acase@tulane.edu / This dissertation is an ethnographic study of the corruption narratives surrounding the quest for and the delivery of reproductive health care in contemporary Romania. Using as case study two public health campaigns targeting cervical cancer through early detection (Papanicolaou testing) and prevention (Human Papilloma Virus vaccination), it explores the ways Romanian women imagine the newly liberalized state and define themselves as post-Socialist citizens. The recent reforms in the provision of medical care have highlighted once again reproduction as a site of contestation. In sharp contrast with the Socialist pro-natalist policies, we currently witness the state’s progressive withdrawal from regulating reproduction, paralleled with the privatization of significant segments of reproductive health care delivery and with the marketization of women’s health. The range of reproductive choices has multiplied, but the emergence of new standards of inclusion/exclusion has limited the access to adequate care for many Romanian women. My interlocutors’ multi-layered discourses of reproduction and corruption are intrinsically ideological, revealing a folded blaming: of the former Socialist state paternalism and of the present post-Socialist state failure. In this context of unprecedented socio-cultural transformation, personhood becomes situational, shifting back and forth from Romanian citizen (when blaming the state for failing to provide proper reproductive assistance), to private person (when resisting mandatory national reproductive care programs). If we aim to decipher women’s responses to the Pap testing and HPV vaccination campaigns, we need to go beyond the ethnographically documented understandings of ‘risk, ’prevention,’ and ‘early detection.’ In a place such as present-day Romania, where bribe-offering is the idiom through which patients and doctors communicate, reproductive health care constitutes a privileged locus for analyzing how corruption discursively tames unsettled medical landscapes. By gathering the corruption narratives surrounding reproductive health care delivery, this dissertation grasps the micro-political factors that shape women’s local interactions, but it also analyzes the impact of “small scale” findings at a national and transnational level. My anthropological account – of what appears in retrospect to be “the chronicle of a failure foretold” – would be a crucial tool for policy makers in their future attempts to implement successful reproductive health programs. / 1 / Cristina A. Pop

Human papillomavirus (HPV) is a sexually transmitted infection that represents a serious health issue that can lead to significant morbidity and mortality. Although FDA-approved vaccines for the prevention against the majority of strains responsible for cervical cancer and genital warts have been available for many years, immunization rates remain low. This study will consider cervical cancer as the main consequence of HPV and thus will investigate parents of daughters. This is of particular relevance to Arizona, given the large Hispanic population and the racial and ethnic disparities that exist in the incidence, mortality and survival of cervical cancer when compared to the national average. Administration of the three-dose series is recommended for girls and boys beginning at 12 years of age. The target population of this study was parents as the HPV vaccine necessitates parental consent and immunization rates remain low. This study specifically aimed to explore the knowledge, attitudes and beliefs of Hispanic parents in Maricopa County toward the HPV vaccine in efforts to identify barriers to immunization and create future implications for practice. Findings were consistent with previous literature: Hispanic parents exhibited suboptimal knowledge regarding HPV and HPV vaccination. Specific opportunities for education include the etiology, transmission and health consequences of HPV. Despite many areas for education, the majority of Hispanic parents indicated they would follow their health providers' recommendation on vaccination.

According to the Centers for Disease Control and Prevention (CDC), there are approximately 14 million new cases of HPV diagnosed each year (men and women combined). The rate of vaccine administration among adolescent males is much less than it is among females. As a result, the CDC has urged health care providers to work with state and local health care providers to improve the utilization of the HPV vaccine. The purpose of this scholarly project was to develop an educational toolkit, one guided by Ajzen and Fishbein's theory of reasoned action, regarding the value of the HPV vaccine. The toolkit was offered through both online and hard copy formats and provided parents of adolescent males with information regarding HPV, the HPV vaccine, helpful websites, and references. The toolkit's efficacy will be determined by a comparison of annual vaccination rates. This project fills a significant knowledge gap in the scholarly literature, as there were only 8 articles that met the inclusion criteria in the review of literature. It also provides a guide for other outpatient clinics that may want to implement a comparable toolkit.

Forskning om stickrädda barn i elevhälsovården bedöms som otillräcklig, men betydelsefull då många vaccinationer sker i skolan. Syftet var att undersöka flickors upplevelser kring HPV- vaccination i elevhälsovården. Uppsatsstudien hade en mixad metod design och studien var baserad på enkätsvar från 14 flickor i årskurs fem och sex. Det kvantitativa resultatet visade att hälften av flickorna skattade sig som rädda i samband med HPV-vaccination och av dem skattade sig 42 % som livrädda. Upplevd smärta och rädslan för eventuell smärta var de faktorer flickorna uppgav skapade rädsla. Att ha en förälder och/eller en kompis med sig vid vaccinationen var enligt flickorna de viktigaste strategierna för att kunna minska deras rädsla. Det fanns en positiv korrelation mellan flickornas skattade rädsla och hur de upplevde att de inte kunde koncentrera sig på skolarbetet under hela veckan innan vaccination (r2=0,761; p=0,002). Det kvalitativa resultatet visade att flickorna upplevde starka fysiska och psykiska reaktioner såsom gråt, illamående, panik och stress, orsakade av rädsla inför, under och efter vaccinationen. Då elevhälsvårdens övergripande mål handlar om att förebygga både fysisk och psykisk ohälsa för barn och ungdomar är det viktigt att belysa problematiken med stickrädsla. Sammanfattningsvis behövs vidare forskning genomföras. Detta för att bättre kunna förstå hur omfattande stickrädsla är bland skolelever och för att sätta elevernas perspektiv i fokus. / Research on children with fear of needles in the student health service is estimated as inadequate but important because many vaccinations take place at school. The aim was to examine girls’ experiences of HPV-vaccination in student health services. The study had mixed method design and the study was based on survey responses from 14 girls in the fifth and sixth grade. The quantitative results showed that half of the girls estimated themselves as frightened during HPV-vaccination, and 42 % rated themselves as terrified. The percieved pain and fear of eventuall pain were the factors in the girls' experiences of HPV- vaccination that caused fear. Having a parent and/or a friend present as support are the two most common strategies for reducing the fear during the HPV-vaccination, according to the girls. There was a positive correlation between the girls' estimated fear and their percieved ability to not be able to concentrate on schoolwork during the week prior to vaccination (r2= 0.761; p = 0.002). The qualitative results showed that before, during and after vaccination, strong physical and psychological reactions such as crying, nausea, panic and stress were caused by fear. The student health services overall goal is about preventing both physical and mental health of children and adolescents and therefor it is important to highlight the problem of fear of needles. Further research is therefor needed to better understand the extent of fear of needles among schoolchildren and focus on their perspective.

Ο καρκίνος του τραχήλου της μήτρας (ΚΤΜ), αποτελεί παγκοσμίως έναν από τους συχνότερα εμφανιζόμενους καρκίνους στο γυναικείο πληθυσμό. Ο ΚΤΜ επιφέρει σημαντική ψυχολογική, κοινωνική και οικονομική επιβάρυνση στους ασθενείς και στα συστήματα υγείας. Η κυριότερη αιτία εμφάνισης της νόσου συσχετίζεται με τη μόλυνση από τον ιό των ανθρώπινων θηλωμάτων – HPV (Human papilloma virus). O HPV συγκαταλέγεται στους πιο συχνά σεξουαλικ ώςμεταδιδόμενους ιούς. Ένα από τα μεγαλυτερα βήματα της δημόσιας υγείας για την προφύλαξη του πληθυσμού έναντι του HPV και κατ’ επέκταση του καρκίνου του τραχήλου της μήτρας, είναι η εισαγωγή του εμβολίου στο Εθνικό Πρόγραμμα Εμβολιασμού. Στα παρακάτω κεφάλαια (θεωρητικό μέρος) γίνεται εκτενής περιγραφή της ιστοπαθολογίας του ΚΤΜ και της βασικής βιολογίας του HPV, καθώς επίσης και του μηχανισμού δράσης του εμβολίου έναντι του ιού. Εν συνεχεία, στο ειδικό μέρος της παρούσας διπλωματικής εργασίας παρατίθενται στοιχεία που αφορούν την ευαισθητοποίηση και την αποδοσχή του πληθυσμού για τον προληπτικό εμβολιασμό έναντι του ιού HPV. / -

The HPV vaccine represents an important step in the primary prevention of cervical cancer, yet uptake rates for the vaccine remain below what is needed to establish "herd immunity" from the virus. While many studies have examined both psychosocial and communication factors affecting HPV vaccination decisions, this study adopts a unique approach to understand the communication environment within which this health decision happens, such as the many and sometimes conflicting messages about vaccine efficacy and safety guiding young women's decisions. Using the message convergence framework, this project identifies how further study of converging and diverging messages in the communication environment in which young women make their vaccination decision can extend research in considering optimal communication strategies to enhance demand for HPV vaccination. In Study 1, 39 unvaccinated women participated in qualitative interviews and were asked questions in order to understand the important elements of the HPV vaccination communication environment that affected their decision (i.e., common sources and content of messages, how they discussed these messages "interacting" and influencing their decision). Study 2 builds on the findings of Study 1 by employing an experimental design to test different message convergence conditions on women's intent to vaccinate (e.g., what happens when a doctor and a family member give conflicting information and recommendations about HPV vaccination?). Three hundred and nine unvaccinated women were randomly assigned to one of nine experimental message conditions and then assessed on behavioral intentions. Support was found for the message convergence framework. This project represents the first formal testing of the message convergence framework and the first time it has been used in the health context. The findings from these studies are discussed in terms of the implications for future cervical cancer research and prevention campaigns, as well as the utility of the message convergence framework for other health communication research topics in which researchers are seeking to better understand and consider the communication environment when designing health behavior interventions.

PURPOSE: To understand why adolescents who initiate the HPV vaccine series fail to complete all three shots. METHODS: Semi-structured interviews were performed with parents/guardians of 11-17 year old daughters and pediatric primary care providers in one inner-city public clinic and three private practices to determine why girls who received at least one dose of the HPV vaccine did or did not complete the series. The number of shots received was confirmed by electronic medical record review. Content analysis was used to identify themes related to series completion. RESULTS: 65 parents/guardians participated: 37 whose daughters received 1 or 2 doses of HPV vaccine and 28 whose daughters completed 3 doses. Most (n=24, 65%) parents/guardians failed to complete the series because they thought the clinics would remind them of subsequent doses. 9 (24%) cited logistical barriers. 4 (11%) decided to stop the vaccine series. 33 providers participated: 24 physicians, 3 nurse practitioners, and 6 registered nurses. 52% of providers told parents to schedule appointments, 41% scheduled the second dose at the time the first dose was given, and 7% tried to immunize patients when they returned for other appointments; providers confirmed that few parents chose to stop the series. No practice had a system in place to ensure series completion. CONCLUSIONS: Most failure to complete the HPV vaccine series occurred because providers expected parents to make appointments while parents expected to be reminded. Increased use of reminder/recall systems and clear communication of expectations regarding appointment scheduling could improve completion rates.

Background: The HPV vaccine has been introduced to the public and the medical community since June 2006 for the vaccination of females and since November 2009 for the vaccination of males ages 9-26 years old. The purposes of this research were to explore multiple factors and relationships among Health Belief Model (HBM) constructs (perceived susceptibility, perceived severity, perceived barriers, and perceived benefits) and mediating factors (self-efficacy and cues to action) related to HPV, HPV-associated diseases, and HPV vaccine among Russian college students and to determine which factors were most important when considering who would/would not seek HPV vaccination. Methods: A quantitative, cross-sectional, descriptive, and correlational survey design was used in this study. An existing self-report questionnaire HPV Study Survey was adapted with the permission from the author. One thousand two hundred participants were contacted by Yaroslav-the-Wise Novgorod State University, Veliky Novgorod, Russia registrar's office through e-mails and messaging using two social networks through simple random sampling method using the SQL statement "ORDER BY NEWID" propriety of Microsoft algorithm out of the total student population (9,923 students). The survey was distributed through SurveyMonkeyTM survey software that was activated December 2011 - April 2012. Results: Two hundred seventy students replied to the survey (22.5% response rate) and 117 participants fully completed it out of 270 who responded to the survey (43.33% completion rate). The initial response rate increased 4.4 times using social networks messaging compared to e-mailing invitations. Overall, average knowledge levels were moderate. Participants' behaviors regarding their sexual activity showed that the majority of participants were sexually active. Participants' perceptions (susceptibility, severity, barriers, and benefits) and mediating factors (cues to action and self-efficacy) were moderate. Participants' behavioral intention to get HPV vaccination was moderate. There were statistically significant differences between males and females in perceived susceptibility, perceived barriers, self-efficacy, behavioral intention, and in three behavioral items (having had sexual contact; age of having had sexual contact and sex for the first time). Sixty percent of the variance in behavioral intention getting HPV vaccination could be explained by two HBM constructs (perceived benefits and self-efficacy). Self-efficacy was the number one predictor of behavioral intention (p < 0.001) and perceived benefits were the number two predictor of behavioral intention (p < 0.01).

Vulval intraepithelial neoplasia (VIN) is a distressing, premalignant condition, frequently associated with type HPV16 infection, with increasing incidence in younger women. Traditional surgical treatment is sub optimal. Several different clinical studies influencing local and/or systemic immunity to HPV have been reported. Imiquimod, an immune response modifier, can stimulate local innate immunity and also drive an adaptive immune response. Therapeutic HPV vaccines are designed to generate cell-mediated immunity against HPV infected cells. The rationale of this study was that local imiquimod treatment, in addition to having a direct effect on VIN could also provide an immunological platform for the therapeutic HPV vaccination to achieve an enhanced and durable response. In this phase II trial, we used a combination of imiquimod and vaccination with TA-CIN (HPV16 E6E7L2 fusion protein). Women with biopsy proven high-grade VIN were recruited. Imiquimod treatment for 8 weeks was followed by three i.m. injections of TA-CIN. The objectives were to measure lesion size, histology, lesion HPV status, symptoms, immune responses before and after treatment as well as safety, toxicity, and tolerability. Lymphoproliferation to HPV antigens was used to analyse immunity to HPV before and after treatment. Local immune factors (CD4, CD8 and T regulatory cells) were assessed by immunofluorescence. 74, 85 and 79% of women had a ≥50% reduction in the size of lesion and 32, 58 and 63% had regression of VIN on histology at weeks 10, 20 and 52 respectively. At baseline, 79% had moderate to severe symptoms compared to 21% at week 52(P=0.01). Of the women who showed histological responses at week 52, 5/10 also cleared their HPV 16 infection. Follow-up for an average of 15 months showed 84% of patients with a ≥50% reduction in lesion size. Treatment was well tolerated. A significant post vaccination increase in proliferation to TA-CIN and its components was associated with histological responders (P=0.008) but not the non-responders (P=0.7). In the group as a whole, significant increases in the number of CD4, CD8 and T regulatory cells (Treg) were evident by week 20 compared to baseline (P=0.03, P=0.01, P= 0.04 respectively); At week 20, the increased CD4 and CD8 density was significantly associated only with the histological responders (P=0.03; P= 0.03) while increased Treg density was associated with only non-responders (P=0.05). Intralesional Treg density was significantly higher in non-responders compared to responders pre and post treatment (P=0.01, 0.05 respectively). This study demonstrated that imiquimod followed by vaccination achieved histological clearance of VIN at 52 weeks in almost 60%. Higher pre-existing and post-treatment levels of Treg cells were associated with a lack of treatment response. Lymphoproliferation of PBMC established that the vaccination was immunogenic and HPV 16 antigen specific. Importantly, these systemic immune responses to HPV 16 antigens were significantly associated with treatment responders.

Bakgrund: HPV är den vanligaste sexuellt överförbara infektionen i Sverige. Flickor vaccineras redan mot HPV, från hösten 2020 kommer pojkar vaccineras. Vaccinationstäckningen är lägre än övriga vaccin i vaccinationsprogrammet. Information och rekommendation från vårdgivare har visat sig ha betydelse för vaccinationstäckningen. Syftet: Studiens syfte var att beskriva skolsköterskors syn på sin roll som vaccinationsförespråkare vid införandet av HPV-vaccination till pojkar i det allmänna vaccinationsprogrammet för barn. Metod: Kvalitativ metod användes i studien. Semistrukturerade intervjuer med åtta skolsköterskor verksamma i Stockholmsområdet genomfördes. Resultatet analyserades med kvalitativ innehållsanalys. Resultat: Analysen resulterade i fyra kategorier; Betydelsen av att ge information, Utmaningar med att vara vaccinationsförespråkare, Betydelsen av egen kunskap, Ansvar som vaccinationsförespråkare. Ur resultatet framträdde temat Ett livräddande engagemang. Konklusion: HPV-infektioner spelar en stor roll för uppkomsten av cancer och orsakar många dödsfall varje år. Skolsköterskors arbete för att uppnå en hög vaccinationstäckning har därför stor betydelse och kan i förlängningen ses som en insats som förhindrar lidande och räddar liv. För att uppnå hög vaccinationstäckning måste skolsköterskor ha goda kunskaper för att ge aktuell och adekvat information till elever och vårdnadshavare. Vaccinets sexuella koppling, relationen till vårdnadshavare och samhällets syn på vaccinet ses av skolsköterskorna som utmaningar för nå en hög vaccinationstäckning. / Background: Human papillomavirus (HPV) is the most common sexually transmitted disease in Sweden. Girls are already vaccinated against HPV and from the autumn of 2020 boys will be initiated. The vaccine uptake is lower compared to other vaccines in the national vaccination program. Information and recommendation from healthcare providers has been proven to be important for vaccine uptake. Aim: The aim of the study was to describe school nurses view on their role as opinion leaders during introduction of HPV-vaccine to boys in the national vaccination program for children. Method: A qualitative methodology was used in the study. Semi-structured interviews with eight school nurses active around Stockholm were accomplished. The results were analyzed by content analysis. Results: The analysis resulted in four categories; The importance of giving information, Challenges being an opinion leader, The importance of individual up to date knowledge and Responsibility as an opinion leader. From the result a theme appeared A lifesaving commitment. Conclusion: HPV-infections plays an important role for the appearance of cancer and causes many deaths each year. School nurses’ assignment to achieve high vaccination uptake has a major importance and may in long term prevent suffering and save life. To achieve high vaccine uptake school nurses need knowledge to be able to give current and adequate information to students and parents. The sexual connection, the relationship to parents and society’s view on the vaccine are seen as challenges to achieve a high vaccine uptake by the school nurses.