round = 3.5 years, N = 1 391 812). For each woman, we calculated the proportion of eligible screening rounds with at least one registered cytology test, and categorised women into one of five longitudinal adherence categories: never-screeners, severe under-screeners, moderate under-screeners, guidelines-based screeners and over-screeners. For each category, we evaluated cancer outcomes such as cancer stage at diagnosis. Results: Only 46% of screen-eligible women were consistently screened at least once every 3.5 years, and the majority of these were over-screened. In contrast, 29% were moderately under-screened, 17% were severely under-screened and 8% had never attended screening. Screening behaviour was associated with cancer outcomes; e.g., the proportion of cancers diagnosed at Stage I increased from 21% among never-screeners to 70% among over-screeners. Conclusion: The longitudinal adherence metric evaluates screening performance as a succession of screening episodes, reflecting both guidelines and the fundamental principles of screening, and may be a valuable addition to existing performance indicators.
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Host Control of Human Papillomavirus Infection and Disease
Article
  • Aug 2017
Most human papillomaviruses cause inapparent infections, subtly affecting epithelial homeostasis, to ensure genome persistence in the epithelial basal layer. As with conspicuous papillomas, these self-limiting lesions shed viral particles to ensure population level maintenance and depend on a balance between viral gene expression, immune cell stimulation and immune surveillance for persistence. The complex immune evasion strategies, characteristic of high-risk HPV types, also allow the deregulated viral gene expression that underlies neoplasia. Neoplasia occurs at particular epithelial sites where vulnerable cells such as the reserve or cuboidal cells of the cervical transformation zone are found. Beta papillomavirus infection can also predispose an individual with immune deficiencies to the development of cancers. The host control of HPV infections thus involves local interactions between keratinocytes and the adaptive immune response. Effective immune detection and surveillance limits overt disease, leading to HPV persistence as productive microlesions or in a true latent state.
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Carcinogenic human papillomavirus infection
Article
  • Dec 2016
Infections with human papillomavirus (HPV) are common and transmitted by direct contact. Although the great majority of infections resolve within 2 years, 13 phylogenetically related, sexually transmitted HPV genotypes, notably HPV16, cause — if not controlled immunologically or by screening — virtually all cervical cancers worldwide, a large fraction of other anogenital cancers and an increasing proportion of oropharyngeal cancers. The carcinogenicity of these HPV types results primarily from the activity of the oncoproteins E6 and E7, which impair growth regulatory pathways. Persistent high-risk HPVs can transition from a productive (virion-producing) to an abortive or transforming infection, after which cancer can result after typically slow accumulation of host genetic mutations. However, which precancerous lesions progress and which do not is unclear; the majority of screening-detected precancers are treated, leading to overtreatment. The discovery of HPV as a carcinogen led to the development of effective preventive vaccines and sensitive HPV DNA and RNA tests. Together, vaccination programmes (the ultimate long-term preventive strategy) and screening using HPV tests could dramatically alter the landscape of HPV-related cancers. HPV testing will probably replace cytology-based cervical screening owing to greater reassurance when the test is negative. However, the effective implementation of HPV vaccination and screening globally remains a challenge.
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