The broad aim of this dissertation is to understand the early impact of HPV vaccination in females at the population level. Three important public health questions are addressed: 1) Is HPV vaccination doing what is expected: decreasing the prevalence of vaccine-type HPV 6, 11, 16 and 18 which are etiologically linked to invasive cervical cancer and genital warts?; 2) Is there evidence of beneficial cross-protection (decreased prevalence) of any of the other non-vaccine-targeted high-risk (HR) HPV genotypes?; and 3) With the expected decline of HPV 16 and 18, are there deleterious virological consequences, such as type-replacement (increased prevalence) with a rise of non-vaccine-targeted HR HPV? In the first chapter, I assess and synthesize peer-reviewed literature published from 2007 to 2013 that documented early impact of HPV vaccination. Seventeen ecological studies were stratified into three tiers based on degree of vaccination impact (cervical abnormalities, genital warts, and HPV DNA) and incidence or prevalence in samples from a pre-HPV vaccination time period (pre-2007) with that of a post-vaccination time period (post-2007) were compared. In the second chapter, I investigate vaccine-type HPV prevalence changes between pre- and post-vaccine periods in over 8,000 females aged 14-59 years enrolled in the NHANES HPV Vaginal Swab Surveys from 2003-2010. In the third chapter, I test for evidence of non-vaccine-targeted HR HPV genotypic cross-protection and type-replacement in NHANES Survey females from the pre- and post-vaccine periods. Finally, I conclude the dissertation with a summary of the findings and a discussion of the public health impltcations and offer suggestions for future research.

The purpose of this grounded theory study was two-fold; first, to explore how mothers develop an understanding of childhood immunization which contributes to the decision¬making process resulting in a decision not to participate in immunization. Second, the perceptions of childhood immunization of health care professionals were also examined. The understanding and decision-making process of eight mothers was compared with the perceptions of twelve health care professionals. A number of themes were constructed from the research and a grounded theory was developed which emphasizes the importance of collaboration between non-immunizing mothers and health care professionals to promote positive health outcomes in children. The findings will assist health care professionals in understanding the factors contributing to the immunization decision-making process, which will subsequently support in delivering immunization programs. Recommendations to promote support and respect for parents' decision not to immunize their children, and assist in educating parents on immunization are also included. / xiii, 275 leaves ; 29 cm