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ORIGINAL RESEARCH PAPER
Year : 2011 | Volume : 24 | Issue : 3 | Page : 479
Perceptions of HPV and cervical cancer among Haitian immigrant women: Implications for vaccine acceptability
E Kobetz1, J Menard2, G Hazan2, T Koru-Sengul1, T Joseph1, J Nissan1, B Barton2, J Blanco2, J Kornfeld3
1 University of Miami, Miller School of Medicine, Miami, Florida, USA
2 University of Miami, Sylvester Comprehensive Cancer Center, Division of Cancer Prevention and Control, Miami, Florida, USA
3 National Cancer Institute, Coastal Cancer Information Service (CIS), Coral Gables, Florida, USA
Date of Submission 29-Apr-2010
Date of Acceptance 11-May-2011
E Kobetz
University of Miami, Miller School of Medicine, Miami, Florida
Introduction: Women in Haiti and throughout the Haitian Diaspora shoulder a disproportionate burden of cervical cancer morbidity and mortality. The widespread Human Papillomavirus (HPV) vaccination holds promise for helping to attenuate this disparity. However, previous research has not fully examined Haitian women's perceptions of, and barriers to, HPV vaccination, which is essential for informing future intervention. The current paper aims to fill this gap.
Methods: As part of ongoing Community-Based Participatory Research (CBPR) efforts, we conducted a series of focus groups with Haitian immigrant women in Little Haiti, the predominantly Haitian neighborhood in Miami, Florida, U.S. Focus group questions assessed women's knowledge and beliefs about cervical cancer and HPV, their opinions of vaccines in general, their knowledge and perceptions of the HPV vaccine specifically and health communications preferences for cervical cancer prevention.
Results: Among the participants who had heard of HPV, many held misconceptions about virus transmission and did not
understand the role of HPV in the development of cervical cancer. Virtually all participants expressed support for vaccines in general as beneficial for health. Some women had heard of the HPV vaccine, primarily as the result of a contemporary popular media campaign promoting the Gardasil; vaccine. Physician recommendation was commonly mentioned as a reason for vaccination, in addition to having more than one sex partner. Women felt the HPV vaccine was less appropriate for adolescent girls who are presumed as not sexually active. Women indicated a strong preference to obtain health information through trusted sources, such as Haitian physicians, Haitian Community Health Workers, and especially Kreyol-language audiovisual media.
Discussion: Study findings indicate a need for culturally and linguistically appropriate educational initiatives to promote awareness of HPV and its role in cervical cancer, the importance of vaccination against the virus, explicitly differentiating HPV from HIV and providing specific information about vaccine safety.
Conclusion: In the U.S., there is a substantial lack of educational information available in Haitian Kreyol about HPV and cervical cancer. This gap results in missed opportunities to promote disease prevention through vaccination and regular screening. Addressing such gaps is essential for achieving health equity among Haitian immigrant women and other, similarly underserved women, who are disproportionately burdened by cervical cancer.
Keywords: Community-based participatory research (CBPR), Human Papillomavirus (HPV), immigrant women
Kobetz E, Menard J, Hazan G, Koru-Sengul T, Joseph T, Nissan J, Barton B, Blanco J, Kornfeld J. Perceptions of HPV and cervical cancer among Haitian immigrant women: Implications for vaccine acceptability. Educ Health 2011;24:479
Kobetz E, Menard J, Hazan G, Koru-Sengul T, Joseph T, Nissan J, Barton B, Blanco J, Kornfeld J. Perceptions of HPV and cervical cancer among Haitian immigrant women: Implications for vaccine acceptability. Educ Health [serial online] 2011 [cited 2022 Jan 21];24:479. Available from: https://www.educationforhealth.net/text.asp?2011/24/3/479/101428
In the United States, cervical cancer disproportionately affects racial/ethnic minorities, foreign-born and medically underserved women1-4. In South Florida, disease incidence is highest among Haitian women, particularly those who are recent immigrants and those who reside in Little Haiti, a large ethnic enclave in the Miami metropolitan area. Between 2004-2007, the estimated incidence of cervical cancer for this enclave was 38/100,0005. This rate is more than four times higher than that reported for Florida generally (8.8/100,000) and for Black women specifically (10.7/100,000) during the same time period6. This disparity primarily reflects underutilization of regular Pap smear screening, the best method available for prevention and early detection of disease7,8. Haitian women face multiple barriers to routinely accessing the formal healthcare system, particularly at the intervals recommended by cancer preventive guidelines9-11. Thus, for this population sub-group, vaccination against Human Papillomavirus (HPV) infection, the principal cause of cervical cancer12, may offer an effective strategy for disease prevention13.
Presently, more than 150 types of HPV have been identified, of which 40 are sexually transmitted14. Low-risk types six and 11 are the most common cause of benign genital warts; whereas, high-risk strains 16 and 18 are responsible for approximately 70-75% of all cervical cancers, as well as cancers of the vulva, vagina and penis14,15. Condoms do not completely protect against HPV infection as the virus is easily transmitted through genital contact16. HPV infection is very common in the population at large, has no identifiable symptoms, and typically clears on its own. Persistent infection with high-risk virus types is associated with carcinogenesis17.
Currently, the U.S. Food and Drug Administration (FDA) has approved two vaccines to protect against persistent HPV infection associated with disease onset. Gardasil® was the first of such vaccines to be approved, in 2006. As a quadrivalent vaccine, it offers protection against four types of HPV, including the two types most commonly associated with genital warts (types six and 11) and the two types responsible for most cervical cancers (types 16 and18). The other vaccine, Cervarix®, was approved by the FDA in 2009. As a bivalent vaccine, it protects against HPV types 16 and 18. Current epidemiologic evidence indicates that both vaccines demonstrate some degree of cross-protection against other similar HPV types, such as 31, 33, and 45 which also have the potential to cause cervical cancer18,19. The vaccines do not protect against all forms of HPV, but they demonstrate high protection against persistent infection with the most common cancer-causing HPV types.
Presently, the FDA has approved Gardasil® for use with females aged nine to 26 years, and Cervarix® is FDA-approved for females aged 10 to 25 years. Gardasil® was also recently approved for use with males aged nine to 26 years, primarily for the prevention of genital warts. These age ranges are based upon safety and efficacy studies and reflect the ideal time period within which vaccination would be most beneficial. Each vaccine requires a series of three injections, which should be completed within six months. The U.S. Centers for Disease Control and Prevention currently recommends that vaccination should begin in females by age 11 to 12 years, with the second injection approximately eight weeks after the first, and the third, and final, injection to be given six months following the first injection15. For greatest efficacy, the HPV vaccination series should be completed prior to sexual debut.
In spite of the benefit of reduced cervical cancer, HPV vaccination remains controversial in the U.S. Barriers to vaccine participation include parental concern about promiscuity with HPV vaccination, concern about vaccine safety and vaccine cost20-24. Existing published studies reveal that HPV vaccine knowledge, awareness and acceptability vary between women of diverse ancestry and English language proficiency25,26. To our knowledge, previous research has not explicitly examined HPV vaccine acceptability among women of Haitian descent. This paper helps address that gap. As part of an ongoing, community-based cancer control initiative in Little Haiti, we conducted a series of focus groups with Haitian immigrant women to understand factors that may impede or enable vaccine uptake. Study findings will inform the development of a culturally responsive intervention to promote vaccine use within Little Haiti and other Haitian enclaves in the United States and abroad.
Community-based Participatory Research (CBPR)
The current study was conducted in 2010 as part of an ongoing Community-based Participatory Research (CBPR) initiative in Little Haiti. CBPR is a research methodology, increasingly popular in the field of public health, which invites community participation throughout the research process, from study conceptualization to dissemination of findings27-29. Accordingly, CBPR reflects, and is often grounded in, community members' socio-cultural orientation to health and disease prevention, their language preferences and literacy levels28. This approach helps dissuade community suspicion about the intent of inquiry, which is prevalent in Little Haiti.
Overview of Patnè en Aksyon
In Little Haiti, CBPR efforts are governed by a campus-community partnership known as Patnè en Aksyon (Partners in Action). This partnership involves active participation of community leaders from Little Haiti, as well as an interdisciplinary team of investigators from a large university in the Miami metropolitan area29. Health priorities were first elicited from Little Haiti residents at the inception of this community-academic partnership in 2004; the prevention of cancer emerged as a top concern. Women in Haiti and the Haitian Diaspora are heavily affected by cervical cancer, which is highly preventable and treatable with routine Pap screening and timely follow up for detected abnormalities.
Accordingly, the partnership's ultimate goals are to reduce the excess burden of cervical cancer experienced by Haitian women and to improve the health status of Little Haiti, more generally. For the focus group research described here, community and academic partners worked collaboratively to develop the focus group guide, giving equal privilege to divergent perspectives regarding study questions of interest, and how to best ask such questions.
Focus group questions were designed to gauge participants' attitudes towards vaccines generally, and towards Gardasil®, the quadrivalent HPV vaccine, specifically. We asked women about Gardasil® because Cervarix® was relatively new to the market at the time of this study. Participants were much more likely to have heard of Gardasil® due to heavy marketing and promotion of Gardasil® in mainstream media.
Community Health Workers (CHWs) were primarily responsible for recruiting study participants and collecting study data. The CHWs were women of Haitian descent, who speak English and Haitian Kreyol fluently, and are knowledgeable about community norms and cultural mores. They were formally employed by a large community-based organization (CBO), whose leadership is active in Patnè en Aksyon and well-respected throughout Little Haiti.
This study was vetted and approved by our university Institutional Review Board (IRB) and the Patnè en Aksyon Community Advisory Board prior to implementation.
Participant Recruitment and Setting
The CHWs recruited women primarily through the extensive network of the CBO where they were formally employed, and by canvassing community venues across Little Haiti, including flea markets, health clinics and laundromats, to identify women meeting study eligibility criteria. Women were eligible to participate if they self-identified as Haitian, currently lived in Little Haiti, and were between the ages of 21 and 75. We set these age parameters because we were primarily interested in hearing the opinions of adult women in several groups. Specifically we sought those who met the current minimum age recommended for beginning regular Pap screening (i.e., 21 years), those who were age eligible for the HPV vaccine (i.e., up to 26 years), or those who could have children or grandchildren who met the HPV vaccine age eligibility criteria. The focus groups were held at a trusted social service organization located in the heart of Little Haiti over a two-day time period. Five groups were conducted in total, each with approximately eight women, for a total of 41 participants.
Focus Group Procedures
One CHW moderated all five focus groups using the focus group guide, which was designed to explore women's knowledge of, and perspectives on, HPV, cervical cancer and different domains of HPV vaccine acceptability. In order to minimize influencing women's responses, participants were first asked if they had heard of HPV and if they knew what it was. After women provided responses about HPV, the CHW briefly explained HPV, taking care to clearly distinguish it from HIV. The CHW followed by asking participants about their familiarity with the HPV vaccine and understanding of its purpose. After hearing responses, the CHW briefly explained that the vaccine protects against HPV infection and is most effective if given before the onset of sexual activity.
The CHW obtained informed consent from each participant prior to initiating group discussion. To address any potential literacy and written language proficiency issues, the CHW read the consent forms aloud to the participants, who then signed the consent form. All participants were also provided with printed copies of the consent forms as well. The groups were conducted in Haitian Kreyol, digitally recorded and then later interpreted and transcribed into English by the CHW. On average, each group lasted two hours. As compensation for their time and contribution to this research, all participants were given a US$ 25 gift card.
For this analysis, we focus on five domains considered significant to understanding issues related to HPV vaccine acceptability within a population of interest30-34. These domains include: 1) general Perceptions of Vaccines; 2) knowledge of HPV; 3) knowledge of HPV Vaccine; 4) perceptions of HPV Vaccine; and, 5) HPV Vaccine Intentions. Our focus group guide assessed these domains and their unique contribution to HPV vaccine acceptance. Table 1 illustrates the questions comprising each domain.
Table 1: Domains of HPV vaccine acceptability
Two researchers independently reviewed the focus group transcripts for emergent themes using a grounded theory approach35,36. The primary purpose of grounded theory is to construct a preliminary framework, rooted in study participants' lived experiences, that informs understanding of a phenomenon or phenomena in question37.
First, we critically reviewed the data, assigning in-vivo codes, when possible, to emergent themes and sub-themes38. In-vivo codes use women's own words and phrases, to define and characterize emergent themes and sub-themes, and in so doing, more accurately reflect participants' perceptions of the phenomena of interest25. Intercoder reliability for open coding was high (k = 0.81, 95% CI 0.67 – 0.94, p<0.0001), indicating a high degree of agreement in the analysis and interpretation of findings between researchers. The two coders discussed any differences in their analyses and came to a consensus about how to best reconcile such variability in the final, combined coding schema.
Upon completing open-coding, we used constant comparison to identify similarities, differences and interrelationships among themes emerging from the response narratives within and across the five focus groups. This process enabled us to develop a conceptual framework to inform understanding of HPV vaccine acceptability among Haitian immigrant women in Little Haiti. While our primary source of data was transcriptions of women's interview responses, we remained aware of the potential pitfall of inadvertently developing a folk theory based solely on participants' perceptions. Thus, throughout the analysis process, we compared women's responses to the CHWs' field notes, and also to existing literature about vaccine acceptability among other medically underserved populations. Importantly, we also sought to understand such barriers in the broader context of Haitian women's perceptions of health and illness. By situating an exploration of vaccine acceptability within this context, we were able to better understand how women perceived cancer etiology and disease prevention. A more comprehensive understanding of women's perceptions within these domains allows for the creation of meaningful health interventions to increase vaccine uptake within this vulnerable population sub-group.
Focus Group Participant Demographics
Table 2 summarizes the demographic characteristics of study participants (n=41). Women ranged in age from 21 to 71, though approximately 34% of the participants were over 50 years of age. A total of 12.2% of participants were, themselves, age-eligible for the HPV vaccine, and although we did not explicitly ask, it can be assumed that approximately 54% had sons or daughters who were age-eligible for the HPV vaccine, based on age-range alone. Most women were not employed in the formal economy, had less than a high school education, and were not married. The majority of study participants primarily spoke Haitian Kreyol and had lived in the U.S. for more than ten years.
Table 2: Socio-demographic characteristics of study participants
Focus Group Findings
Analysis of the focus group transcripts yielded patterns in participants' responses. Emergent major themes and sub-themes in the study domains were largely consistent across the five focus groups. The following sections detail findings in each study domain.
Domain 1: General Vaccine Perceptions
We assessed women's perceptions of vaccines in general as a means of understanding their orientation to disease prevention and how such an orientation may influence HPV vaccine acceptance. The majority of women felt highly positive about vaccines and there was a general consensus that vaccines themselves do not cause illness. Participants described immunizations as important, beneficial actions to prevent illness.
'Vaccines are important [and] that [is] why it is mandatory for children.'
'Yes, vaccines can help you not to get sick.'
While most participants felt positive about vaccines, ambivalence and fear comprised a sub-theme. Ambivalence and skepticism concerning general vaccine efficacy was evident in some women's responses. Vaccine fear was associated with pain from injections and the potential for allergic reactions.
Sometimes the injection can cause an infection.
Am afraid of the shot.
Not everyone's body system [is] able to take a vaccine [because] they have allergies.
[You may have a vaccination], but you cannot say you [are] not going to get sick.
Domain 2: Knowledge of HPV
Women's knowledge of HPV generally was low. Pap smear screening was frequently mentioned as a strategy for disease prevention among the few women who had heard of HPV, although the relationship between HPV and screening was generally not well understood. Many study participants knew that HPV is a sexually transmitted infection that may cause cervical cancer. However, there were some misconceptions about viral transmission and the role of HPV in carcinogenesis. For example, some women felt that sexual transmission of HPV was predicated upon sexual position during intercourse. Others expressed the notion that the virus itself can become cancer. A number of participants confused HPV with HIV and AIDS.
We heard about cervical cancer, but not HPV.
I also know you get [HPV] when having sex with several partners or the position that you are taking.
It's a virus that could turn into cervical cancer.
It can lead to AIDS.
Furthermore, the majority of women believed that HPV likely caused discernible physical symptoms (primarily pain, skin irritations and bleeding), and were uncertain about how to reduce their risk of infection. When women were asked where they had learned about HPV, the majority of them indicated audiovisual sources, such as Haitian Kreyol local radio and television programs. To a lesser extent, they had learned from social networks including family, school and church.
Domain 3: Knowledge of HPV Vaccine
Although most women were unfamiliar with a vaccine for HPV, some women likely recognized the vaccine by its branded name, Gardasil®. Among those women, all cited hearing of Gardasil® on television. While some women acknowledged hearing of Gardasil®, its purpose and action remained largely unclear.
I heard it on TV but never [paid attention to] it. I know it is a vaccine.
I know [it] is a prevention vaccine, but I have not researched it.
Domain 4: Perceptions of HPV Vaccine
After women were asked to discuss what they knew about the HPV vaccine, the CHW briefly explained the purpose of Gardasil®, so that we could further gauge women's perceptions of HPV vaccination. While most women felt positively about a vaccine that could prevent HPV infection and cervical cancer, women also felt uncertain about the vaccine since it is relatively new. Participants consistently reiterated the need to seek a doctor's advice about the vaccine. Others believed the vaccine to be only beneficial for people who had multiple sex partners.
If it could prevent cancer, it is a good idea.
It is new, and that is why I'm fearful.
I'm skeptical because it is new. When [vaccines] first come out [they are] good, but after 3 years they recall them.
I don't know if it is good, but my doctor will tell me.
My first impression is that it's a good idea for the people that have more than one partner.
Domain 5: HPV Vaccine Intentions
When women were asked if they would consider getting the HPV vaccine for themselves, the majority responded positively, provided the vaccine be affordable and recommended by their doctor. Concerning intent to vaccinate daughters, participants were generally positive, on the conditions that 1) the vaccine was doctor-recommended, and 2) daughters were older and, thus, more likely to be sexually active. Participants overwhelmingly felt that the HPV vaccine would be beneficial for their sons.
If I really need [the vaccine], I have to be able to pay for it.
I would have to get my doctor's point of view first.
If I'm not active sexually, I will not take it.
I would have my daughter get the vaccine if she is sexually active.
At the age of nine, that is too young for my daughter [to be vaccinated].
Conditions of Vaccine Acceptability
When considered collectively, the themes comprising these five domains may serve as indicators of HPV vaccine acceptability among Haitian immigrant women in our study. The themes cluster into broader categories that reflect the conditions under which participants deem the vaccine either acceptable or unacceptable. The most frequently cited reason for vaccination was physician recommendation. Other important factors to warren vaccination were demonstrated vaccine safety, efficacy and affordability. Women also described conditions of HPV vaccination in relation to sexual activity. The vaccine is not suitable for younger, pre-adolescent girls, who presumably are not sexually active and may perceive the vaccine as encouraging the initiation of sexual activity. For monogamous women, getting the vaccine might implicate infidelity and is thus unacceptable. Women felt the vaccine would be most beneficial for persons with multiple sex partners. For the sexually abstinent, women felt the vaccine was not necessary.
For medically underserved women with limited access to routine Pap smears, vaccination against HPV is a promising strategy to reduce suffering and deaths due to cervical cancer. Strategies to educate women about HPV, cervical cancer and prevention of cervical cancer through vaccination must be responsive to women's knowledge levels of HPV. Among women in our study who had heard of HPV, most were uncertain about the function of Gardasil® to protect against HPV infection. Together, these findings illustrate the need for, and importance of, culturally tailored education to address gaps in knowledge of HPV and cervical cancer. Such basic information must serve as the foundation for effective outreach efforts to promote HPV vaccination and disease prevention.
For the women in our study, multiple factors contribute to HPV vaccine acceptability and such acceptance is predicated upon specific conditions, as illustrated in Table 3. These conditions highlight multiple challenges to implementing vaccination for primary prevention in Little Haiti. For example, physician recommendation was the most frequently cited reason in support of HPV vaccination; however, women also mentioned multiple barriers to accessing the formal healthcare system. Beyond issues of accessibility, women expressed concerns about the safety and efficacy of the HPV vaccine. At the time of this writing, the vaccine is relatively new and remains in post-marketing surveillance in the U.S. Thus, long-term data on the vaccine's safety and efficacy, which women considered integral to their decision-making, are not yet available. Women also stressed the need for the vaccine to be affordable. Currently, Gardasil® is not uniformly covered by insurers39, resulting in higher out-of-pocket costs. It would almost certainly be cost-prohibitive for women with no health insurance, who have no usual source of care, and who are low-income, which are characteristics disproportionately shared by women in Little Haiti. Utilization of the Vaccines for Children program (for Medicaid-eligible women and young females aged 18 or under), or Gardasil® manufacturer Merck's Patient Assistance Program, may constitute alternative options to accessing the vaccine. In this instance, Federally-qualified Community Health Centers (CHCs) and other community-based health clinics could serve as key points of distribution for women meeting such age and income eligibility criteria.
Table 3: Conditions of HPV vaccine acceptability
We also uncovered some potential challenges to widespread HPV vaccine adoption related to women's cultural belief systems and health knowledge. For example, many women felt that the vaccine would be more beneficial to women who have more than one sex partner and not necessary for women in a monogamous relationship. Such reasoning indicates the belief that monogamy confers protection against HPV infection, although some women openly recognized that partner infidelity could increase a woman's risk of contracting HPV. These assumptions suggest that health education about cervical cancer and HPV should include the topics of past sexual history and multiple partners in discussions of health risk. Further, when considering the HPV vaccine for their sons and daughters, important differences emerged among mothers according to gender. Some mothers were uncomfortable with the vaccine series beginning in pre-adolescence for their daughters, when they believed that their daughters would not be sexually active. This reasoning is important for health professionals to understand, as it demands culturally sensitive education to explain the improved efficacy of Gardasil® if administered prior to the onset of sexual activity. In contrast, the majority of women felt strongly that Gardasil® could be of substantial benefit to their sons when it becomes available and that the vaccine could afford some protection. As participants explained, it is more commonly accepted for boys to have an earlier sexual debut and continue sexual activity with multiple partners through adulthood.
Our study findings are similar to those of other recent studies that assessed HPV knowledge and vaccine acceptability. Tiro and colleagues (2007) analyzed national data from the 2005 U.S. Health Information National Trends Survey (n=3,076) and found that awareness of HPV in the U.S. was generally low. Women who had heard of HPV (approximately 40% of those surveyed) were characterized as younger in age, non-Hispanic whites, with higher education, and having unfettered access to trusted health information and preventive care such as routine Pap screening. As was similar in our study, having some level of familiarity with HPV was not indicative of an accurate understanding of HPV and its role in cervical carcinogenesis40. The women in our study are disproportionately medically underserved; thus, the fact that many women had not heard of HPV, or otherwise incompletely understood HPV, is consistent with national trends. This underscores the need for culturally and linguistically tailored health information.
Concerning vaccine acceptability, Wong and colleagues (2008) held focus groups with ethnically diverse young women (Indian, Malay and Chinese) to discern opinions and perceptions of HPV and found that low knowledge about HPV did not affect women's acceptance of the vaccine32. Many women felt positively about the vaccine, although they had some concerns about the vaccine's cost, its relative newness and associated safety, which were similar to the concerns of women in our study. Other findings differed from our study findings, and included women's concerns about the vaccine being halal, or developed in accordance with Muslim dietary restrictions, as well as its potential to promote promiscuity. Wong and colleagues (2009) also examined HPV vaccine acceptability among mothers of eligible vaccine recipients in the same ethnic Malaysian populations using focus group methodology41. Their findings were similar to those of their previous study among women who were eligible for the vaccine, including an overall positive attitude toward the vaccine, safety and efficacy concerns especially for younger girls, and the monetary cost of the vaccine, which also reflect concerns of the women in our study.
In the U.S., Scarinci and colleagues (2007) assessed HPV vaccine acceptability among Latina immigrants and African American women using focus group methodology31. The majority of participants had never heard of HPV and each focus group was provided with a brief presentation about HPV and cervical cancer. While both ethnic groups felt the HPV vaccine was acceptable, motivations for getting the vaccine, and concerns about the vaccine differed by ethnicity. For example, African American women were more likely to express concerns about safety and efficacy, as well as, about the potential for promiscuous behavior resulting from the use of the vaccine. Latinas had fewer concerns and unanimously indicated they would be willing to get the vaccine. Motivations for immunization among African Americans included affordability, information about the vaccine's trials results, and having a social network with others who were immunized. Latinas felt that widespread adoption of the HPV vaccine would need to be preceded by a large-scale educational effort that involved multiple points of information dissemination including Spanish language media, doctors' offices, churches and peers. Our participants also indicated the importance of utilizing multiple sources, including churches, physician offices and Kreyol-language media, to promote HPV vaccine education.
Our findings, in conjunction with those of other researchers, point to the need for intervention development that is community-based, as well as responsive to cultural beliefs and literacy levels, to achieve widespread acceptance of the HPV vaccine. In the U.S., there is a serious lack of educational information available in Haitian Kreyol about HPV and cervical cancer. Women in our study requested more education and strongly suggested the use of trusted resources through which to deliver such information (e.g., Haitian physicians, Haitian Community Health Workers, and especially, using audiovisual media in consideration of low literacy and limited English proficiency).
The affiliation between the CHWs and this organization was, in many ways, critical to the study's success. By providing the study a 'community home,' we did not encounter many barriers to implementation and, perhaps more importantly, were able to build organizational capacity to support future research and intervention.
There are some limitations to this study. As a qualitative, exploratory study, our findings are not clearly generalizable to all Haitian immigrant women. Additionally, the CHW who conducted the focus groups was the only person to transcribe the focus group recordings in Kreyol and provide interpretations of responses in English. In spite of this limitation, the CHW's long-term experience in working on community health issues in Little Haiti, familiarity with the community, and full proficiency in both Kreyol and English lend her invaluable insight into participants' responses and discussion. Such insight and language proficiency allows for better accuracy for interpreting meaning from focus group dialogue.
Our findings represent a first attempt to understand HPV vaccine perceptions among Haitian women in the U.S., who experience an excess burden of cervical cancer. Our findings can guide further formative research to develop a culturally relevant, community-based educational intervention about HPV vaccination. This work also adds to the growing body of literature on vaccine uptake in cross-cultural populations.
The authors would like to thank the members of the Patnè en Aksyon's Advisory Board for their commitment to improving the health of Haitian women in Little Haiti, as well as our Community Health Worker (CHW), Lyssa Larsen, who collected study data and helped to garner community support for future research and intervention in Little Haiti. This research was funded by the National Cancer Institute (R21-CA-11981-01), the American Cancer Society (MRSGT-07-159-01-CPHPS) and the University of Miami Sylvester Comprehensive Cancer Center.
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26. Kobetz E, Kornfeld J, Vanderpool RC, Finney Rutten LJ, Parekh N, O'Bryan G, Menard J.Knowledge of HPV among United States Hispanic women: opportunities and challenges for cancer prevention. Journal of Health Communication. 2010; 15:22-29.
27. Minkler M, Wallerstein N. Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass; 2003.
28. Israel B, Schulz A, Parker E, Becker A, Allen A, Guzman R. Critical Issues in Developing and Following Community Based Research Principles. San Franciso, CA:Jossey-Bass; 2003.
29. Edgren K, Parker E, Israel B, Lewis T, Salinas M, Robins T, et al. Community involvement in the conduct of a health education intervention and research project: Community Action Against Asthma. Health Promotion Practice. 2005; 6:263-269.
30. Gerend MA, Lee SC, Shepherd JE. Predictors of human papillomavirus vaccination acceptability among underserved women. Sexually Transmitted Diseases. 2007; 34(7):468-471.
31. Scarinci IC, Garces-Palacio IC, Partridge EE. An examination of acceptability of HPV vaccination among African American women and Latina immigrants. Journal of Women's Health (Larchmt). 2007;16(8):1224-1233.
32. Wong LP. Young multiethnic women's attitudes toward the HPV vaccine and HPV vaccination. International Journal of Gynecology & Obstetrics. 2008; 103(2):131-135.
33. Zimet GD, Liddon N, Rosenthal SL, Lazcano-Ponce E, Allen B. Chapter 24: Psychosocial aspects of vaccine acceptability. Vaccine. 2006; 24 Suppl 3:S3/201-209.
34. Cates JR, Brewer NT, Fazekas KI, Mitchell CE, Smith JS. Racial differences in HPV knowledge, HPV vaccine acceptability, and related beliefs among rural, southern women. The Journal of Rural Health. 2009; 25(1):93-97.
35. Krippendorff K. Content analysis: an introduction to its methodology By 2nd ed. Thousand Oaks, CA: Sage; 2004.
36. Neuendorf K. The Content Analysis Guidebook. Thousand Oaks, CA: Sage; 2002.
37. Creswell JW. Qualitative inquiry and research design: Choosing among five traditions. Thousand Oaks, CA: Sage; 1998.
38. Corbin J, Strauss AL. Basics of qualitative research: Grounded theory procedures and techniques. 3rd ed. London: Sage; 2007.
39. Keating K, Brewer N, Gottlieb S, Liddon N, Ludema C, Smith J. Potential barriers to HPV vaccine provision among medical practices in an area with high rates of cervical cancer. Journal of Adolescent Health 2008; 43(4 Suppl):S61-67.
40. Tiro J. What do women in the U.S. know about human papillomavirus and cervical cancer? Cancer Epidemiology Biomarkers & Prevention. 2007; 16(2):288-294.
41. Wong LP. Preventing cervical cancer through human papillomavirus vaccination: perspective from focus groups. Journal of Lower Genital Tract Disease. 2009; 13(2):85-93.
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MRSA Nasal Colonization Screening As An Antimicrobial Stewardship Tool For Tailoring Pneumonia Therapy
In this interview authors of a recent meta-analysis published in Clinical Infectious Diseases discuss their project and provide insights on MRSA nasal colonization screening as an antimicrobial stewardship tool.
Interview with: Diane M. Parente, Pharm.D. and Tristan Timbrook, Pharm.D., MBA, BCPS
Interview by: Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
[Last updated: 2 May 2018]
Does everyone in the hospital with bacterial pneumonia need antibiotic therapy that includes coverage for methicillin resistant Staphylococcus aureus (MRSA)? Of course not, but how do clinicians know who should get MRSA coverage and who should not? In addition, why is covering MRSA such a big deal?
First, let's focus on that second question. In the hospital setting antibiotic coverage for MRSA typically means a course of intravenous vancomycin. Unfortunately, vancomycin has been associated with nephrotoxicity, which makes many clinicians nervous for their patient's kidneys when they have to prescribe it. In addition vancomycin requires, patient-specific dosing strategies, therapeutic drug monitoring, and long infusion times. This can all translate to risk for the patient plus a fair deal of work for the prescriber, pharmacist, nurse, and lab. In turn, nobody wants to use vancomycin unless it is truly indicated.
Circling back to that first question, there are a variety of means for differentiating between pneumonia caused by MRSA and pneumonia caused by other pathogens, but this is still an area in which further research is needed. One emerging tool that may be used for this purpose is MRSA nasal colonization status. This is the motivation for this article and the focus of the below interview.
According to CDC, about one in three people is colonized with Staphylococcus aureus in their nose and one in 50 people is colonized with methicillin resistant Staphylococcus aureus (MRSA) in their nose [1]. People that are colonized with MRSA who get pneumonia will not necessarily have MRSA pneumonia, but the chances for it may be greater than people not colonized with MRSA. So, if a patient is found to be negative for MRSA nasal colonization, can the vancomycin therapy be discontinued or maybe never even started? This is one of the big questions people are interested in today.
Recently Parente et al evaluated the diagnostic value of MRSA nasal colonization screening as an antimicrobial stewardship tool for pneumonia. They published their work in Clinical Infectious Diseases:
Parente DM, Cunha CB, Mylonakis E, Timbrook TT. Clinical utility of methicillin resistant Staphylococcus aureus (MRSA) nasal screening to rule out MRSA pneumonia: a diagnostic meta-analysis with antimicrobial stewardship implications. Clinical Infectious Diseases. 2018. Epub ahead of print.
Since this has become somewhat of a hot topic in the field of antimicrobial stewardship, I reached out to the authors and requested an interview. They were gracious enough to accept and the following was developed.
For the purpose of this article the following definitions are provided:
Negative predictive value (NPV): the probability that a negative test result is accurate. The higher the value, the more reliable the test.
Positive predictive value (PPV): the probability that a positive test result is accurate. The higher the value, the more reliable the test.
HAP = hospital acquired pneumonia
VAP = ventilator associated pneumonia
Here are insights on MRSA nasal colonization screening as an antimicrobial stewardship tool…
1. What prompted undertaking the task of performing a meta-analysis on the clinical utility of MRSA nasal screening to rule out MRSA pneumonia?
For us, it was reading the Infectious Diseases Society of America (IDSA) HAP/VAP guideline [2] with a nod on page 23 for MRSA avoidance based on NPV, but no official recommendation on avoidance of antibiotic coverage based on the NPV of MRSA nasal PCR, leaning heavily towards MRSA coverage based on risk factors including overall prevalence of methicillin resistance among S. aureus isolates, antibiotic use within last 90 days, and either previous positive culture or screens for MRSA.
Moreover, on page 12, the IDSA HAP/VAP guidelines note "However, to our knowledge, there are no studies that have prospectively evaluated the use of MRSA screening to inform empiric treatment choices." which appeared to be very short sighted, as Boyce AAC 2013 [3] clearly evaluated this approach and is well recognized in the literature being cited >30 times.
Further, while not prospective we realized there was a decent amount of literature evaluating the clinical utility of MRSA nares screens for MRSA pneumonia.
Overall, we felt the guidelines missed out on a major opportunity for antimicrobial stewardship and avoidance of unnecessary patient exposure to anti-MRSA antibiotics; specifically, the potential nephrotoxicity of vancomycin and associated healthcare costs in a large number of patients, all in the face of readily available and good data.
2. From your research, what is the main take home point about using MRSA nasal colonization status as it relates to treating pneumonia?
No MRSA nares colonization = no vancomycin in the absence of persistent hemodynamic instability, VAP, structural lung disease, or other exclusion/strong indication.
3. Is there anything that you found particularly interesting or surprising in the process of completing this meta-analysis?
While less related to the meta-analysis and more related to the practical implications thereof and consideration for implementation, vancomycin has very little if any effect on colonization and therefore conversations about post-antibiotic specimen obtainment are a nonstarter [4-7].
4. What should antimicrobial stewards know about the NPV and PPV of MRSA nasal colonization status to rule out MRSA pneumonia?
Similar to procalcitonin, think not only about the test but also about what patients with MRSA pneumonia look like – think severely ill with the exception of patients with structural lung disease.
With the likely incidence of MRSA pneumonia being 5% or less and true MRSA pneumonia epidemiology suggesting ~90% admitted to ICU, the conditional probabilities of a MRSA pneumonia in a medical floor patient is probably half a percent or less (10% x 5% = 0.5%).
In terms of NPV and PPV of MRSA nasal colonization status, for CAP/HAP there is a high NPV (98.1%) meaning that if the MRSA nares test is negative then it is highly unlikely the patient has MRSA pneumonia and therefore in a patient who is clinically stable without structural lung disease discontinue or do not initiate anti-MRSA therapy.
There is a low PPV of MRSA nasal colonization status to rule in MRSA pneumonia (44.8%), meaning when the result of an MRSA nares test is positive, there is not certainty that the patient does or does not have MRSA pneumonia and therefore the MRSA nares results should not weigh as heavily when making the decision to start or continue anti-MRSA therapy.
It is important to note CA-MRSA pneumonia should be suspected in patients with multilobular cavitating alveolar infiltrates or necrotizing pneumonia seen on imaging, preceding a recent infection with influenza, hemoptysis, severe hypoxemia, high fever, leukopenia, hypotension, or cyanosis. Again, emphasizing these patients will look severely ill.
5. Are there clinical circumstances when you would give considerably less weight to MRSA nasal colonization status for determining whether or not to cover MRSA empirically for pneumonia?
Note above discussion.
Patients with a positive MRSA nares test, VAP, structural lung disease (e.g., cystic fibrosis or bronchiectasis), recent nasal decolonization prior to nares screen, or an MRSA infection within 30 days.
6. What future research is needed when it comes to using MRSA nasal colonization status for managing patients with suspected or confirmed pneumonia?
It would be nice to see a large study with propensity matching, the effect on LOS and nephrotoxicity by doing early de-escalations, and outcomes in those with early de-escalations versus those without.
1. Centers for Disease Control and Prevention. MRSA Tracking. Accessed 30 April 2018.
2. Kalil AC et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clinical Infectious Diseases. 2016;63(5):e61–111.
3. Boyce JM et al. A trial of discontinuation of empiric vancomycin therapy in patients with suspected methicillin-resistant Staphylococcus aureus health care-associated pneumonia. Antimicrobial Agents and Chemotherapy. 2013; 57(3): 1163-8.
4. Keene A, et al. Staphylococcus aureus colonization and the risk of infection in critically ill patients. Infection Control and Hospital Epidemiology. 2005; 26(7): 622-8.
5. Vikram HR et al. Discontinuation of contact precautions for patients no longer colonized with methicillin-resistant Staphylococcus aureus. Infection Control and Hospital Epidemiology. 2010; 31(5): 541-3.
6. Yu VL et al. Staphylococcus aureus nasal carriage and infection in patients on hemodialysis. Efficacy of antibiotic prophylaxis. New England Journal of Medicine. 1986; 315(2): 91-6.
7. Bernard L et al. Effect of vancomycin therapy for osteomyelitis on colonization by methicillin-resistant Staphylococcus aureus: lack of emergence of glycopeptide resistance. Infection Control and Hospital Epidemiology. 2003; 24(9): 650-4.
ADDITIONAL RELEVANT RESOURCES
Willis C et al. Impact of a pharmacist-driven methicillin-resistant Staphylococcus aureus surveillance protocol. American Journal of Health-System Pharmacy. 2017; 74(21): 1765-1773.
Smith EA, et al. Nasal methicillin-resistant Staphylococcus aureus screening in patients with pneumonia: A powerful antimicrobial stewardship tool. American Journal of Infection Control. 2017; 45(11): 1295-1296.
Acuna-Villaorduna C, et al. Active identification of patients who are methicillin-resistant Staphylococcus aureus colonized is not associated with longer duration of vancomycin therapy. America Journal of Infection Control. 2017; 45(10): 1081-1085.
Stanford Health Care. Vancomycin De-Escalation Guide.
I would like to express my utmost appreciation to Dr. Parente and Dr. Timbrook for taking the time to complete this interview and share their perspectives.
ABOUT THE INTERVIEWEES
Diane M. Parente, Pharm.D. is the clinical pharmacist specialist in infectious diseases and antimicrobial stewardship at The Miriam Hospital in Providence, RI. Her primary responsibilities include antimicrobial stewardship, participation on adult infectious diseases consultation rounds, precepting pharmacy students and residents, and lecturing at the University of Rhode Island, Bryant University, and Johnson and Wales University.
Diane received her PharmD degree at the University of Rhode Island in 2012. She then completed a PGY-1 Pharmacy Practice Residency at UF Health Jacksonville in Jacksonville, FL followed by a Post-Doctoral Fellowship in outcomes and antimicrobial stewardship at the Providence VA Medical Center in Providence, RI.
Her research and practice interests include antimicrobial stewardship quality improvement and outcomes.
Tristan Timbrook, Pharm.D., MBA, BCPS is an Antimicrobial Stewardship Pharmacist at University of Utah Health (Salt Lake City, UT).
Dr. Timbrook obtained his PharmD and MBA at Sullivan University (Louisville, KY). He then completed his PGY-1 Pharmacy Practice Residency and PGY-2 Infectious Diseases Pharmacy Residency at Medical University of South Carolina (Charleston, SC). He is a former Post-Doctorl Outcomes Pharmacy Fellow in Antimicrobial Stewardship at the Providence VA Medical Center (Providence, RI).
His primary interests include integrations of rapid diagnostics and antimicrobial stewardship, comparative effectiveness research, and medical informatics with particular interest given to clinical decision support systems.
You can find him on Twitter @TimbrookTT.

redpajama_set_name: RedPajamaCommonCrawl


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The Golden Circle. Hella.
July 13, 2016 July 13, 2016 Kristin KalningLeave a comment
Gulfoss. Just another jaw-droppingly beautiful waterfall.
Before I describe our journey along Iceland's Ring Road, I missed a part of our Reykjavik adventure in yesterday's post: The National Gallery of Iceland, and also, the Reykjavik Museum of Photography, which is actually a gallery room on the top floor of the Reykjavik Library.
I don't want to be disparaging about Icelandic artists, but it is telling that the main exhibit at the National Gallery was of a Belgian sculptor. A very depressing Belgian sculptor called Berlinde de Bruyckere, whose exhibit was described (and I'm paraphrasing) as depicting humans and animals in various stages of agony and death.
So, from there, we checked out the work of prominent Icelandic artists, who, without exception, trained in Denmark. There was lots of Impressionism, Cezanne-worship and still lifes. (Still lives?) And that makes sense: Iceland's population was, as someone described to me, trying not to starve until 1944. Much of its art was religious in nature, which we saw at The National Museum the day before.
The photography exhibit was really interesting. It showed farm life in West Fjords of Iceland, which is rapidly diminishing. One-third of Iceland's population now lives in Reykjavik, with people from the countryside migrating to get jobs in the exploding tourism industry, or in fishing. It showed a side of Iceland that we won't see — snow-covered tundras, life on working farms, herding sheep, surviving the tough winters.
OK. So, on Monday, we packed up and, in our astronomically expensive Toyota RAV4, hit the Ring Road. It's a manual transmission, because Europe, but thankfully both Steve and I are Big Kids who can drive stick. It does take a little getting used to, though.
Once we were out of Reykjavik and environs, the landscape changed dramatically. Rows and rows of apartment buildings that can best be described as "functional" gave way to pastoral agrarian scenes, complete with fuzzy green rolling hills, dramatic mountain ranges and huge, expansive skies. One good thing we got out of the National Gallery was the use of the word "limpid" to describe the light in Iceland: It's a very apt description. The clouds are low, and the sunlight is scattered. The greens are very green and the fields are covered with purple, white and yellow wildflowers. It's just stunning, Iceland is — beautiful in a way that I've never experienced.
People have asked Steve and I why we would go to Iceland. I think we gave answers like, we've always wanted to go there, it looks cool, etc. But as I was walking between the tectonic plates at Thingvellir, it came to me: We came to Iceland to see new things. To experience new things. It's exciting and humbling to be in a place where nothing looks or feels totally familiar.
Standing between the North American and Eurasian tectonic plates.
Thingvellir is the site of the world's oldest parliament, established in 930 by a bunch of Vikings. Of course, they met outside, because Iceland. Thingveillir is a designated UNESCO World Heritage site both because of its historical significance, but also because it is a visual representation of continental drift. You can actually scuba dive between the two plates. We wandered the moors for about an hour, swatting flies and checking out the diverse flora and fauna. I also had never been on a moor, and kept thinking about "Wuthering Heights."
From there, we hopped back in the car and headed towards Geysir, which is The First Geyser. The original. I was ready to eat my hand at this point, and eschewed Steve's idea of eating Zing Bars in the car, so we stopped at a strange little town and paid $70 for a chicken sandwich and a bowl of tomato soup. Did I mention that Iceland is SO VERY EXPENSIVE?
Geysir's little brother, whose very complicated Icelandic name escapes me.
OK. So we get to the Geysir, which isn't active anymore. But its brother is, so we watched a couple of rounds of Little Brother spurting up water and steam. We also saw profoundly stupid people attempting to ford the rivers of boiling hot water coming from the geysers. We also saw lots of really bad European denim: Dark, distressed white, with white stitching and bling. I kept trying to get Steve to snap a picture, but it's hard to do without being an asshole.
They were sweet. But they really wanted food.
From Geysir, we headed to Gulfoss, a gigantic, gorgeous, tour-bus infested waterfall. We were beginning to recognize people from both Thingvellir and Geysir, and their Bad Dark Denim. Gulfoss is a very popular day trip from Reykjavik, and the third stop on the Golden Circle tour. We marveled in Gulfoss' beauty, snapped some photos and headed toward Hella. Along the way, we pulled over so I could pet some horses. They were disappointed that I came empty-handed.
Hella was where we were headed next, and since Icelandic radio is terrible, we listened to a depressing "This American Life" podcast to pass the time. Our hotel for the next three nights, The Stracta, is one of three hotels in Hella, which is comprised of one street. There is a grocery store, a bakery, a pharmacy, a gas station and two downmarket restaurants. The Stracta, which we dubbed the Arctic Research Base, looks as though it was created from a dozen shipping containers. It's actually quite nice, and new and clean, and in keeping with the Scandinavian design that I so admire. It's just that the siding is corrugated metal, meant to withstand the worst of Iceland's weather. Which, I gather, can be quite punishing. Still, the restaurant is good, there are two hot tubs, and several saunas to rest your weary bones.
The Stracta Hotel. Or, the Arctic Research Base. Take your pick.
Tomorrow: The waylaid hike, the rainy glacier, puffins and a four-star dinner in the middle of nowhere.
Tagged: Geysir, Gulfoss, Hella, Iceland, Reykjavik, Thingvellir
Previous Reykjavik: Windy, spendy, quirky
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isoproterenol is a topic covered in the Davis's Drug Guide.
Quiring, Courtney, et al. "Isoproterenol." Davis's Drug Guide, 16th ed., F.A. Davis Company, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/Davis-Drug-Guide/51419/all/isoproterenol.
Quiring C, Sanoski CA, Vallerand AH. Isoproterenol. Davis's Drug Guide. 16th ed. F.A. Davis Company; 2019. https://im.unboundmedicine.com/medicine/view/Davis-Drug-Guide/51419/all/isoproterenol. Accessed April 20, 2019.
Quiring C, Sanoski CA, Vallerand AH. Isoproterenol [Internet]. In: Davis's Drug Guide. F.A. Davis Company; 2019. [cited 2019 April 20]. Available from: https://im.unboundmedicine.com/medicine/view/Davis-Drug-Guide/51419/all/isoproterenol.


Your friends and family will feel love with hand-made Valentine's Day Gifts like these. Check out these creative crafts and special gift ideas!
From our heart to yours, Happy Valentine's Day!
Punch your heart out this Valentine's Day with Swingline's Low Force Punch!
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For the office thief in your life…Excuse me, I believe you have my stapler!
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Kick off your heels this Valentine's Day with Swingline's High Heel Stapler!
Whether you are using in your home office or in a corporate setting, Swingline's High Heel Stapler sure to raise your office desk's profile just like a good high heel!
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Whether at home or in the office, this stylish High Heel desktop stapler will demand the same attention as any trendy wardrobe accessory on Valentine's Day and every day!
"Take Note" of that special person on Valentine's Day!
Make Sure Your Bright Ideas Are Seen, with the Astrobrights Collection.
Why settle for a plain, boring notebook, when you could use this gorgeous Astrobrights Flex Journal instead?
The bright colorful pages with contrasting rules make sure your ideas jump off the page and get noticed.
We love the contrasting stitching on the spine, which adds elegance to your journal. The super durable covers withstand everyday use. This is one long lasting journal!
This elegant journal will add color to your day, and fits neatly in most totes, purses and backpacks.
We absolutely love Astrobrights Twin Wire Journal. It features 180 pages, and includes a Black Super-Soft-Touch Cover. At 6 ½" x 8 ½" it's large enough to take lots of notes, but small enough to travel easily.
We appreciate the elastic closure, which prevents the pages from becoming exposed when traveling or when stored away.
The colored pages with contrasting rules make sure your ideas are noticed.
The twin-wire binding allows pages to open completely for effortless writing.
When it's time to show appreciation, Astrobrights Foil Enhanced Certificates are just what you need.
In gorgeous "Fireball Fuchsia" Card Stock, these 8.5″ x 11″ certificates get noticed. Each sheet features foil enhancements, and are compatible with your inkjet/laser printers or copiers.
Summer is the best time to spend outdoors with family and friends. We love camping, hiking, pool parties, picnics, outdoor concerts and watching fireworks.
The more spontaneous these events, the better! That's why we keep delicious treats from Office Snax on hand for any occasion.
You already know that Office Snax items are great in your office breakroom, but did you know that their convenient, non-breakable containers are ideal to keep in the car, boat or camper?
Great for a day at the beach, on a picnic, out in the boat or around the fire pit. Choose your favorite! Resealable tub maintains freshness and travels easily.
These delicious braided pretzels will easily become your new summer snack favorite.
Salted pretzels, nugget style filled with peanut butter. Resealable tub goes where you go!
Something for everyone! Carry a mix of candy appealing to everyone from your toddlers to their Great Grandparents. This assortment of popular candy comes in a reusable, resealable tub to maintain freshness.
Classic Favorites like these make road trips happier. Assorted candy Airheads, Now and Laters, Bit-O-Honey, and Tootsie Roll. All in a resealable liner.
While you're enjoying summer snacks, don't forget Fido! We keep a box of Doggie Snax on hand for all our outdoor adventures. Handy to have in the car when we go for hikes, we also use them for positive reinforcement training with our ten month old lab. She gobbles them up!
A good business newsletter is an effective tool for reaching your audiences with important information. Our partners at International Paper/Hammermill Paper understand this, and have shared their knowledge with you in this blog.
You can use your newsletter to expand your customer base, keep existing customers excited about your business, or attract new sources of funding. It can be strategic by demonstrating your business plan in action or it can be pragmatic and introduce new products, services or capabilities. Or it can do both.
There are a few things to keep in mind when putting your newsletter together to make sure it is as effective as possible. We've put together some pointers to help make it easier.
Ready to create your newsletter? Check out our Business Newsletter Templates.
Who are you trying to reach with your newsletter? Make sure you have a clear idea of your audiences, then try to organize your newsletter contents to reach them in order of priority. In other words, speak to your most important audience first and then secondary audiences after. You can dedicate an entire newsletter to a single audience and reach a different audience with the next one or you can try to reach as many audiences as possible in each newsletter.
To reach each of your audiences with the information they value, it's a good idea to develop an editorial calendar. Think through who you are trying to reach and how often you want to speak to them. This will help you decide what each newsletter needs to accomplish, as well as how often you need to send them out.
Your newsletter should provide your audience with information that is valuable to them. A newsletter that speaks only to your accomplishments or capabilities isn't really customer-focused. Take the extra step to show how your accomplishments or capabilities can help your customers achieve their goals.
Begin with stating the customer benefit in the headline, then provide a summary explanation in the subhead. The body copy can go into more detail as needed. This helps audiences pressed for time get the most important information quickly while also allowing anyone who is interested the details that are important to them.
Good imagery can generate interest by showing people what you are talking about. Remember that quality is important. A quick shot with your phone camera is probably not going to show your product in its best light. Take the time to use good imagery, but remember…too much of a good thing can work against you. If your newsletter has too many images, the imagery can distract from your messaging and what you want your audiences to know and do.
To make all of this easier to put into practice, we've developed some useful Business Newsletter Templates that will help you organize news and information in a way that is easily read. It's a good idea to check your work by printing it out first–we recommend using a quality paper like Hammermill Premium Multi-Purpose 24LB. printer paper.
We are happy to share C-Line's recent blog post with you, and offer you a chance to WIN their new UColor Two-Pocket Coloring Photos. C-Line Products are available at Penny Wise Office Products.
To WIN Your Own Two-Pocket Coloring Folders, comment below, or on our Facebook Page.
Do you ever wonder if you are really being heard? All of us want to feel that what we have to say is important. Even in casual conversation, we expect to receive the courtesy of our listener's attention.
In business and professional settings, being heard can be even more important.
Active listening can be defined as concentrating completely on what a person is saying and confirming that the message is both received and understood. Common courtesy dictates that we owe anyone that takes the time to speak with us the courtesy of our complete attention – to actively listen.
We have all experienced the frustration of saying something which we feel is important to someone who doesn't seem to be listening. We instinctively know what poor listening looks and feels like. So, if we reverse what a poor listener does, we can easily see then what a good listener SHOULD do.
• A poor listener provides little or no verbal feedback. Good listeners nod their heads and provide some vocal confirmation that the speaker was heard.
• A poor listener might assume a very relaxed posture. Good listeners sit up and even lean forward to hear better.
• Poor listeners will ask few pertinent questions. Good listeners want to make sure that they understand and might ask a lot of questions.
• Poor listeners come without a pad or pen. In business settings, it is very important to be prepared to take notes.
• Poor listeners leave the speaker wondering if the message was really received. Good listeners always re-cap what they heard to confirm the message.
Your "mess" may be comfortable to you, but it might make others in your office very uncomfortable!
You know where everything is and you can find that important piece of paper quickly. Still, if it looks like the paper is winning the battle for control of your work area, you may be losing face with your co-workers, and more importantly, with your boss!
We've heard that we would someday be working in a "paperless office". But, computer reports, printed e-mails, high-speed copiers and technology in general have all conspired to increase paper in the workplace. Sometimes it seems that most of it ends up on your desk!
Some people may feel that their job is more secure if they "look" busy. But clutter can signal a lack of control. A cluttered desk equals a cluttered mind. Employers view clutter as inefficiency, so if you appear too busy, maybe you are just inefficient. Inefficiency costs money and that is not a good way to get recognized.
1.	Get rid of the piles. Dump anything that you might, possibly, could, maybe use, read or act on "someday".
a. A "tickler file" by date of future work – items you can't do this week. Move next week's tasks to active each Friday.
b. An "active file" for current work – all due this week in priority sequence by day. This is the basis for your daily "TO DO" list.
c. A "meeting folder" for topics pertinent to specific meetings or for articles you want to read while you wait for the meeting to begin.
d. Create "The Boss" folder for issues that concern your employer.
e. Folders for subordinates or colleagues by name – for regular meetings with your people – not confidential material.
3. Label anything that is on, in or around your desk. You should be able to go on vacation and be comfortable that your boss or subordinates can find important information – easily.
Your desk is now organized, labeled and task oriented. Take care of urgent issues as they come up. Don't waste time filing them. If possible, put all of these files away at the end of each day so your desk is clear of paperwork.
There is another benefit to clearing the mess and organizing your work area. When you are in control of your space, your mind will be more alert, confident and creative. You will impress those around you, including your boss, with your command of your job. You will be ready for your boss's questions, prepared for meetings, and able to complete tasks on time. You might even have time to think! Who would dare "mess" with you?
How do you manage your paper clutter? Let us know!
One of the greatest challenges for parents during the school year, is organizing the never-ending flood of paperwork that comes home in those completely stuffed backpacks!
Having four kids myself, I recall several stressful nights searching for the missing permission slip or report card to be initialed and sent back.
In addition, each child had paperwork that had to be sent back to school, as well as paperwork that stayed home. Often, the paperwork that stayed home was necessary to refer to again later, when studying for year-end exams, etc.
1) Find the Paperwork. Open up those stuffed-to-the-gills backpacks, and pull out the paperwork to sort through. Yes, you may find half-eaten lunches in there and other mystery items, but it's important to know what you're dealing with. This is a good project for your child and will teach him/her the importance of taking care of their important paperwork. After all, if the permission slip isn't signed, they may not get to attend the fun activity they were looking forward to.
C-Line's Storage Box with 3 Compartments Color code each child's stay-at-home notes and supplies by storing them in one of these colorful storage boxes by C-Line. In addition to holding small notes, the Storage boxes hold pencils, erasers, and other small supply items. They make an ideal homework supply storage station.
C-Line's Poly Expanding Files. These durable poly expanding files are ideal for older children, who need to save papers based on school subject. Again, we recommend one for each child to keep paperwork separate and easily accessible. Files may be labeled for each class subject for quick reference.
With just a little effort and a few minutes of daily maintenance, you can manage the flood of paperwork and effortlessly "ride the wave"!
Have you found a great way to manage paperwork? We'd love to hear about it. Let us know, and you could WIN one of these great storage items from our friends at C-Line.


GREENCASTLE, Ind. -- Top-seeded and seventh-ranked Johns Hopkins won its second consecutive ITA National Team Indoor Championship on Sunday with an 8-1 win against ninth-ranked Carnegie Mellon. Sunday's final was a rematch of last year's championship, which the Blue Jays won 5-4. Hopkins (3-0) becomes the second team to win back-to-back titles at the championship, which began in 2009.
Junior Elaine Baik and freshman Mikey Barthelmass gave the Blue Jays an early 1-0 lead with an 8-4 win at second doubles against Katie Cecil and Angela Pratt. Juniors Shannon Herndon and Stephanie Rettig pushed the lead to two as they beat Lydia Utkin and Nicholle Torres 8-1 at third. The Tartans (7-1) cut the deficit in half when Vanessa Pavia and Bryn Raschke won a hard-fought 9-8 (7) match versus senior Hailey Hogan and sophomore Sydney Lehman at first.
Hogan gave Hopkins a 3-1 lead as she was the first one off the court in singles play. She defeated Brooke Tsu 6-0, 7-6 at third for her 42nd career singles win, moving her into eighth in program history. Lehman followed with a 6-1, 7-5 win versus Pratt at second at JHU was just one point shy of the title. Freshman Amanda Austi came up big for the Jays at first with a come-from-behind win to clinch the title. After losing her first set 6-4 to Pavia, Austi dropped just one game in winning 6-1, 6-0 in the final two sets to take the win. Herndon then beat Torres 6-2, 6-1 at fifth and the lead was 6-1. Baik dropped her first set to Cecil 6-4, but was up 4-1 in the second when Cecil retired. Rettig wrapped up the win at sixth as she beat Elizabeth Martin 6-3, 6-0.


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Russell Dickerson tops the country chart for a second week with "Love You Like I Used To"
Triple Tigers Records
With a second week at number one, Russell Dickerson is now walking a path forged by Luke Combs.
Russell's current single "Love You Like I Used To" sits in the top spot on the Billboard Country Airplay chart for the second week in a row. The song is his fourth consecutive number-one hit.
Following a trio of previous chart-toppers — "Yours," "Blue Tacoma" and "Every Little Thing" — Russell is now the second artist since Luke to launch his career with four consecutive number-ones on the Country Airplay chart.
The Tennessee native is also the second solo artist, and fourth in history, to have four or more singles reach the top of the Airplay chart in its 30-year history.
"There is no better way to kick off a sophomore album than with a 2 week number one," Russell shares. "Every song on this record is one of my favorite songs I've ever written and the fact that the fans feel that with 'Love You Like I Used To' means the world! Thank you country radio!!!!"
"Love You Like I Used To" is the lead single from Russell's sophomore album Southern Symphony, which will be released on December 4.


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Although the Earth was formed some 4.500 million years ago, it had to wait another thousand million years before life emerged in the primeval soup of the Precambrian ocean.
Our world had taken the decisive step towards its differentiation in a lifeless solar system. Appropriate physical and chemical conditions allowed the appearance of matter capable of perpetuating itself: life had emerged in a humble but unstoppable way.
The complexity of living forms grew as environmental conditions changed. Body structures became more sophisticated giving rise to creatures that were more capable of exploiting the energy of the environment in order to metabolise it and convert it into living matter capable of reproducing its genetic endowment. The first bacteria and single-cell algae made way for the first invertebrates and from those soft functional creatures arose a new much more complex order with an internal skeleton: the vertebrates.
The appearance of fish marked the starting point for one of life's greatest adventures. Oceans and seas had been conquered by plants and animals, but beyond, outside the protective water, stretched the world of the planet's surface, a different world full of promise but also full of innumerable obstacles and limitations. And living creatures, after preparing themselves for it for three thousand million years, decided to go out and conquer it.
Chap. I : Adapting itself to the environment
The surface of the Earth is very diverse. Different ecosystems form different worlds where physical environmental conditions form barriers for the species. If a living creature wants to establish itself in any of the worlds on the surface it will have to learn to overcome the particular limitations presented by temperature, humidity, altitude and other similar factors.
It is a task which is impossible to perform for isolated individuals, but life has such a powerful genetic tool that it has made it possible: evolution.
Chap. II : Gathering energy
From the origins of time obtaining food was like obtaining fuel for the engine of life.
All species had to face this first challenge on an almost daily basis and they used a whole array of curious strategies. Sharpened, powerful weapons, deadly poisons, perfect camouflage, etc., a complete biological arsenal at the disposal of the species.
It was, and still is, an arms race. New acquisitions allowed them to be more competitive when it came to looking for food or avoiding being eaten and the penalty for falling behind was death.
Chap. III : Perpetuating the species
All the adaptations brought along the long and difficult road to colonise the earth produced species that were increasingly better equipped to face the challenges of survival. But all of these achievements, over millions of years, were only possible because each and every one of these living beings was capable of producing descendents.
Perpetuating the species, continuing the process of life is a risky, dangerous mission. You have to find a mate, competing against other candidates, find the right place to bring your children into the world, build a home, defend them from enemies and feed them until they become independent. An exhausting task, simply to pass on your genes to future generations.
Explora Films / Impala
The Third Planet
Keepers of the Planet


The Business Tax department of this leading practice prides itself on providing bespoke tax services to it's clients and deals with all queries from basic compliance through to high-level advisory work. This team is renowned for it's work with the OMB sector and entrepreneurs.
As Business Tax Senior Manager you will be responsible for your own portfolio of clients of mainly OMB's but may also include international groups. You will be responsible for the preparation and submission of corporate tax returns and associated tax computations. In addition, you will be required to carry out tax planning/consultancy work. As Senior Manager you will also be expected to be capable of building strong new client relationships and develop existing relationships therefore business development will be a key aspect of this role.
In order to be considered you must be accountancy or tax qualified with prior experience in corporate tax.
You will be joining an ambitious firm with a great culture nurtured by a strong leadership team united by a shared goal to provide exceptional service to their clients. A culture where you are encouraged to reach your full potential.


Castlepines, one of the leading financial companies of its kind specializing in major global infrastructure projects, has taken major steps ahead in the renewable energy business.
Japan's feed-in-tariff (FIT) system was inaugurated in 2012, the year after the Tōhoku earthquake and tsunami and nuclear disasters in North-East Japan. The system was developed to accelerate Japan's investment into renewable energy creation, in which electric power companies must purchase electricity generated from renewable energy sources on a fixed-period contract at a price set by the Ministry of Economy, Trade and Industry.
For most genres, a 20-year fixed power sales price is applied. Biomass-generated electricity is a safe energy that decreases CO2, but increases employment and locally accessible energy. In terms of the feedstock supply, which has posed a challenge in many countries, Castlepines promotes global business networks among Asian countries, allowing simultaneous development of biomass generation to the amount of $1.0 billion in Japan plus feedstock projects in South Asia.
As a G-20 member and the largest economy in Southeast Asia, Indonesia is a thriving nation with dramatic growth of both economy and population. In 2017, the country's produced a GDP growth rate of 5.1 percent, its highest in 4 years. According to a 2018 World Bank report, Indonesia has experienced increased prosperity as a result of net exports, growing global trade, recovery of commodity prices – and crucially – stronger investments. Amongst a population of 264 million, local energy demand is growing too. On the other hand, bio-waste disposal has become a serious problem in recent years.
Castlepines has offered one solution: to build renewable energy plant projects that utilize food wastes for fuel, which can decrease CO2 emissions and pollution, while simultaneously increasing local energy supply and employment in any given region. Aware of the major economic opportunity and human capital potential by investing in Indonesia's future, Castlepines' funds and its global network have allocated $600 million to support these projects across the country.
Brazil is home to a relatively young, but burgeoning biomass industry. Supported by the country's 851 million hectares of land, wood biofuel can be derived from the 32% of the country deemed arable land. More than 80% of Brazilian pellet production is concentrated in the Southern states of Paraná, Santa Catarina and Rio Grande do Sul. Despite a weak domestic demand for pellet fuel at present, its favorable climate and soil properties, as well as support from policy makers, positions Brazil as a promising opportunity for harnessing massive amounts of natural waste energy.
Castlepines is helping one local Brazilian company start a sustainable and renewable energy project that will assist European and Asian countries in the reduction of their fossil fuel consumption, by utilizing timber industry waste and by-products into wood pellets. In allocating the current wealth of renewable forests – mainly eucalyptus and pine – as feedstock that had no prior commercial use, the Castlepines investment in this project will bring jobs and create wealth in the region. Furthermore, support from Castlepines will aid major global economies in reducing CO2 emissions and meeting renewable energy goals with a reliable and sustainable source of biomass from Brazil.
The global solar power market grew by nearly 30% YoY in 2017. China was responsible for creating 53% of the world's new solar capacity (52.8 GW), followed by the United States in 2nd place with 10.6 GW and India with 9.6 GW of new installations. 2017 also marked a record year in PV installations, according to a joint report by the BNEF and FS-UNEP-CC. The 98 GW of solar power was greater than the new installations of all other renewables – coal, gas, nuclear power – combined.
Castlepines is accelerating availability of this energy to corporate consumers by investing in PV solar projects across major urban centres. Their position is further strengthened by a new operations partnership with a world-class global supplier of equipment, ensuring that PV solar projects can be installed wherever there is a transmission line that will facilitate the supply of energy to consumption centres, with less complicated licenses and permits. The United Nations predicts that by 2050, 2.5 billion people – two-thirds of the world's population – will live in cities. By investing early and significantly in urban PV solar supply, Castlepines has secured its role as an integral player in providing efficient solar power to the world's future megacities.
As the global economy strives to strengthen its alternative energy sources, substantial capital investments are required to drive responsible and sustainable returns. Castlepines is poised to leverage its strong track record of success in the infrastructure sector into a diversified renewable energy portfolio that will provide long-term growth while at the same time enriching local economies for decades.


"winemaker's notes: Barbera d'Alba is an intense, Cardinal red with sparkling tones. It has a resolute bouquet, with trace aromas of ripe plum and an undercurrent of mixed spices. This wine is has full flavor with long persistence. A wine suited to hearty Italian dishes as well as refined meat dishes and aged cheeses. Commencing with the 2011 vintage, the name ""Torriglione"" will not appear on Ratti's Barbera d'Alba label. alcohol by volume: 14.0%"


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Dorsky Exhibit of "1980s Style: Image and Design"
Kelsey Damrad May 1, 2014
Dorsky Exhibition from The Little Rebellion on Vimeo.
The 80's are alive and well on the SUNY New Paltz campus, as the Samuel Dorsky Museum showcases the decade in its current exhibition.
With an array of jewelry, photography and prints dating back to the era, the eclectic collection entitled '1980s Style: Image and Design' reviews all aspects of '80s art, from fashion to photography.
It showcases blunt geometric shapes, powerful colors and a digital revolution, according to the 1980s exhibit's online feature. The artists took the decade's troubles into their own hands to create suggestive abstraction and aesthetically provocative artwork.
The goal of 80's artists was to employ relatively mundane images while using a pattern that harbored substantial content.
According to the museum and exhibition's curator Daniel Belasco, the selected pieces were chosen due to their significant portrayal of aggression, anger, anxiety and 1980s political developments. No matter the medium of archival, he said, artists working in the 1980s valued using art to face prominent issues including AIDS, nuclear war, advertising and Reaganomics.
These artists used their work to confront pervasive and relevant issues in an edgy way, said Belasco.
Among the pieces featured in the Dorsky's collection, the most notable include an Andy Warhol screenplay, an untitled George McNeil piece from his 'The Atelier Project' and Barbara Kasten's 'Construct A + A' Polaroid print.
"It's the aggression of the time period that makes these pieces so notable," Belasco said. "The colors, the styles, everything embodies the emotions of the decade."
Belasco was appointed the curator for The Dorsky's exhibitions and programs in 2013 and says that the selected pieces are "arresting" examples of how artists strayed from conventional styles and were "shameless in their expressions of fear" and desire for activism. This, he said, is what makes their artwork a stark contrast to that of today.
According to Rachel Beaudoin, third-year art history major and the museum's curatorial intern since 2013, each of the pieces of artwork in the exhibit "deal with the sense of fear and anxiety that dominates the 80s." Some of the pieces are more obvious in their approach than others, she said.
"By selecting works in this manner I think we were really able to create a collection of objects that allow for a new interpretation of how art functioned during this decade," Beaudoin said. "I hope that visitors are able to grasp a sense of the time period, both aesthetically and emotionally."
For New Paltz Professor Ann Lovett, whose photography is also featured in the exhibit, the message she hopes viewers take away from her work is to question how information is mediated to the public. This, she says, was an issue anchored in the 1980s that is still pervasive in society today.
"Ubiquitous advertising images and messages seduce and mislead us," Lovett said. "[My] series uses advertising images and other found materials to comment on how information about politics and social issues is packaged to make it more palatable to the American public."
As the '80s are considered one of the most lucrative eras, advertisement to and treatment of consumers is a topical issue expressed in the gallery's artwork.
Lovett's work features "20 by 24" Polaroid prints made with a camera available to artists in the 1980s and 1990s through a special access grant program. Her work has also been featured in numerous faculty exhibitions at the Dorsky over the years, including a solo exhibition when the space was still called the College Art Gallery.
"Ann's work is really unique to a specific issue," Belasco said.
Her photography is dedicated an entire wall in the gallery, and features seven popular advertisements of the decade.
For the viewers, Belasco said he hopes they leave with a renewed comprehension of the era. The artwork, he said, really speaks to the issues and emotions encompassing the 80s.
"Artwork is a product of its time," Beaudoin said. "In all forms, art often responds to the socio-cultural and political realities of the time in which they were created."
"1980s Style" debuted on Wednesday, Feb. 5 and will be open to the public until July 13.
Posted in FEATURESTagged #1980s Style: Image and Design #Kelsey Damrad #Samuel Dorsky Museum of Art
Kelsey Damrad
Food Waste By The Numbers
Thu May 1 , 2014
Next time your unfinished egg sandwich and untouched banana gets thrown out in the dining hall, it may get composted and end up enriching the soil in a local garden. But students rarely think about what happens to food they toss out. Efforts to change that are underway, and the […]
Sound Off! Sole Survivor
Alumni Profile: Sarah Bradshaw
Literary Journalism: Uncertainty
Fair Trade for Dummies
Under the Golden Arches
Dumbledore's Army of New Paltz Chases the Golden Snitch for Charity


When you see something like this... Don't you have to ask the question to yourself - "How did we get Collin Sexton for free?"
Its like Zion Williamson getting a big $$$ offer from KU, including employment for the family, but yet he chose to go to Duke... FOR FREE.
So, you are laughing at UA and suggesting that Bama cheated to sign Colin.
You were really quick to defend Kirby when we know he's been lying to recruits. It was "prove it" and suggestions Saban was cheating as well."
Yep... On all accounts. I think Bball is far more corrupt than football in the recruiting stages... Because of the 1 and done aspect vs the 3 year minimum.
That became even clearer last Thursday, when ESPN reported evidence produced by the federal government in a New York court showed Christian Dawkins, a former runner for NBA agent Andy Miller, acknowledging giving Sexton $5,000 and concocting a plan to pay the former Alabama guard $1,500 per month, supply $21,000 in travel expenses for his family and provide his brother a job that would net him a total of $170,000 over four years.
Will NCAA penalize Alabama after latest Collin Sexton news?
Got anything like that on Kirby? If so, it could sway my opinion.
Do you think Sexton came to Alabama for free? On on a larger scale, are any of these big time hoop recruits going ANYWHERE for free? Or just sensitive about the Kirby issue?
April 4th: Reports have Wade and LSU nearing an agreement.
April 5th: Reports have the FBI still investigating Wade.
No way I would attempt to wait this out with Will Wade and the FBI/NCAA. Unless your plan is to promote from within and the players know that. Firing with cause is almost a slam dunk at this point. But hey, it's LSU and no one does political chaos like the Cajuns.


Make Space is designed for aspiring artists (aged 18-24) who wish to expand and explore themselves and their creative abilities through site-responsive contemporary performance-making.
Across four weeks (two in July and two in September) participants worked collaboratively with and from a chosen site, to experiment in the making of their own work.
Make Space 2015 was the third in a series of vocational summer projects run by Artsadmin and artist Nic Green. In 2015, the project invited participants to consider the idea of 'perspective'. A word with multiple meanings, the group worked to explore this theme through performance, in relation to site and space.


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Chance the Rapper Rolls Out "Hot Shower" Video
The clip from 'The Big Day' features DaBaby and MadeinTYO
Fresh off another appearance on Saturday Night Live, Chance the Rapper has shared a new video for The Big Day cut "Hot Shower."
Following his video for "We Go High," the latest wild clip finds the Chicagoan playing the role of a judge, a suitably shredded fitness instructor and a baby.
Elsewhere, DaBaby tears up a courtroom while MadeinTYO tears up a racetrack. You can watch the Reel Goats-directed clip in the player below.
The Big Day is out now. Last month, Chance rescheduled his entire tour behind the album.
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In case you missed it, United recently announced a strict policy for dealing with overweight passengers. This has prompted two other airlines to clarify their own such policies, and it's no surprise that the airlines in question—Southwest and US Airways—are a bit more generous than United.
I think these statements more or less speak for themselves, so I won't say much. But it's refreshing to see at least two airlines trying to preserve the comfort and personal space of their passengers without punishing overweight flyers by forcing them to purchase a second seat under most circumstances. It's not always easy to find a realistic and fair compromise, but it's worth a shot.