Health Outcomes and Biomedical Informatics 2020 Projects

Project Title: Text and Talk: A multi-level intervention to increase provider HPV vaccine recommendation effectiveness

Faculty Mentor: Stephanie Staras 

Student: Samari Blair  

Research Project Description:

The human papillomavirus (HPV) vaccine prevents up to six types of cancer including cervical and oropharyngeal cancers and is recommended for all 11- to 12-year-olds. (1) In Florida, adolescent HPV vaccination rates are below the national average (initiation: Florida = 64.1% versus US = 68.1% and up-to-date: Florida = 46.5% versus US = 51.1%). At the same time, Florida has the 4th highest rate of HPV-related cancers by state. (2) Despite the impressive potential of HPV vaccines to prevent multiple forms of cancer, HPV vaccine coverage rates in the United States remain substantially lower than other vaccines and Healthy People 2020 targets.

The Integrated Behavioral Model suggests emphasizing the importance of the HPV vaccine for parents will help intention become vaccination, ultimately increasing HPV vaccination rates for recommended populations. (3,4) One of the CDC Community Guide recommended strategies to increase vaccination rates includes parented-targeted reminders. Client reminder and recall interventions are used to remind members of a target population that vaccinations are due
(reminders) or late (recall). (5) Reminders and recalls differ in content and are delivered by various methods—telephone, letter, postcard, text messages, or other, with most being accompanied by an educational message about the importance of vaccination. (5)

Moreover, provider recommendations play a significant role in HPV vaccination. Research shows that high-quality recommendations from providers regarding HPV vaccination were positively associated with vaccine uptake. (6) However, currently, many providers (30-40% US and 70% Florida) do not routinely recommend the HPV vaccine to parents of 11- to 12-year-olds. (7,8) The goal of this study is to increase the acceptability and motivation potential of parent-targeted reminders and provider recommendations regarding HPV vaccination, thus increasing HPV vaccination rates among girls and boys within the United States.

This study will engage parents in the development of an interactive text message. The text messages will act as the primary modality for parent-targeted reminders as recommended by the CDC Community Guide. The research team chose interactive text messages as the parent-targeted reminder strategy for three reasons. First, text message reminders are recommended with high certainty to increase HPV vaccination. (9) Second, text messages have exceptional population reach. (10) As of 2018, 95% of Americans own a cell phone capable of receiving text messages and 90% have unlimited text message plans. (8-10) Third, text messages are likely sustainable and scalable because 68% of health organizations use text messages to send appointment reminders and text messages are inexpensive for clinics to send (< 10 cents per message). (11-12) A previous study that surveyed parents and physicians identified messages that could motivate HPV vaccination, even among parents disinclined to vaccinate their children. (13)

In addition to developing text messages for parents, developing strong provider recommendations for the HPV vaccination also has major implications in the effort to increase HPV vaccinations for adolescents. A systemic review indicated that providers often sent mixed messages by failing to endorse HPV vaccine strongly, differentiating it from other vaccines, and presenting it as an “optional” vaccine that could be delayed. (14) There is a need to conduct more research on how providers can deliver effective recommendations on HPV vaccination.

  1. Walker TY, Elam-Evans LD, Yankey D, et al. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years – United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68(33):718-723.
  2. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers – United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666.
  3. Montaño DE, Kasprzyk D. Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In: Health behavior: Theory, research, and practice, 5th ed. San Francisco, CA, US: Jossey-Bass; 2015:95-124.
  4. Jaccard J, Dodge T, Dittus P. Parent‐adolescent communication about sex and birth control: A conceptual framework. New Dir Child Adolesc Dev. 2002;2002(97):9-42.
  5. Jacob V, Chattopadhyay SK, Hopkins DP, Murphy-Morgan J, Pitan AA, Clymer JM, Community Preventive Services Task Force. Increasing coverage of appropriate vaccinations: A Community Guide systematic economic review. American Journal of Preventative Medicine. 2016;50(6):797–808.
  6. Gilkey MB, Calo WA, Moss JL, Shah PD, Marciniak MW, Brewer NT. Provider communication and HPV vaccination: the impact of recommendation quality. Vaccine. 2016;34(9):1187-92.
  7. Gilkey MB, Malo TL, Shah PD, Hall ME, Brewer NT. Quality of physician communication about human papillomavirus vaccine: findings from a national survey. Cancer Epidem Biomar. 2015;24(11):1673-9.
  8. Malo TL, Ali KN, Sutton SK, Perkins RB, Giuliano AR, Vadaparampil ST. The content and context of physicians’ communication with males about human papillomavirus vaccination. Hum Vaccin Immunother. 2016;12(6):1511-8.
  9. Jacobson Vann JC, Jacobson RM, Coyne-Beasley T, Asafu-Adjei JK, Szilagyi PG. Patient reminder and recall interventions to improve immunization rates. Cochrane Database Syst Rev. 2018;1:Cd003941.
  10. Lenhart A. Cell phones and American adults. 2010;
  11. Pew Research Center. Mobile Fact Sheet. 2018;
  12. Zagorsky J. Almost 90% of Americans Have Unlimited Texting. Instant Census Blog 2015;
  13. Malo TL, Gilkey MB, Hall ME, Shah PD, Brewer NT. Messages to Motivate Human Papillomavirus Vaccination: National Studies of Parents and Physicians. Cancer Epidemiology Biomarkers & Prevention. 2016;25(10):1383-1391. doi:10.1158/1055-9965.epi-16-0224
  14. Gilkey MB, Mcree A-L. Provider communication about HPV vaccination: A systematic review. Human Vaccines & Immunotherapeutics. 2016;12(6):1454-1468. doi:10.1080/21645515.2015.1129090
  15. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. Los Angeles, CA: SAGE Publications.
  16. Rieger KL. Discriminating among grounded theory approaches. Nursing Inquiry. 2018;26(1). doi:10.1111/nin.12261

Project Title: Provider documentation of electronic nicotine delivery systems use among contraceptive users

Faculty Mentor: Ramzi Salloum

Student: Joanna Theophilopoulos 

Research Project Description:

Electronic nicotine delivery systems (ENDS) use has increased exponentially over the past decade, especially in adolescents. The 2019 National Youth Tobacco Survey found that 27.5% of high school students reported current ENDS use(1). ENDS use has also increased among adults. Data from the National Health Interview Survey shows that the prevalence of “ever using” ENDS increased among adults of all races, sexes, and income levels between 2014 and 2016(2).

The long-term consequences of ENDS use are unclear. The cardiovascular effects of ENDS use are one area of concern. The nicotine content of different ENDS products can vary drastically. The total level of nicotine in vapor generated from 15 puffs of an ENDS product can vary between 0.5-15.4 mg(3). Nicotine is known to increase coronary vasoconstriction(4). It may also contribute to a hyper-coagulable state(5). These factors can increase the risk of adverse events such as myocardial infarction, stroke, and venous thromboembolism (VTE). One study found that compared to non-users, ENDS users had a sympathetic shift in cardiac sympathovagal response and higher levels of oxidative stress(6). This may suggest ENDS use can contribute to cardiovascular disease.

One population that may be even more sensitive to these effects is women who use combined hormonal contraception (CHC). Women who use CHC have a 3-5-fold increased risk of VTE(7). Consequently, CHC use is often contraindicated or discouraged in women who smoke cigarettes. The Centers for Disease Control published the most recent update to the U.S. Medical Eligibility Criteria for Contraceptive Use in 2016. Smokers who are under 35 can generally use CHC, although careful follow-up may be required. Women who are over 35 and smoke less than 15 cigarettes per day are not recommended to use CHC, unless there are no other contraception options. The use of CHC is contraindicated in women over 35 who smoke more than 15 cigarettes per day because of unacceptable health risks(8). The most recent guidelines do not address ENDS use, although it may be a risk factor for patients seeking contraception.

The absolute risk for adverse cardiovascular events is low in pre-menopausal women. However, because CHC is widely used, it is responsible for a large proportion of VTE in young women(9). Adequate counseling and appropriate choice of contraception can help decrease the incidence of these events. Regardless of age, providers should counsel patients on the risks of smoking when prescribing CHC. Given the uncertainty surrounding the adverse effects of ENDS use and the fact that use has risen exponentially over the past few years, providers should be cognizant of this being an additional potential risk factor for patients seeking CHC. I expect to find documentation of ENDS use and counseling in patient charts. However, because of a potential lag between the rise in ENDS use and provider awareness and documentation practices, there may be under-documentation.

This study will explore the factors associated with provider decision making for prescription of hormonal contraception in women under 35. We will examine whether patients who are prescribed hormonal contraception are counseled on electronic nicotine delivery systems (ENDS) use, and whether ENDS use is documented in their electronic health records.

  1. Cullen, K. A., Gentzke, A. S., Sawdey, M. D., Chang, J. T., Anic, G. M., Wang, T. W., King, B. A. (2019). e-Cigarette Use Among Youth in the United States, 2019. JAMA, 322(21), 2095. doi: 10.1001/jama.2019.18387
  2. Bao, Wei, et al. “Changes in Electronic Cigarette Use Among Adults in the United States, 2014-2016.” JAMA, vol. 319, no. 19, 2018, p. 2039., doi:10.1001/jama.2018.4658.
  3. Goniewicz, Maciej L., et al. “Nicotine Content of Electronic Cigarettes, Its Release in Vapour and Its Consistency across Batches: Regulatory Implications.” Addiction, vol. 109, no. 3, 2013, pp. 500–507., doi:10.1111/add.12410.
  4. Benowitz, Neal L. “The Role of Nicotine in Smoking-Related Cardiovascular Disease.” Preventive Medicine, vol. 26, no. 4, 1997, pp. 412–417., doi:10.1006/pmed.1997.0175.
  5. Zidovetzki, Raphael, et al. “Nicotine Increases Plasminogen Activator Inhibitor-1 Production by Human Brain Endothelial Cells via Protein Kinase C–Associated Pathway.” Stroke, vol. 30, no. 3, 1999, pp. 651–655., doi:10.1161/01.str.30.3.651.
  6. Moheimani, Roya S., et al. “Increased Cardiac Sympathetic Activity and Oxidative Stress in Habitual Electronic Cigarette Users.” JAMA Cardiology, vol. 2, no. 3, 2017, p. 278., doi:10.1001/jamacardio.2016.5303.
  7. Bartz, Deborah A, et al. UpToDate, 26 Dec. 2019,
  8. Curtis, Kathryn M., et al. “U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.” MMWR. Recommendations and Reports, vol. 65, no. 3, 2016, pp. 1–103., doi:10.15585/mmwr.rr6503a1.

Project Title: Unpacking the multifactorial barriers for adolescents with overweight and obesity

Faculty Mentor: Michelle Cardel 

Student: Charlette Williams 

Research Project Description:

Adolescent obesity is an unresolved problem in the United States that has the potential to put afflicted individuals at risk for severe comorbidities, stigma, discrimination, and emotional distress. This chronic disease is associated with the metabolic syndrome consisting of hypertension, dyslipidemia, and impaired glucose metabolism; which has been known to increase the risk of certain types of cancers [1]. Understanding the complexities of the adolescent obesity epidemic requires a thorough analysis of the various sociocultural factors that have an ubiquitous influence over our health outcomes.

The current prevalence of obesity is at 18.5%, for children and adolescents aged 2-19 years; affecting more than 13.7 million people in our country [2]. Moreover, our currently available behavioral, surgical, pharmacological, and device interventions have not been effective in reducing obesity at the population level [3]. The negative downstream consequences could be mediated if successful interventions were created and implemented as a treatment and/or preventative measure.

Currently, within the adolescent population, there are significant barriers to accessing evidence-based obesity treatment. Additionally, due to the heterogeneous nature of adolescent obesity, currently available weight management interventions that are not specifically tailored to adolescents lead to modest weight loss and weight regain is common. An advantageous treatment approach would have to account for age, race, ethnicity, gender, pubertal status, severity of obesity, and the underlying etiology shaped by all of the multifactorial contributors (eg: mood disturbances, obesogenic environment, epigenetics, etc.) [1,4]. The Cardel Lab believes that an integration of treatment approaches would best tackle the profound resistance to weight-loss.

The WATCH (Wellness Achieved Through Changing Habits) weight management intervention program is part of an IRB-approved research study from the University of Florida led by Dr. Michelle Cardel. Dr. Cardel is an obesity and nutrition scientist and registered dietitian at UF. This study seeks to develop a novel healthy lifestyle intervention for adolescents with overweight and obesity and compare its preliminary effectiveness against an enhanced care condition via a randomized control trial.

  1. Cardel, Michelle I., et al. “Obesity treatment among adolescents: a review of current evidence and future directions.” JAMA pediatrics (2020).
  2. Hales, Craig M., et al. “Prevalence of obesity among adults and youth: United States, 2015–2016.” (2017).
  3. SteinbeckKS,ListerNB,GowN,BaurLA. Treatment of adolescent obesity. Nat Rev Endocrinol. 2018;14(6):331-344. doi:10.1038/s41574-018-0002- 8
  4. GarnettSP,BaurLA,JonesAMD,HardyLL. Trends in the prevalence of morbid and severe obesity in Australian children aged 7-15 years, 1985-2012. PLoS One. 2016;11(5):e0154879. doi:10. 1371/journal.pone.0154879
  5. Cardel, Michelle I., et al. “Youth subjective social status (SSS) is associated with parent SSS, income, and food insecurity but not weight loss among low‐income Hispanic youth.” Obesity 26.12 (2018): 1923-1930.
  6. Cardel, Michelle I., et al. “Association of psychosocial stressors with metabolic syndrome severity among African Americans in the Jackson Heart Study.” Psychoneuroendocrinology 90 (2018): 141-147.
  7. Cardel, Michelle I., et al. “Acceptance-based therapy: the potential to augment behavioral interventions in the treatment of type 2 diabetes.” Nutrition & Diabetes 10.1 (2020): 1-6.
  8. Acceptance-Based Therapy Weight Loss Intervention for Adolescents: A Pilot, Randomized Controlled Trial, 2018-2023. Cardel, M. (Principal Investigator). NIH National Heart, Lung, and Blood Institute K01HL141535.

Project Title: Adverse Childhood Experiences (ACEs) and Cardiometabolic Health among Hispanic Adolescents and Young Adults

Faculty Mentor: Michelle Cardel

Student: Joanne Andrade

Research Project Description:

The obesity and severe obesity epidemic in the United States continues to grow with a disproportionate burden on non-Hispanic blacks and Hispanics (1). The once regarded energy balance model of obesity is now being disputed, and there is significant research into the possible etiologies of obesity (2, 3), including biopsychosocial factors (4). There has been a tremendous amount of research demonstrating the dose-response relationship between adverse childhood experiences (ACEs) and adverse outcomes in adulthood including cardiovascular disease (5), depression, diabetes, and even premature mortality (6, 7). There has also been research looking at the positive association between physical and emotional childhood abuse and obesity in young adulthood (8). Given the ever-increasing prevalence of obesity,there is a pressing need to explore ways to reduce its disease burden, particularly among non-Hispanic blacks and Hispanics. Racial and ethnic minorities are not only unequally burdened by obesity, but they also endure more ACEs
than their non-minority counterparts. A 2018 survey conducted across 23 states found that black, Hispanic, and multiracial respondents reported a significantly greater number of ACEs compared to their white respondents (9). These results have been affirmed by other studies, including a 2009 survey that found that Hispanic respondents were more likely to report five or more ACEs compared to non-Hispanic black and non-Hispanic white respondents (10). Another 2002 survey done in Texas found that Hispanic respondents had the highest prevalence of combined household dysfunction and childhood abuse compared to all other racial categories: non-Hispanic blacks, non-Hispanic whites, and other (11). Given Dr. Cardel’s research in predisposing risk factors of obesity among Hispanic youth, we are hoping to elucidate some of the underlying connections between adverse childhood experiences and cardiometabolic markers in a young Hispanic population. By better understanding this relationship, we hope to eventually discover protective factors and inform effective, targeted interventions that can prevent obesity’s harmful effects on the morbidity and mortality of Hispanic populations in the United States.

We hypothesize that those who report four or more ACEs will have worse cardiometabolic health than those who report three or less ACEs. We believe that there is a positive association between childhood trauma and obesity in young adulthood.

Statistics. 2020. Retrieved from

  1. Baranowski, T., Motil, K.J. & Moreno, J.P. Multi-etiological Perspective on Child Obesity Prevention.
    Curr Nutr Rep 8, 1–10 (2019).
  2. Ludwig, D. S., & Ebbeling, C. B. (2018). The Carbohydrate-Insulin Model of Obesity: Beyond “Calories
    In, Calories Out”. JAMA internal medicine, 178(8), 1098–1103.
  3. Hall KD, Guyenet SJ, Leibel RL. The Carbohydrate-Insulin Model of Obesity Is Difficult to Reconcile
    With Current Evidence. JAMA Intern Med. 2018;178(8):1103–1105.
  4. Dong, M., Giles, W. H., Felitti, V. J., Dube, S. R., Williams, J. E., Chapman, D. P., & Anda, R. F.
    (2004). Insights Into Causal Pathways for Ischemic Heart Disease. Circulation, 110(13), 1761–1766. doi:
  5. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … Marks, J. S.
    (1998). Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of
    Death in Adults. American Journal of Preventive Medicine, 14(4), 245–258. doi: 10.1016/s0749-
  6. Gilbert, L. K., Breiding, M. J., Merrick, M. T., Thompson, W. W., Ford, D. C., Dhingra, S. S., & Parks,
    S. E. (2015). Childhood Adversity and Adult Chronic Disease. American Journal of Preventive Medicine,
    48(3), 345–349. doi: 10.1016/j.amepre.2014.09.006
  7. Williamson, D., Thompson, T., Anda, R., Dietz, W., & Felitti, V. (2002). Body weight and obesity in
    adults and self-reported abuse in childhood. International Journal of Obesity, 26(8), 1075–1082. doi:
  8. Merrick, M. T., Ford, D. C., Ports, K. A., & Guinn, A. S. (2018). Prevalence of Adverse Childhood
    Experiences From the 2011-2014 Behavioral Risk Factor Surveillance System in 23 States. JAMA
    pediatrics, 172(11), 1038–1044.
  9. Centers for Disease Control and Prevention. (2010, December 17). Adverse Childhood Experiences
    Reported by Adults — Five States, 2009. Morbidity and Mortality Weekly Reports. Retrieved from
  10. Dube SR, Cook ML, Edwards VJ. Health-related outcomes of adverse childhood experiences in
    Texas, 2002. Prev Chronic Dis 2010;7(3):A52.
    may/09_0158.htm. Accessed May 3, 2020.