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Infektionen mit Humanen Papillomviren (HPV) sind eine weltweit häufig auftretende Erkrankung. In den meisten Fällen heilt diese folgenlos aus, in rund 10% der Fälle kommt es aber zu einer verlängerten Persistenz des Virus im Gewebe. Eine maligne Transformation ist möglich und gilt als ätiologische Bedingung für die Entstehung des Zervixkarzinoms. HPV sind ebenfalls an der Pathogenese andere anogenitaler Krebserkrankungen (Vaginal-, Vulva-, Anal-, Peniskarzinom) und an der Entstehung eines Anteils von Oropharynxkarzinomen beteiligt. Auch Genitalwarzen werden durch eine Infektion mit HPV ausgelöst. Weltweit sind jährlich knapp 700.000 Krebsneuerkrankungen auf eine Infektion mit HPV zurückzuführen. In Deutschland sind pro Jahr ca. 7.500 neu aufgetretene Krebserkrankungen HPV-attributabel. Eine HPV-Infektion ist nicht kausal therapierbar. Seit einigen Jahren sind Schutzimpfungen gegen HPV verfügbar. Die drei in der EU zugelassenen Impfstoffe decken allesamt die epidemiologisch dominanten Hochrisikotypen 16 und 18 ab, zwei der Impfstoffe ebenfalls auch die Niedrigrisikotypen 6 und 11 als Schutz vor Genitalwarzen. Internationale Studien belegen eine deutliche Abnahme der Inzidenz des Zervixkarzinoms bei geimpften Populationen. Die bei Studiendurchführung aktuelle Impfempfehlung der Ständigen Impfkommission (STIKO) des Robert Koch-Instituts (RKI) umfasst alle Personen im Alter von 9 bis 14 Jahren, Nachholimpfungen sollen bis zum 17. Lebensjahr erfolgen. Trotz eines guten Sicherheitsprofils der Impfstoffe sind die Impfquoten in Deutschland bisher niedrig, vor allem im jüngeren Altersbereich. Gründe für die niedrige Impfbereitschaft liegen beispielsweise in einer geringen Risikoperzeption auf Elternseite, der Angst vor Nebenwirkungen der Impfung oder fehlendem Vertrauen in medizinische Versorgungsstrukturen. Zielgerichtete Beratung und Aufklärung der Eltern haben sich als wichtige Antwort auf diese Bedenken erwiesen. Erfahrungen aus anderen Ländern legen nahe, dass insbesondere auch Schulimpfprogramme ein niederschwelliger Ansatz zur Erhöhung der Impfquoten sein können. Basierend auf diesen Erfahrungen wurde 2018 das HPV-Schulimpfprojekt in Sachsen gegründet. Es hat zum Ziel, die Impfrate bei 9- bis 14-Jährigen durch ein niederschwelliges Impfangebot in der Schule zu erhöhen. Dazu werden an ausgewählten Schulen Informationselternabende und Impftermine vor Ort angeboten. Ziel der vorliegenden Arbeit war es, den Erfolg des HPV-Schulimpfprojektes im Zeitraum des Schuljahres 2020/21 zu evaluieren. Dazu wurden die Impfquoten nach Projektende erhoben und mit den Impfsurveillancedaten des RKI verglichen. Weiterhin erfolgten eine Befragung der Eltern mittels Fragebogen und eine statistische Analyse zur Detektion von Unterschieden zwischen einzelnen demografischen Gruppen. Am Modell des begleiteten HPV-Schulimpfprojektes wurden Erkenntnisse und Handlungsempfehlungen abgeleitet. Im besagten Impfjahr wurden acht Schulen vom HPV-Schulimpfprojekt besucht. Die Anzahl der geimpften Kinder wurde durch das ärztliche Personal auf einem Prüfbogen dokumentiert. Die Impfquoten wurden berechnet und tabellarisch und grafisch aufbereitet. Danach erfolgte zunächst die deskriptive statistische Auswertung des Fragebogens. Um eine genauere Beantwortung einzelner Forschungsfragen in fünf Themenblöcken zu ermöglichen, führten wir anschließend Vergleiche zwischen dichotom gruppierten Teilen des Studienkollektivs durch. Alle Ergebnisse aus der Berechnung der Impfquoten, sowie der Auswertung des Studienfragebogens sind in der Arbeit ausführlich dargestellt. In der anschließenden statistischen Analyse wurde untersucht, ob Unterschiede im Antwortverhalten zwischen dichotomen demografischen Gruppen bestehen. Als statistisch signifikant stellte sich unter anderem heraus, dass die Eltern von Kindern aus Klassenstufe 4 die Möglichkeit der Impfung in der Schule besser bewerteten als die Eltern von Fünftklässler:innen, ebenfalls wurde diese von Eltern mit akademischem Hintergrund und Eltern, deren Kinder eine Schule innerhalb Leipzigs besuchen, befürwortet. Eltern ohne Impfwunsch hatten einen geringeren Bedarf an Informationen zu Impfungen im Schulkontext. Die Eltern von Jungen änderten ihre Einstellung zur HPV-Impfung häufiger als die Eltern von Mädchen. Diese und weitere Erkenntnisse können dabei helfen, Gruppen zu identifizieren, die von einer gezielten Ansprache profitieren, und Handlungsbereiche zu definieren, die bei zukünftiger Projektdurchführung optimiert werden können. Im Rahmen des HPV-Schulimpfprojektes konnten die Impfquoten im Altersbereich zwischen 9 und 11 Jahren gegenüber den in der RKI-Impfsurveillance ermittelten Daten gesteigert werden. Ebenfalls konnten bei Jungen und Mädchen nahezu gleich hohe Impfraten erreicht werden. Schulbasiertes Impfen bietet insbesondere für Eltern jüngerer Kinder ein niederschwelliges Angebot, welches laufende Präventionsstrategien ergänzen kann. Um eine flächendeckende Erhöhung der Impfquote zu erhalten, müssen Schulimpfprojekte langfristig etabliert und in der öffentlichen Gesundheitsfürsorge verankert werden. Aus der begleitenden Fragebogenstudie wurde ersichtlich, dass ein Teil der Elternschaft die Möglichkeit des schulbasierten Impfens begrüßt und der Wunsch nach mehr Informationen und Angeboten zum Thema Impfungen besteht. Insbesondere für die Eltern von Jungen zeigte sich, dass der Informationselternabend einen Einfluss auf die Impfentscheidung hatte. Schulbasiertes Impfen bietet einen Ansatz, Versorgungslücken in der Präventionsmedizin zu schließen. Gezielte Strategien zur Ansprache von Eltern mit Bedenken müssen in Folgestudien weiter exploriert werden. Die Beobachtungen der Studie können modellhaft für die Planung weiterer Schulimpfprojekte in Betracht gezogen werden. Zur weiteren Optimierung wurden Erkenntnisse und Handlungsvorschläge entwickelt, welche die gezeigten Erfolgschancen schulbasierten Impfens weiter erhöhen sollen. Langfristiges Ziel bleibt die wissenschaftlich begleitete flächendeckende Etablierung und Implementierung von Schulimpfprogrammen zur Erhöhung der HPV-Impfraten. Dies kann zukünftig die Krankheitslast durch HPV-assoziierte Krebserkrankungen, Vorläuferläsionen und Genitalwarzen deutlich verringern.:Tabellenverzeichnis 1 Abbildungsverzeichnis 2 Abkürzungsverzeichnis 3 1. Einführung 5 1.1. Humane Papillomviren und assoziierte Erkrankungen 5 1.1.1. Entdeckung, Struktur, HPV-Typen 5 1.1.2. HPV-assoziierte Erkrankungen, Pathogenese 7 1.1.2.1 Neoplasien und Vorstufen (Zervix, Anogenitalregion, Kopf-Hals) 7 1.1.2.2. Genitalwarzen (Condylomata acuminata) 10 1.1.3. Epidemiologie (Deutschland, weltweit) 10 1.1.3.1. HPV-Infektionen 10 1.1.3.2. HPV-attributable Karzinome und Vorstufen 11 1.1.3.3. Genitalwarzen 13 1.1.4. Diagnostik und Risikofaktoren 13 1.1.5. Therapie 14 1.2. Schutzimpfung 15 1.2.1. Zugelassene Impfstoffe, Funktionsweise 15 1.2.2. Aktuelle Impfempfehlung für Deutschland 17 1.2.3. Impfquoten der RKI-Impfsurveillance in Deutschland 18 1.2.4. Verträglichkeit der Impfung, Nebenwirkungen 21 1.2.5. Gründe für geringe Impfquoten, Lösungsansätze 21 1.2.6. Strukturierte Impfprogramme 24 1.3. HPV-Schulimpfprojekt 26 1.4. SARS-CoV-2-Pandemie, aktuelle Herausforderungen 27 2. Aufgabenstellung 29 3. Materialien und Methoden 30 3.1. Studienkollektiv, Projektablauf 30 3.2. Studiendokumente 31 3.3. Statistische Auswertung 33 3.3.1. Erster Studienteil: Impfquoten 33 3.3.2. Zweiter Studienteil: Befragung der Eltern 35 3.3.3. Analysen zum Gruppenvergleich 35 4. Ergebnisse 38 4.1. Charakterisierung der Grundgesamtheit 38 4.2. Erster Studienteil: Impfquoten 39 4.3. Zweiter Studienteil: Befragung der Eltern 45 4.3.1. Studienablauf und -beteiligung 45 4.3.2. Charakterisierung des Studienkollektivs 46 4.3.3. Deskriptive Auswertung des Studienfragebogens 48 4.3.3.1. Impfentscheidung 48 4.3.3.2. Item 4 - Einstellung zur Schulimpfung 51 4.3.3.3. Item 5 - Einstellung zur HPV-Impfung nach Elternabend 51 4.3.3.4. Item 6 - Impfmotivation ohne Schulimpfprojekt 53 4.3.3.5. Item 7 - Informationsmenge 54 4.3.3.6. Items 8 und 9 - Vorwissen zur Erkrankung und Impfung 54 4.3.3.7. Item 10 - Risikoskala 56 4.3.3.8. Items 11 bis 14 - generelle Einstellung zum Impfen 57 4.3.3.9. Item 15 - Auswirkung der SARS-CoV-2-Pandemie 60 4.3.4. Analyse von Zusammenhängen zwischen Merkmalen, Gruppenvergleiche 61 4.3.4.1. Themenblock 1: Projektteilnahme und Impfwunsch 61 4.3.4.2. Themenblock 2: Einstellung zu Impfangeboten im schulischen Kontext 62 4.3.4.3. Themenblock 3: Einfluss des Projektes auf die Impfentscheidung 64 4.3.4.4. Themenblock 4: Vorwissen zu HPV 66 4.3.4.5. Themenblock 5: Einstellung zu impfrelevanten Fragestellungen 67 5. Diskussion 70 5.1. Impfquoten und Teilnahmemotivation 70 5.1.1. Ergebnisinterpretation von Impfquoten verschiedener Teilgruppen 70 5.1.2. Impfmotivation, Datengrundlage, Erreichen des Projektziels 74 5.1.3. Vergleich zum Ausland, Einfluss der strukturellen Gegebenheiten 75 5.1.4. Unsicherheiten und Limitationen bei der Ergebnisinterpretation 76 5.2. Ergebnisinterpretation zweiter Studienteil 78 5.2.1. Interpretation der deskriptiven Auswertung 79 5.2.2. Interpretation der statistischen Analyse, Gruppenvergleiche 82 5.2.3. Unsicherheiten und Limitationen 86 5.3. Evaluationserkenntnisse, Gesamteinschätzung 86 5.3.1. Abgeleitete Erkenntnisse und Handlungsempfehlungen 86 5.3.2. Einschätzung zum Untersuchungsziel, Hürden und kritische Reflexion 88 5.3.3. Pandemiesituation 89 5.3.4. Ausblick und zukünftige Herausforderungen 90 5.4. Fazit 91 6. Zusammenfassung der Arbeit 93 7. Literaturverzeichnis 98 8. Anlagen 107 Einwilligungserklärung zur Teilnahme an der Begleitstudie I Studienfragebogen II Prüfbogen für Impfärztinnen III Selbstständigkeitserklärung IV Lebenslauf V Publikationsübersicht VI Danksagung VII

The human papilloma virus (HPV) is the most frequent cause of sexually transmitted diseases (STDs) and cancers for U.S. adults. The Affordable Care Act (ACA), enacted in 2010, eliminated copay expenses for childhood immunizations and expanded access to health care. The purpose of this secondary data analysis study was to determine if there was an association between ACA and the usage of HPV vaccine among adolescent females in Georgia. Data concerning HPV vaccinations from 2011 to 2015 were obtained from the National Immunization Survey-Teen dataset. Andersen's BM of health care use was applied to ascertain the factors that enhanced the usage of HPV vaccine. Multiple logistic regression analysis was used to determine if there was any association between ACA and HPV vaccination. The study results showed a significant association between ACA and provider visit (p<.05). Also, provider visit was significantly associated with HPV vaccination rate (p<.05). Adolescent females with health insurance had a higher rate of provider visit after the passage of ACA. From 2011 to 2015, 87.2% of insured adolescent females visited their provider. The rate of HPV vaccination increased among the insured adolescent females who visited the provider from 35.3% in 2011 to 53.9% in 2015. Provider visit was identified as the most influencing factor that enhanced usage of HPV vaccine. The knowledge gained from the results contributed to social change by providing insight on how, through increased provider visits, ACA has improved the HPV vaccination rate among teenage females in Georgia. The conclusion will assist in developing effective strategies and policies that will achieve the Healthy People 2020 goal of 80% of herd immunity against HPV.

Introdução: As infecções pelo papiloma vírus (HPV), geralmente são assintomáticas e transitórias, porém, em indivíduos com doenças autoimune, onde há um comprometimento da imunidade causado por mecanismo inerentes a própria doença e pelo tratamento com drogas imunossupressoras, o risco destas infecções evoluírem para lesões metaplásicas e neoplásicas é alto. A forma mais eficiente de prevenção deste tipo de desfecho é a vacinação contra HPV. Assim, a indicação desta vacina seria fundamental para a proteção destes pacientes, porém, devido aos fatores citados, pressupõem-se que a resposta poderia ser menos eficiente. Objetivo: Avaliar a imunogenicidade da vacina contra HPV quadrivalente em pacientes com Lúpus Eritematoso Sistêmico Juvenil (LESJ) e Dermatomiosite juvenil (DMJ). Métodos: Estudo prospectivo de intervenção multicêntrico, onde foram incluídas 328 meninas e adolescentes (9-20 anos) em 13 centros oriundos de diferentes regiões do Brasil. Porém apenas 246 indivíduos preencheram os critérios de inclusão. O protocolo do estudo previa a aplicação de 3 doses da vacina (0,2 e 6 meses). Os grupos foram divididos em: Grupo A (paciente 206 portadoras de LESJ); Grupo B (pacientes 40 portadoras de DMJ); Grupo C (controle 41 indivíduos saudáveis). A avaliação sorológica foi realizada nos momentos 0, 3, 7 e 12 meses do início do estudo e para mensurar os níveis de anticorpos produzidos para subtipos HPV 16 e HPV18 foi utilizado o imunoensaio Luminex. Foram considerados respondedoras as pacientes ou controles que apresentassem anti-HPV 16 acima do cutt-off= 9 mMU/ml e para antiHPV 18 acima de 13 mMU/ml. Resultados: 246 meninas e adolescentes completaram o protocolo do estudo, sendo 206 pacientes do grupo A, 40 pacientes do grupo B e 41 controles grupo C. Ao todo tivemos 39 indivíduos que não responderam a vacina, sendo 23 do grupo A,8 grupo B e 8 grupo C. E 82 descontinuidades do estudo por motivos diversos como: receio a reações a vacina, mudança de cidade, gravidez e óbito. Na análises comparativas feitas entre os grupos. Não foi observado nenhum fator de risco que influenciou na não resposta a vacina dentre as variáveis consideradas: faixa etária (9-13, 14- 20 anos), número de doses (2 ou 3), tipo e atividade da doença de base, além das várias drogas utilizadas no tratamento, analisadas individual e em associações. Conclusão: A vacinação contra HPV parece ser imunogênica para o grupo de pacientes com LESJ ou DMJ, porém parte delas apresentam uma resposta parcial à vacina, com resposta efetiva a apenas um dos sorotipos avaliados (16 ou 18). Nenhum fator de risco foi encontrado que possa ter influenciado na não resposta a vacina. / Introduction: Papillomavirus (HPV) infections are generally asymptomatic and transient, but in individuals with autoimmune diseases whom used to have a compromise of the immunity caused by mechanisms inherent to the disease itself in addition to the treatment with immunosuppressive drugs. Thus, the risk of these infections progress for metaplastic and neoplastic lesions is high in these individuals. Vaccination is essential for the protection of these patients, however because the characteristics of their immune system may be less effective. The most efficient way to prevent this type of outcome is vaccination against HPV. Thus, the indication of this vaccine would be fundamental for the protection of these patients, however due to the compromise in the immune system, it is possible to assumed that the response could be less efficient. Objective: To evaluate the immunogenicity of the quadrivalent HPV vaccine in patients with Juvenile Systemic Lupus Erythematosus (JSLE) and Juvenile Dermatomyositis (JDM). Methods: A multicenter prospective study, including 328 girls and adolescents (9-20 years) in 13 centers from different regions of Brazil. The study protocol provided for the application of 3 doses of the vaccine (0.2 and 6 months). During the study blood collections and serological evaluation was performed at time points 0, 3, 7 and 12 months after the start of the study in 206 SLEJ patients (group A), 40 JDM patients (group B) and 41 healthy controls (group C). To evaluate the levels of antibodies produced for HPV 16 and HPV18 subtypes the Luminex immunoassay was used. Patients or controls with anti-HPV 16 cutt-off = 9 anti-HPV 18 = 13 were considered as responders. RESULTS: Of the 328 girls and adolescents included, 246 girls and adolescents completed the study protocol, being 206 patients in group A, 40 patients in group B and 41 controls in group C. In all we had 39 individuals who did not respond to the vaccine, being 23 of group A, 8 group B and 8 group C. E 82 study discontinuities for various reasons such as: fear of reactions to the vaccine, city change, pregnancy and death. In the comparative analyzes made between the groups. No risk factor was observed that influenced the non-response to the vaccine among the variables considered: age range (9-13, 14-20 years), number of doses (2 or 3), type and activity of the underlying disease, Of the various drugs used in the treatment, analyzed individually and in associations. 287 completed the study. Conclusion: the vaccine anti-HPV seems to be immunogenic in JLES and JDM patient, however a percentage of patients have showed a partial response to the vaccine, just a one of the serotypes 16 or 18. No risk factor was found that May have influenced the nonresponse to the vaccine.

Introdução: As infecções pelo papiloma vírus (HPV), geralmente são assintomáticas e transitórias, porém, em indivíduos com doenças autoimune, onde há um comprometimento da imunidade causado por mecanismo inerentes a própria doença e pelo tratamento com drogas imunossupressoras, o risco destas infecções evoluírem para lesões metaplásicas e neoplásicas é alto. A forma mais eficiente de prevenção deste tipo de desfecho é a vacinação contra HPV. Assim, a indicação desta vacina seria fundamental para a proteção destes pacientes, porém, devido aos fatores citados, pressupõem-se que a resposta poderia ser menos eficiente. Objetivo: Avaliar a imunogenicidade da vacina contra HPV quadrivalente em pacientes com Lúpus Eritematoso Sistêmico Juvenil (LESJ) e Dermatomiosite juvenil (DMJ). Métodos: Estudo prospectivo de intervenção multicêntrico, onde foram incluídas 328 meninas e adolescentes (9-20 anos) em 13 centros oriundos de diferentes regiões do Brasil. Porém apenas 246 indivíduos preencheram os critérios de inclusão. O protocolo do estudo previa a aplicação de 3 doses da vacina (0,2 e 6 meses). Os grupos foram divididos em: Grupo A (paciente 206 portadoras de LESJ); Grupo B (pacientes 40 portadoras de DMJ); Grupo C (controle 41 indivíduos saudáveis). A avaliação sorológica foi realizada nos momentos 0, 3, 7 e 12 meses do início do estudo e para mensurar os níveis de anticorpos produzidos para subtipos HPV 16 e HPV18 foi utilizado o imunoensaio Luminex. Foram considerados respondedoras as pacientes ou controles que apresentassem anti-HPV 16 acima do cutt-off= 9 mMU/ml e para antiHPV 18 acima de 13 mMU/ml. Resultados: 246 meninas e adolescentes completaram o protocolo do estudo, sendo 206 pacientes do grupo A, 40 pacientes do grupo B e 41 controles grupo C. Ao todo tivemos 39 indivíduos que não responderam a vacina, sendo 23 do grupo A,8 grupo B e 8 grupo C. E 82 descontinuidades do estudo por motivos diversos como: receio a reações a vacina, mudança de cidade, gravidez e óbito. Na análises comparativas feitas entre os grupos. Não foi observado nenhum fator de risco que influenciou na não resposta a vacina dentre as variáveis consideradas: faixa etária (9-13, 14- 20 anos), número de doses (2 ou 3), tipo e atividade da doença de base, além das várias drogas utilizadas no tratamento, analisadas individual e em associações. Conclusão: A vacinação contra HPV parece ser imunogênica para o grupo de pacientes com LESJ ou DMJ, porém parte delas apresentam uma resposta parcial à vacina, com resposta efetiva a apenas um dos sorotipos avaliados (16 ou 18). Nenhum fator de risco foi encontrado que possa ter influenciado na não resposta a vacina. / Introduction: Papillomavirus (HPV) infections are generally asymptomatic and transient, but in individuals with autoimmune diseases whom used to have a compromise of the immunity caused by mechanisms inherent to the disease itself in addition to the treatment with immunosuppressive drugs. Thus, the risk of these infections progress for metaplastic and neoplastic lesions is high in these individuals. Vaccination is essential for the protection of these patients, however because the characteristics of their immune system may be less effective. The most efficient way to prevent this type of outcome is vaccination against HPV. Thus, the indication of this vaccine would be fundamental for the protection of these patients, however due to the compromise in the immune system, it is possible to assumed that the response could be less efficient. Objective: To evaluate the immunogenicity of the quadrivalent HPV vaccine in patients with Juvenile Systemic Lupus Erythematosus (JSLE) and Juvenile Dermatomyositis (JDM). Methods: A multicenter prospective study, including 328 girls and adolescents (9-20 years) in 13 centers from different regions of Brazil. The study protocol provided for the application of 3 doses of the vaccine (0.2 and 6 months). During the study blood collections and serological evaluation was performed at time points 0, 3, 7 and 12 months after the start of the study in 206 SLEJ patients (group A), 40 JDM patients (group B) and 41 healthy controls (group C). To evaluate the levels of antibodies produced for HPV 16 and HPV18 subtypes the Luminex immunoassay was used. Patients or controls with anti-HPV 16 cutt-off = 9 anti-HPV 18 = 13 were considered as responders. RESULTS: Of the 328 girls and adolescents included, 246 girls and adolescents completed the study protocol, being 206 patients in group A, 40 patients in group B and 41 controls in group C. In all we had 39 individuals who did not respond to the vaccine, being 23 of group A, 8 group B and 8 group C. E 82 study discontinuities for various reasons such as: fear of reactions to the vaccine, city change, pregnancy and death. In the comparative analyzes made between the groups. No risk factor was observed that influenced the non-response to the vaccine among the variables considered: age range (9-13, 14-20 years), number of doses (2 or 3), type and activity of the underlying disease, Of the various drugs used in the treatment, analyzed individually and in associations. 287 completed the study. Conclusion: the vaccine anti-HPV seems to be immunogenic in JLES and JDM patient, however a percentage of patients have showed a partial response to the vaccine, just a one of the serotypes 16 or 18. No risk factor was found that May have influenced the nonresponse to the vaccine.

<p>This dissertation aimed at examining the predictors of HPV vaccination intentions of college students in a Kenyan university and those in a Midwest university in the United States of America (USA). Using the theory of planned behavior (TPB), the dissertation investigated the most salient factors that predict the vaccination intentions of college male and female students in Kenya and the USA. A mixed method approach was utilized to collect data from the participants. Specifically, interviews with 43 students (22 from Kenya and 21 from USA) were used to collect the qualitative data from the students. The quantitative data were collected using closed-ended surveys with 512 Kenyan students at a large university in Uasin Gishu County and 522 students at the Midwestern university, USA. The qualitative findings revealed that identification had a major influence on how students sought health, ate, and related with their peers. In particular, identification through religiosity influenced the students’ attitudes toward sex and perception of oneself. Thus, many respondents reported viewing their bodies as the temple of God and sex as an activity for married couples. Thus, when they engaged in premarital sex, they often felt disconnected with God and they resulted to seeking forgiveness, minimizing their actions, and normalizing their actions.</p><p>Overall, the quantitative results suggested that college students in Kenya and the USA converged in certain health trends but differed in several others. For example, the Kenyan participants depicted a low understanding of HPV and HPV vaccine compared to the participants at the Midwestern university. The country of the participant also moderated the relationships between subjective norms and intentions, sex attitudes, vaccine attitudes, and intention to get vaccinated. The participants from the USA, for example, reported a stronger relationship between subjective norms and the intention to be vaccinated compared to the participants from Kenya. The results of this study also showed that the gender of the participant had an influence on the attitudes of students toward sex, with male participants having more favorable attitudes toward sex compared to female participants. Overall, subjective norms and cancer worry were the only common vaccine predictors among both female and male participants from Kenya and the USA. Surprisingly, although religiosity was correlated with other variables under consideration, it did not emerge as a direct predictor of the intention to get vaccinated. This might suggest it as a probable indirect predictor.</p><p>Being a comparative study of students in two countries, this dissertation offers unique insights that can inform theory, research, practice, and policy development. Specifically, the results point to the need for health practitioners designing health campaigns to consider the unique differences that exist among male and female students in Kenya and the USA. Some of the weaknesses of the study include use of self-report measures, which are limited to the memory of participants. This study suggests that researchers continue to explore the role of religiosity in influencing health-seeking behaviors among college students.</p>

Cervical cancer rates in Sub-Saharan Africa (SSA) are amongst the highest in the world. The World Health Organization currently estimates that worldwide, cervical cancer will kill more than 443,000 women per year by 2030, of which 90% of deaths are predicted to occur in SSA. The Human Papillomavirus (HPV) vaccine provides primary protection against the most common cancer-causing strains of HPV that are responsible for cervical cancer. Over the last five years, there has been a slow increase in the number of African countries that have introduced the HPV vaccine via demonstration and pilot projects, and a minority of African countries that have incorporated the HPV vaccine into their National Immunisation Programmes. As part of this systematic review, a literature review was conducted and revealed that research has been conducted on top-down barriers and facilitators to HPV vaccine uptake and have found that poor health system capabilities, inaccessibility to medical care, low cervical cancer screening levels, inadequate infrastructure, finances, and health worker training are significant systemic barriers to HPV vaccination success in SSA. Little research has been conducted on demand-side or end-user perspectives of, and decisions around, the HPV vaccine. In order to complement existing research, and inform current and future implementation approaches, this qualitative systematic review explored stakeholder understandings of the HPV vaccine in SSA. This review searched the following databases: Embase (via Scopus), Scopus, MEDLINE (via PubMed), PubMed, EBSCOhost, Academic Search Premier, Africa-Wide Information, CINAHL, PsycARTICLES, PsycINFO, SocINDEX, Web of Science, and the Cochrane Controlled Register of Trials (CENTRAL) and found a total of 259 articles. Of these, 31 articles met the inclusion and exclusion criteria and were included in the review. Braun and Clarke’s six step process for conducting a thematic analysis was used for analysis and studies were assessed for quality using the Critical Appraisal Skills Programme (CASP) checklist. Three major themes emerged from the thematic analysis: knowledge is intertwined with misinformation; fear shapes contradictory perceptions about the HPV vaccine; and social norms and gender dynamics are relevant factors in how stakeholders understand the HPV vaccine in SSA. This review iterates the importance of first working with communities to gauge understandings of the HPV vaccine, before trying to implement change through education, sensitization and behavior change.

No description available.

Neste trabalho produzo uma descrição do processo de implantação da vacina contra o HPV (papilomavírus humano) no sistema público de saúde brasileiro, a partir da leitura dos documentos do Ministério da Saúde que abordam as decisões e as justificativas para inclusão da vacina nos Calendários de Vacinas do Programa Nacional de Imunizações. Nesses documentos, percebo os campos de especialização e os métodos científicos que legitimam a necessidade da tecnologia da vacina, além das articulações econômicas envolvidas e a forma como o processo de implantação é escrito e disponibilizado para acesso “aos cidadãos”, o que me permite uma abordagem das coproduções entre as práticas de Estado e os conhecimentos científicos que performam o HPV e o câncer de colo do útero. A vacinação com foco na prevenção desse câncer começou em 2014, direcionada para meninas (entre 9 e 13 anos). Em 2015, foi ampliada para meninas e mulheres vivendo com HIV/Aids (9-26 anos) e, em 2017, para meninos (9-13 anos) e meninos e homens vivendo com HIV/Aids (9-26 anos). Nesse sentido, considerando essa divisão do público a que se direciona e suas justificativas nos documentos, proponho também uma discussão sobre as interferências dessa política de saúde (e de conhecimento sobre corpos) no performar de diferenças entre os sexos. / In this work I produce a description of the HPV (human papillomavirus) vaccine implantation process in the Brazilian public health system, based on the Ministry of Health documents that address the decisions and justifications for inclusion of the vaccine in the Vaccine Calendars of the National Immunization Program. In these documents, I understand the fields of expertise and the scientific methods that legitimize the need for vaccine technology, as well as the economic articulations involved, and the way the implantation process is written and made available for "citizen" access, what allows me to approach coproductions between state practices and scientific knowledges that enact HPV and cervical cancer. Vaccination focused on the prevention of this cancer began in 2014, targeted at girls (between 9 and 13 years old). In 2015, it was expanded for girls and women living with HIV/AIDS (9-26 years old) and in 2017 for boys (9-13 years old) and boys and men living with HIV/AIDS (9-26 years old). In this sense, considering this division of the public targeted and its justifications in the documents, I also propose a discussion on the interferences of this health policy (and knowledge policy about bodies) in the enactment of differences between sexes.

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection in the U.S., where one HPV-related cancer is diagnosed every 20 minutes. The most common HPV-related cancer is cervical cancer, with an estimated incidence of 12,000 cases annually, a third of which lead to death. Cervical cancer disparately affects women of ethnic minority groups and geographically isolated regions, such as Appalachia. Tennessee ranks third highest in cervical cancer incidence in the country. Many cases of cervical cancer could be prevented through vaccination against HPV, however, vaccination rates for females in Tennessee are among the lowest in the country. This mixed-methods study included an in-depth exploration of the factors that influence HPV vaccine acceptance in Appalachian Tennessee. Healthcare providers, mothers of adolescent girls, and college-aged women were recruited to participate in the study. From October 2016 to January 2017, interviews were conducted with healthcare providers (n=12), focus groups were conducted with mothers (n=13), and a survey was administered to college women (n=479). Interview and focus group sessions were recorded, transcribed and analyzed using a thematic framework. Survey responses were analyzed using descriptive tests, comparison of means, and regression analyses. The predominant barriers to vaccine acceptance identified in the study were: cost and novelty of the vaccine, vaccine safety, lack of school-entry requirement, and the implication of vaccine acceptance on adolescents’ sexual activity. Most negative perceptions towards the vaccine appeared to be propagated by the sociocultural influence on sex and reproductive health communication within the community. Perceived benefits for cancer prevention and receipt of strong and personal provider recommendations facilitated vaccine acceptance. Additionally, college students who reported vaccine acceptance reported discussing sexual health topics with their mothers more often than those who had not been vaccinated. The findings from this study provide foundational insights about the facilitators and barriers of HPV vaccine acceptance in Appalachian Tennessee. Identifying and understanding these factors is crucial to improving HPV vaccination rates and essential to maximizing the primary benefit of the vaccine in addressing the existing cervical cancer disparity in the region.