In 2015, there were 257,524 women with cervical cancer (CC) in the United States (U.S.). CC is preventable; screening detects early-stage cancer when treatment is most successful. This study aimed to identify predictors for CC screening adherence among U.S. women, describe predictors for screening adherence by marital status, and examine physician recommendation for CC screening and adherence to those recommendations. Predictors were grouped as demographic, acculturation, access to care, chronic conditions, and health behaviors. Descriptive analyses were performed on a sample of 10,667 women from the 2015 National Health Interview Survey, and multiple logistic regression models determined predictors of CC screening adherence, physician recommendations, and adherence to physician recommendations. Overall, 81.7% (95%CI=80.7-82.7%) of U.S. women adhered to CC screening guidelines. Adherence declined with increasing age after 39 years old. Never married women (adjusted odds ratio[aOR]=0.67, CI=0.56-0.79) or current smokers (aOR=0.70, CI=0.59-0.84) had lower odds, while college-educated women had greater odds (aOR=1.38, CI=1.14-1.67) of CC screening adherence. Among unmarried women, 78.6% adhered to CC screening. Unmarried women who were unemployed (aOR=0.48, CI=0.38-0.62), had no physician visits (aOR=0.58, CI=0.40-0.85), no usual source of care (aOR=0.67, CI=0.50-0.89), never heard of HPV (aOR=0.59, CI=0.46-0.76), never received HPV vaccine (aOR=0.50, CI=0.34-0.75), no birth control use (aOR=0.33, CI=0.23-0.47), no flu shot (aOR=0.62, CI=0.48-0.80), and perceived low breast cancer risk (aOR=0.66, CI=0.47-0.92) had lower odds of adherence. Among women with a physician, 55.6% received screening recommendations. Race/ethnicity, access to care, HPV knowledge and vaccine receipt, age when first child was born, and flu shot were significant predictors of physician recommendation for CC screening. Significant predictors of adherence to physician recommendation included education, employment, English proficiency, outpatient clinic visits, usual source of care, age when first child was born, birth control, alcohol use, smoking status, flu shot, and health status. Based on our results, two levels of intervention should be explored. First, targeted interventions are needed for women who are unmarried, have low socio-economic status, and limited access to care to reduce cervical cancer risk. Second, interventions for physicians to increase screening recommendations to all eligible women are needed to improve national screening rates.

Minority women groups in the United States have the highest incidence and mortality rates of cervical cancer. Hispanic women have the highest incidence rate and the second highest mortality rate of the disease. Researchers have examined the lower rates of cervical cancer screening among Hispanic women, as compared to other groups of U.S. women, but researchers have not examined the extent to which socioeconomic status, acculturation, and sexual activity impact Hispanic women's compliance with screening. The purpose of this study was to examine the association between compliance with cervical cancer screening and acculturation, socioeconomic status, and sexual activity among U.S. Hispanic women. The framework for investigating the extent of association between these identified barriers and willingness to comply with screening was the behavioral model for vulnerable populations. Chi-square tests and logistic regression were used to analyze data from the National Health Interview Survey for 2011, 2012, and 2013, focusing on U.S. Hispanic women ages 21 - 65 (N = 739). The findings from this study revealed that educational level was significantly associated with U.S. Hispanic women's cervical cancer screening; however, no statistically significant associations were found for socioeconomic status, acculturation, and sexual activity and screening rates for this group. Findings from this study can better inform researchers and others of the lower rate of screening for cervical cancer among U.S. Hispanic women. The findings will also promote positive social change by targeting U.S. Hispanic women and other minority women groups for programs that promote cervical cancer screening.

High-risk mucosal human papillomaviruses (HPVs) are major aetiological agents for the development of cervical cancer. Thus, the current goal of cervical cancer treatment is to develop vaccines against HPV s. Such vaccines would either prevent cervical cancer by eliminating HPV infection or be useful for treating established lesions by the destruction of cells displaying HPV proteins. The aim of this thesis was to characterise immune responses to the E5 protein of HPV -16, one of several antigens with possible use in vaccination. To determine whether immune responses to HPV -16 E5 existed and whether they could be correlated with disease severity or with the presence of HPV -16 DNA, both cell mediated (Chapter Two) and humoral (Chapter Three) immunity was investigated in women with and without cervical disease. Cellular responses in a minority of women were inversely correlated with disease severity. However, E5 specific antibodies were negatively correlated with the absence of HPV -16 DNA. Thus, although some immune responses were evident, these were generally limited to a small number of subjects and were not associated with the detection of HPV-16 E5 mRNA or DNA sequence variants. Due to the immune responses in women, E5 was further investigated to determine if the absence of HPV -16 E5 specific immune responses was due to the poor antigenicity of HPV -16. Mice were immunised with synthetic peptides corresponding to full length HPV -16 E5 (Chapter Four). As with the human data, cellular responses and weak antibody responses were detected in mice. Some mice also exhibited cytotoxic T -lymphocyte responses and when E5/major histocompatibility class I (MHC-I) interactions were investigated, a number of peptides showed a high percentage of binding. The E5/MHC-I interactions were further investigated (Chapter Five). The surface expression of MHC-I on cells containing HPV-16 or -18 DNA was found to be lower than on HPV DNA negative cell lines even after stimulation with interferon-gamma. Stimulation with E5 synthetic peptides increased expression of cell surface MHC-I molecules on cell lines negative for HPV DNA. Furthermore, the presence of the E5 gene reduced the expression of the ovalbumin gene in normal human keratinocytes. In conclusion, the data contained within this thesis indicate that HPV-16 E5 CMI is inversely correlated with disease status. It is possible to induce cell mediated responses to HPV -16 E5 and low-titre antibody responses. The presence of HPV16 E5 DNA may impair normal cellular function.

Cervical cancer is the second most common type of cancer in women worldwide. Because cervical cancer is usually asymptomatic until the disease is in its advanced stages, cervical screening is of central importance towards combating cervical cancer. Alternative screening strategies are evaluated from an economic point of view through cost-effectiveness analysis. In the literature however, studies perform cost-effectiveness analysis on a limited number of de facto or predetermined screening policies. At present, no attempt has been made to construct efficient screening strategies through optimization, before cost-effectiveness analysis is applied. In this study simulation optimization is used to construct efficient screening strategies for cervical cancer by properly timing the screenings. The constructed strategies are highly cost-effective when a small number of lifetime screenings is available, and are more cost-effective than screening strategies used in practice or considered in the literature so far, indicating the value of optimal timing for other screened diseases as well.

BACKGROUND: Now considered a cornerstone of healthcare, patient-provider communication has long been studied and analyzed. Medical associations such as the Joint Commission and the American Association of Orthopaedic Surgeons (AAOS) have strongly endorsed for physicians to exercise patient-focused communication, a practice that involves showing empathy, involving patients in medical care decisions, eliciting concerns, and educating patients on treatment options (Joint Commission, 2016; AAOS, 2017). A lack of patient-provider communication has previously been identified as a significant factor in adverse medical outcomes occurring within hospitals (Khan et al., 2017). Bridging the communication disparity between patients and providers is crucial to improving overall patient outcome. Primary care providers are especially essential to improving overall patient outcome because they serve as the first point of contact for many patients accessing the healthcare system. While there is much literature on the importance of effective patient-provider communication, few studies provide technology-based tools that can enhance this establishment of communication. Human Papillomavirus is presently the most common sexually transmitted infection (STI) nationwide with 79 million Americans currently infected (CDC, 2017). Approximately 42,700 HPV-attributable cancers are diagnosed in the United States annually, and HPV is believed to be responsible for over 90% of cervical cancer cases (CDC, 2018). The Advisory Committee on Immunization Practices (ACIP) currently recommends three preventative HPV vaccines. Despite high rates of infection, HPV vaccination rates nationwide remain low as coverage of the HPV vaccine falls behind that of coverage for required vaccines like the tetanus, diphtheria, and acellular pertussis vaccine (Tdap) (Reagan-Steiner, 2016). Previous studies have sought to address factors that affect decisions to vaccinate children. An analyzation of the National Immunization Survey of Teens has identified that parents’ belief that the HPV was not necessary as a main factor (Darden et al., 2013). As a result, there is a gap needed to be filled by providers to educate parents on the importance of the HPV vaccine. PURPOSE: The current study sought to determine the effectiveness of a web-based mobile health education program called Wheel of Wellness (WoW) on patient-provider communication, to assess the viability and impact of WoW to increase HPV vaccination rates in age eligible children (boys and girls aged 9-17) and to augment awareness about the benefits of HPV vaccination in both these children and their guardians. RESEARCH METHOD AND DESIGN: As of August 2018, twenty-seven parents of children between the ages of 9 and 17 years of age within the Pediatrics and Adolescent departments of Boston Medical Center (BMC) have been recruited. Parents enrolled in the WoW program to compile a list of concerns to be shown to a provider during their child’s appointment. Participants were asked questions to determine initial knowledge on the HPV vaccine, and their opinions on the HPV vaccine. Following their appointment, participants completed a questionnaire to assess opinions on the WoW program in facilitating communication with their provider on the HPV vaccine and related cancers. Seven physicians were interviewed to assess their views on the WoW program in facilitating communication with their patients on the HPV vaccine and related cancers. RESULTS: Initial stages of this study found that views on the effectiveness of the WoW program in facilitating patient and provider communication on the different aspects of HPV vaccination and affecting parents’ decisions to vaccinate their children were mixed by both patients and their providers. Based on the WoW feedback collected from parents, the system was widely acceptable in terms of ease in usage and with the majority of parents (92%) reporting that the WoW website is helpful for communicating their health concerns with their provider. However, the majority of providers reported having never been presented the WoW system and expressed views that WoW was inefficient as it was a parallel system to existing workflow. This study determined that of the 12 participants who had one dose of the vaccine prior to enrollment, 75% of these participants completed the HPV vaccine series during the study. CONCLUSION: Based on the initiation and completion statistics reported, this shows great potential for the use of the BNI coupled with the WoW system to help improve rates of initiation and completion of HPV vaccination going forward as the intervention may have helped encourage parents to either initiate vaccination or complete their child’s previously started series. Further studies should explore ways of empowering patients to facilitate more communication with their providers and improvements to technology to enhance provider recommendation in order to promote an increase in HPV vaccine completion. / 2021-06-17T00:00:00Z

Esta tese se fundamenta na necessidade de novos tratamentos para o câncer do colo de útero visando o aumento da adesão dos pacientes aos tratamentos, assim como à qualidade de vida dos mesmos. Nesse sentido, formulações nanotecnológicas foram desenvolvidas com o objetivo de carrear o fármaco imiquimode para um local específico – a mucosa vaginal – esperando gerar melhores desempenhos nesse tratamento quando comparados com a formulação comercial. Três nanoestruturas com morfologias distintas foram propostas visando potencializar o efeito do fármaco em células de câncer cervical (SiHa). As formulações desenvolvidas compreenderam: nanoemulsões (NEimiq), nanocápsulas poliméricas (NCimiq) e nanocápsulas poliméricas revestidas com quitosana (NCimiq-chit). Observou-se que nanocápsulas poliméricas produzidas com poli(ε-caprolactona) apresentaram efeito mais pronunciado frente às células SiHa. Para tanto, essas formulações (NCimiq e NCimiq-chit) foram incorporadas em hidrogéis de quitosana e de hidroxietilcelulose a fim de possibilitar uma melhor futura aplicação para o paciente. Estudos envolvendo mucosa vaginal suína demonstraram que ambas as formulações são mucoadesivas e permeiam a mucosa vaginal. Porém, a formulação produzida com hidrogel de quitosana (NCimiq) apresentou maior desempenho. Esta foi a formulação escolhida para dar continuidade aos estudos deste trabalho, sendo objeto de estudo posterior em cultura de células SiHa a fim de elucidar o mecanismo de ação da mesma. Esses estudos demonstraram que há uma ocorrência de processos combinados de diminuição da viabilidade celular de maneira tempo-dependente e que mecanismos como apoptose, autofagia e parada de ciclo celular estão presentes. Essa formulação (NCimiq) apresentou porcentagens de morte celular significativas, mesmo utilizando baixas concentrações do fármaco. Portanto, os achados desta tese constataram que nanoestruturas modulam efetivamente a interação do fármaco com as células. / This thesis deals with the need of new treatments for cervical cancer in order to increase the adherence of patients to the treatment as well as to improve their quality of life. In this sense, nanotechnological formulations were developed to carry imiquimod to a specific site – the vaginal mucosa – expecting to obtain better performance than the commercial drug in the cervical cancer treatment. Three nanostructures with different morphologies were proposed to potentilize the drug effect on cervical cancer cells (SiHa). The developed formulations are: nanoemulsions (NEimiq), polymeric nanocapsules (NCimiq) and polymeric nanocapsules coated with chitosan (NCimiq-chit). It was observed that polymeric nanocapsules produced with poly(ε-caprolactone) presented a stronger effect against SiHa cells. Therefore, formulations NCimiq and NCimiq-chit were incorporated into hydrogels of chitosan and hydroxyethylcellulose to enable a better future application on patients. The studies of this thesis involving porcine vaginal mucosa demonstrated that both formulations are mucoadhesive and that they provided a good drug permeation. However, the formulation produced with chitosan hydrogel (NCimiq) showed a better performance. This formulation was therefore chosen to follow the next steps of this work, conducted in SiHa cell culture to elucidate its action mechanism. This study demonstrated that there is an occurrence of combined processes of decreasing cell viability in a time-dependent type. The study also showed that mechanisms such as apoptosis, autophagy and cell cycle arrest are simultaneously present. The formulation NCimiq presented a significantly percentage of cellular death, even when low concentrations of the drug were used. Consequently, the findings of this thesis indicate that nanostructures effectively modulate the interaction of the drug with the cancer cells.

MPH, University of the Witwatersrand, Faculty of Health Sciences / Introduction Sex workers are considered to be a high risk group in the acquisition and transmission of sexually transmitted infections which include Human Immunodeficiency Virus (HIV) and Human Papillomavirus (HPV). Infection with HPV has been clearly established as a causative agent that infects the cells of the cervix and slowly causes cellular changes (dysplasia) or abnormal cells that can later develop into cancer. Women who are HIV positive are thought to be at higher risk of having HPV infection, and subsequently also at higher risk of having abnormal cervical lesions. Objectives The main focus of this study is to describe the prevalence of abnormal Pap-smears among sex workers and to further identify the difference between Pap-smear results of sex workers who are HIV-positive and HIV negative. Methods This is a retrospective descriptive study, where data was obtained from sex workers records from January 2004 to December 2006. The study population included all sex workers who attended the Esselen Street Clinic and sex worker outreach clinic in Hillbrow, in the inner-city of Johannesburg. Three hundred and nine records were randomly selected, of which 200 met the inclusion criteria. Data was collected on socio-demographic information including the age and place of residence, laboratory results (Pap-smear and HIV) and history of sexually transmitted infection at the last physical examination. Extracted data was captured in excel spreadsheet and transferred to Stata Computer Package software version 9.0 for data management and analysis. Descriptive analysis included frequency distributions of categorical variables (e.g. residence, Pap-smear results, HIV status and age group) and summary statistics of continuous variables (e.g. age). Pearson chi-square test or Fisher Exact test when necessary, where conducted to obtain proportions of the sex workers with abnormal Pap-smear results corresponding to each category of the explanatory variables for example age, HIV status and place of residence or business or business transactions. For continuous explanatory variables, such as age, two sample t-tests were used to determine differences between sex workers in terms of abnormal and normal Pap-smears. In all statistical considerations, a probability level of ≤0.05 was used. Results There were 200 records which were analysed to achieve the study objectives. These included 146 records of HIV positive (73%) and 54 of HIV negative sex workers (27%). Their ages ranged from 18 to 45 years with a mean of 26.85 years and median of 26.0 years. More than 70% (n=141) of the sex workers were below the age of 30 years. More than two thirds of sex workers lived in hotels and almost 90% was considered to be symptomatic for STIs. Eighty-eight (44%) of the sex workers were found to have had an abnormal smear result, of whom 58 (65.9%) were below the age of 30 years. Age, as a continuous variable, and place of residence (living on the street) was found to be statistically significantly associated with having an abnormal smear result. However, age (being older than 30), having symptoms of an STI and being HIV positive was not found to be statistically significantly associated with having an abnormal Pap-smear result. Conclusion This study has shown that the prevalence of abnormal Pap-smears among Hillbrow sex workers was high, especially in young sex workers. Sex workers who operated from the street were found to have a higher percentage of abnormal smear results as compared to those operating from the brothels and flats, signifying a need for a controlled environment and to improve sex workers access to health care services. No significant association was found between HIV status and abnormal Pap-smears. Further studies are required in this area. The study indicates that they may be a need to review the National Cervical Cancer Screening Policy to take into consideration the needs of high risk population, such as sex workers.

This cross-sectional, mixed-methods study examined the nature of, and association between, causal attributions and current smoking behavior in cervical cancer survivors who were smokers at cancer diagnosis (n=50). As a whole, participants’ beliefs about smoking as a risk factor or cause of cervical cancer in general (i.e., global attribution) and/or their own cervical cancer (i.e., personal attribution) reflected far greater endorsement of global than personal attributions. Data collection involved a quantitative survey and an optional semi-structured interview to assess key variables (i.e., smoking behavior and causal attributions). Data were analyzed via descriptive statistics and inferential tests, all of which illustrated greater endorsement of global smoking-related causal attributions versus personal attributions within the sample. In conclusion, the results of this formative study highlights the potential role of causal attributions in understanding the smoking behavior of cervical cancer survivors, the results of which aids understanding of how cancer survivors think about, and make changes in, their smoking behavior.

Introduction: Over 74,000 US women are diagnosed annually with endometrial or cervical cancers and experience significant treatment-related difficulties with body image, sexuality, and sexuality. The aims of the research were to examine relationships among body image, sexuality, and sexual functioning, and understand women’s views of these concepts. A novel theoretical framework encompassing these three concepts and contextual variables guided the research. Methods: A non-experimental cross-sectional pilot study was conducted with pre-menopausal women in an academic medical center who had stages I-III cervical or endometrial cancer, were 3-36 months post-treatment, and had no mental health diagnoses. Participants completed the Body Image Scale, Female Sexual Function Index, Female Sexuality Questionnaire, a demographic questionnaire, and open-ended questions and the researchers collected clinical data from the medical record. Results: Twenty women participated, and most reported disruption in body image, sexuality, and sexual functioning. Significant relationships were found between body image and sexuality (p = 0.0244) and sexuality and sexual functioning (p <0.0003). Stages II-III disease were significantly (p= 0.0371) associated with worse body image. Women reported issues with body image, sexuality, sexual functioning, psychosocial areas, reproduction, and communication with healthcare providers and personal caregivers. Discussion: This study is one of the first to examine relationships among body image, sexuality, and sexual functioning simultaneously, highlighting the importance of this approach. Despite design and sample limitations, results demonstrate a need for longitudinal studies using larger samples to further examine relationships among these concepts and selected contextual variables, explore communication issues, and refine the theoretical framework.

Hispanic and African American women are infected with sexually transmitted diseases more often than are Caucasian women. This racial disparity is also seen in the incidence of human papillomavirus (HPV) and cervical cancer. The medical connection between HPV and cervical cancer is often unknown or misunderstood among women. This study addressed the beliefs and subsequent health decisions of minority parents regarding whether to get their daughters vaccinated against HPV. The theoretical framework for this study was Rosenstock's health belief model (HBM). The specific study design used was Husserl and Heidegher's theory on Phenomenology. This qualitative study utilized focus groups containing mothers of young girls ages 9 to 12 years, who were recruited from local churches in San Antonio, TX. Twenty-seven mothers, African American (9), Hispanic (7), and Caucasian (11), participated in one of two focus groups for each racial group. Each focus group session was audiotaped and NVivo for Mac was used to perform a content analysis and to identify the themes present. Minority parents held stronger cultural and spiritual beliefs against vaccinating their daughters for a sexually transmitted disease more so than believing that their daughters were at risk for being exposed to STDs such as HPV. These beliefs presented as barriers to initiating the desired HPV prevention and screening practices. Gaps in the current knowledge of all parents exist and must be thoroughly addressed for all racial/ ethnic groups. Future educational programs need to not only address the gaps in knowledge but also shape and package public health messages with sensitivity to cultural and spiritual concerns.