Orientador: Paulo Traiman / Resumo: Analisar a eficácia da eletrocoagulação, como terapêutica nas pacientes portadoras de lesão intra-epitelial escamosa de alto grau de colo uterino. Pacientes e métodos: Estudaram-se prospectivamente 116 pacientes portadoras de lesão intra-epitelial escamosa de alto grau do colo de útero, distribuídas aleatoriamente, com 49 pacientes no grupo de estudo e 67 pacientes no grupo controle. Ambos os grupos foram avaliados quanto à idade, coitarca, paridade, hábito de tabagismo, número de parceiros sexuais, uso de drogas, presença ou antecedente de lesão condilomatosa vulvar, raça e escolaridade. Essas variáveis apresentaram-se homogêneas em ambos os grupos. Todas as pacientes do grupo de estudo e do grupo-controle foram submetidas a colposcopia... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Analyzing the efficiency of electrocoagulation as therapeutics in patients carrying high degree squamous intraepithelial lesion of the uterine cervix. Patients and methods: 116 patients carrying high risk intraepithelial lesion of the uterine cervix were prospectively studied, randomly distributed, being 49 patients in the study-group and 67 patients in the control-group. Both groups were evaluated according to age, first copulation, parity, smoking habits, number of sex partners, drug usage, presence or previous condylomatous lesion of the vulva, race and schooling. Such variables were found to be even in both groups. All patients from both groups were submitted to colposcopy, oncological cytology and biopsy of the uterine cervix. The study- group patients were treated with electrocoagulation of the uterine cervix and later submitted to conization after two months. The control-group patients underwent conization only. To assess the significance of the resuts, qui-square and Kappa agreement test were used. Results: In the study-group, electrocoagulation of the uterine cervix caused regression of the lesion in 73,5% of the cases, 20,4% remained unchanged, and there was progression... (Complete abstract click electronic access below) / Mestre

A infecção pelo Papilomavírus Humano (HPV) é a principal responsável pelo desenvolvimento de lesões intraepiteliais e, potencialmente, do câncer cervical (CC). A presença de fatores como inflamação e outros agentes infecciosos contribuem para a instalação e persistência do vírus. A inclusão da pesquisa do HPV e de outros agentes infecciosos relacionados junto a programas de rastreamento do CC ainda é controversa. Além disso, sabe-se que o processo inflamatório e as lesões celulares decorrentes da presença de HPV e seus cofatores provocam alterações na expressão de diversas proteínas, entre elas a S100A4, que poderia funcionar como biomarcador de exposição. Desta forma, foram analisadas amostras de esfregaços cervicais para investigação da relação do diagnóstico citológico com a presença de agentes infecciosos, além do padrão de expressão da proteína S100A4. Nossos resultados demonstraram que o aparecimento de lesões ou atipias citológicas apresentou associação com a presença de HPV, tanto na infecção simples como na infecção por múltiplos genótipos de alto risco oncogênico, sugerindo a pesquisa molecular do HPV complementar à citologia. A presença de infecção latente pelo HPV também foi observada, a qual deve ser acompanhada com exames citológicos periódicos. A infecção por Chlamydia trachomatis desempenha importante papel como cofator para o desenvolvimento do CC e foi prevalente na população estudada, demonstrando associação com a presença de diferentes genótipos de HPV. Tanto nas pacientes sintomáticas como nas assintomáticas houve a detecção de leveduras do gênero Candida, sendo que a mais prevalente foi a C. albicans apresentando-se sensível à Anidulafungina e Anfotericina B, na maioria dos casos, e resistente ao Fluconazol. Com relação à expressão da proteína S100A4, houve associação com as alterações citológicas características do HPV, nas quais houve redução de sua expressão à medida que aumentou o grau da lesão. No entanto, também observamos que há expressão fisiológica da proteína S100A4 no epitélio escamoso estratificado da ectocérvice que varia de acordo com o grau de maturação celular e a presença de alterações citológicas inflamatórias, onde foi demonstrado aumento da sua expressão. Portanto, a avaliação da expressão da proteína S100A4 pode auxiliar no diagnóstico precoce do câncer de colo do útero nas lesões intraepiteliais cervicais positivas para HPV. Analisando-se globalmente, estes resultados sugerem a inclusão da pesquisa molecular de HPV e C. trachomatis, bem como a identificação de leveduras do gênero Candida complementares à citologia esfoliativa junto a programas de rastreamento. Além disso, a proteína S100A4, mostrou-se promissora como biomarcador dos efeitos celulares dos fatores associados. Observa-se que a associação de diferentes metodologias permite a detecção precoce de lesões e, consequentemente, contribuem para a redução da incidência do CC. / Human papillomavirus (HPV) infection is the main responsible for the development of intraepithelial lesions and potentially cervical cancer (CC). The presence of factors such as inflammation and other infectious agents contribute to the onset and persistence of the virus. The inclusion of HPV research and other infectious agents associated in the CC screening programs is still controversial. In addition, it is known that inflammation and cell injury caused by the presence of HPV and their cofactors cause changes in gene expression and function of several proteins, including the S100A4 which could function as a biomarker of exposure. Thereby, samples of cervical specimens were analyzed to investigate the relationship of cytological diagnosis in the presence of infectious agents, other than the standard expression of S100A4 protein. Our results demonstrated that the development of lesions or cytological atypia was associated with the presence of HPV in either simple infection or infection by multiple genotypes of high oncogenic risk, indicating the importance of molecular HPV analysis complementary to cytology. The presence of latent infection was also observed and must be monitored with periodic cytological examinations. The Chlamydia trachomatis infection plays an important role as a cofactor for the development of CC and was prevalent in the population studied, demonstrating association with the presence of different HPV genotypes. For both symptomatic and asymptomatic patients there was a yeast detection of Candida, and the most prevalent was the Candida albicans presenting sensitive to Anidulafungin and Amphotericin B, in most cases, and resistant Fluconazole. Regarding the S100A4 protein expression, there was association with abnormal cytological HPV characteristics where a reduction of expression could be observed and the degree of injury increased. However, we also observed that there are physiological expression of S100A4 protein in the stratified squamous epithelium of the ectocervix and this varies according to the degree of cell maturation and the presence of inflammatory cell alterations, increased expression where demonstrated. Therefore, the evaluation of the expression of S100A4 protein may assist in the early diagnosis of cervical cancer in cervical intraepithelial lesions positive for HPV. Overall, these results suggest the inclusion of molecular research of HPV and C. trachomatis, and the identification of yeasts Candida complementary to exfoliative cytology in screening programs. In addition, the S100A4 protein has shown to be promising as a biomarker for cellular effects of associated factors. It was observed that the association of different methodologies allows early detection of lesions and therefore contribute to reducing the incidence of CC.

Objetivos: O objetivo do nosso estudo foi verificar se a umidificação dos comprimidos com formulação brasileira de misoprostol vaginal aumenta a dilatação cervical antes da aspiração manual por vácuo (AMIU), em comparação com o uso de misoprostol seco nos abortos espontâneos no primeiro trimestre. O objetivo secundário foi verificar se houve correlação entre o pH vaginal e o grau de dilatação cervical usando um comprimido de misoprostol umedecido ou seco. Métodos: Estudo unicêntrico, duplo cego e randomizado, com 46 pacientes com aborto espontâneo de primeiro trimestre foram alocados aleatoriamente para o tratamento com 400 μg de misoprostol seco ou umedecido (com 200 μl de água destilada). Resultados: A dilatação cervical mediana (intervalo) nos grupos úmido e seco foi de 8 mm (6-12 mm) e 7 mm (5-10 mm), respectivamente ( p = 0,06). O tempo médio entre a inserção de misoprostol e a realização do procedimento não diferiu entre os grupos seco (406 min, intervalo 180-550 min) e molhado (448 min, intervalo 180-526 min) ( p = 0,1). Não foi encontrada correlação entre o pH vaginal e a dilatação cervical usando dados continuos ( p = 0.57; r = 0.08; intervalo de confiança de 95% -0.02, 0.3) ou dados dicotômicos (pH ≤5 /> 5, dilatação cervical ≥8 mm ou <8 mm; p = 0,8). Conclusão: Não foi observada diferença na dilatação cervical entre o uso de misoprostol umedecido e não umedecido antes do AMIU. / Objectives: The aim of our study was to ascertain whether moistening the Brazilian formulation of vaginal misoprostol tablets increases cervical dilation before manual vacuum aspiration (MVA), compared with use of dry misoprostol, in first-trimester miscarriage. The secondary objective was to ascertain whether there was any correlation between vaginal pH and the degree of cervical dilation using a moistened or dry misoprostol tablet. Methods: In a single-centre, double-blind, randomised trial, 46 patients with first-trimester miscarriage were randomly allocated to treatment with dry or moistened (with 200 μl distilled water) 400μg of misoprostol. Results: The median (range) cervical dilation in the wet and dry groups was 8 mm (6–12 mm) and 7 mm (5–10 mm), respectively (p=0.06). The median time between misoprostol insertion and carrying out the procedure did not differ between the dry (406 min, range 180–550 min) and wet (448 min, range 180–526 min) groups (p=0.1). No correlation was found between vaginal pH and cervical dilation using continuous data (p=0.57; r=0.08; 95% confidence interval -0.02, 0.3) or dichotomous data (pH ≤5/>5; cervical dilation ≥8 mm or <8 mm; p=0.8). Conclusion: No difference was observed in cervical dilation between moistened and non-moistened misoprostol use prior to MVA.

Dissertação (mestrado) - Universidade Federal de Santa Catarina, Centro de Ciências da Saúde. / Made available in DSpace on 2012-10-18T02:39:31Z (GMT). No. of bitstreams: 0Bitstream added on 2014-09-25T17:35:01Z : No. of bitstreams: 1 175865.pdf: 1561437 bytes, checksum: 5b60a9346752f570ea703468af719ff0 (MD5) / Esta dissertação tem por objetivo medir a prevalência e a severidade da dor cervical e lombar nos servidores técnico-administrativos da Universidade Federal de Santa Maria-RS, em relação a características individuais, ocupacionais e percepção de causas. É um estudo transversal descritivo; a população de estudo (n=429) foi selecionada por amostra probabilística proporcional, referente aos servidores dos níveis superior, intermediário e auxiliar. Os dados foram coletados por meio de questionário. Utilizou-se o teste de Qui-quadrado para medidas de associação (p*0,05). Quanto às variáveis individuais, o sexo feminino apresentou mais dor do que o masculino. Os indivíduos mais jovens (24 a 36 anos) apresentaram mais dor cervical e menos dor cervical e lombar. Verificou-se que 36,5% das pessoas referiram dor nas costas severa. As mulheres relataram mais dor cervical severa do que os homens. O trabalho doméstico, no período de lazer, esteve fortemente associado à dor severa. As pessoas com dor nas costas severa praticam menos exercícios físicos. A análise das cargas de trabalho e da severidade da dor nas costas mostrou que o trabalho sentado, o trabalho físico dinâmico e a carga psicológica estão associados ao sintoma. Os fatores pessoais, emocionais, esforço físico ou postura incômoda e ambientais mostraram associação na percepção de causas da dor.

The female genital tract is a mucosal epithelium that has an array of factors contributing to the cervicovaginal immune environment. Like with systemic immunity, innate and adaptive immune mediators are integrated in the efficiency for fighting infections in the female genital tract. Our study addresses the role of pregnancy and HIV infection on concentrations of cytokines in genital tract fluid that play a role in HIV sexual transmission. We focused on two pathways: The NF-KB inflammation pathway that has been implicated in susceptibility to HIV infection, and two interferon pathways that have been associated with antiviral immune defense. We hypothesized that pregnant women have increased proinflammatory cytokines in genital secretions, potentially putting them at increased risk for HIV infection, and that HIV-infected women could have upregulated Type 1 interferon pathways that may regulate HIV replication in the genital tract, and infection by other viruses. This study compared the immune mediator profiles in genital secretions of women between the ages of 18 and 40 years old belonging to four groups: HIV Negative/ Non Pregnant, HIV Negative/Pregnant, HIV Positive/ Non Pregnant, and HIV positive/ pregnant. Cytokine concentrations in cervicovaginal lavage fluid were measured using ELISA and MAGPIX assays. A number of statistical methods were used to characterize cytokine pathways and to link pathway associated cytokines to HIV serostatus and/or pregnancy. The study showed that HIV positive women had higher levels of proinflammatory cytokines including IL-1α, IL-2RA, IL-4, IL-5, IL-6, IL-7, IL-12, IL-17, MIF, MIG, MIP-1ß, SCGF, TNF-α, and TRAIL. Only the antimicrobial peptide lysozyme was significantly decreased in HIV positive women. However, lysozyme was significantly increased in pregnant women where as the following cytokines were significantly decreased in pregnant women: ß-NGF, G-CSF, GM-CSF, GRO-α, HGF, IGN-α2, IFN-γ, IL-2RA, IL-3, IL-4, IL-6, IL-7, IL-12, IL-13, IL-16, IL-17, TNF-α, TRAIL. The correlation analysis showed that HIV positive nonpregnant women could have upregulated: NFκB, type I interferon and interferon-γ pathways. The correlation analysis showed that the NFκB pathway could be upregulated in pregnant HIV negative women and these findings suggest that vaginal inflammation may play a role in HIV transmission from HIV-infected women to uninfected pregnant women. Moreover, upregulated interferon pathways could help understand how the body regulates genital viral infections in HIV-infected women.

BACKGROUND: Patient navigators have been shown to reduce cancer disparities among racial/ethnic minorities by improving timely diagnosis and treatment of cancer. We sought to determine if race/ethnicity and language concordance of patients and their navigator improved time to diagnostic resolution of breast and cervical cancer screening abnormalities. METHODS: Demographic data on patients and navigators from the Boston Patient Navigation Research Program were used to assess concordance by race, ethnicity, and language. Kaplan-Meier survival curves and Cox proportional hazards regression models examined the association of race/ethnicity and language concordance on time to definitive diagnosis of cancer screening abnormalities. All analyses were performed separately for breast and cervical groups. RESULTS: There were 1257 patients and 23 navigators in this study. In the breast group (n=655), 44% of patient-navigator pairs were concordant by race/ethnicity and 75% were language concordant. In the cervical group (n=602), 70% of patient-navigator pairs were race/ethnicity concordant and 87% were language concordant. There was no association with race/ethnicity concordance and time to diagnostic resolution for the breast group, aHR 1.19 (95% CI: 0.97, 1.46) or cervical group, aHR 1.23 (95% CI: 0.99, 1.53). However, in the stratified analysis, race/ethnicity concordance was associated with timelier resolution for minority women with breast and cervical cancer screening abnormalities but not for Whites. For cervical cancer screening abnormalities resolving in less than 90 days, language concordance was also associated with timelier resolution, aHR of 1.46 (95% CI: 1.18, 1.80) but there was no association in the breast group. In the subgroup analysis of Spanish concordance there was also an association of timelier resolution for those with cervical cancer screening abnormalities resolving in less than 90 days. CONCLUSION: Patient-navigator race/ethnicity concordance is associated with timelier diagnostic resolution of breast and cervical cancer screening abnormalities among minority women. Language concordance is also associated with timelier resolution in participants with cervical cancer screening abnormalities despite the availability and use of interpreters. Given poorer cancer outcomes among minority women, the use of patient navigators that are diverse by race/ethnicity and multilingual may help address barriers to care and improve health outcomes among low-income minorities.

African Americans have higher rates of HPV-related cancer incidence than other ethnicities. A review of 18 studies completed on African Americans and people of African descent was done. African Americans do, in fact have higher rates of HPV-related cancer than other racial groups. The disparity appears to be decreasing over time with increased distribution of knowledge about the human papillomavirus to African American groups. However, studies show that many African American communities lack essential knowledge about the severity of HPV-related cancer, HPV transmission and commonality, and the HPV vaccine itself.

Orientador: João Guilherme Padilha Filho / Banca: Márcia Rita Fernandes Machado / Banca: Everton Regonato / Banca: Paola Castro Moraes / Banca: Roberta Renzo / Resumo: A espondilomielopatia cervical (EMC) foi descrita pela primeira vez na década de 1950; desde então, esse distúrbio neurológico tem se tornado desafio para médicos veterinários. É uma doença complexa, com causas multifatoriais, resultante de compressão da medula espinhal, que leva aos mais variados sinais clínicos. Sabe-se que o prognóstico dos pacientes está diretamente relacionado com a severidade da sintomatologia. A despeito da existência de inúmeros trabalhos na literatura versando sobre abordagem terapêutica na EMC, especialmente aquela que é decorrente de metodologias invasivas, restam muitas dúvidas sobre a eficácia destes tratamentos frente as várias complicações da doença. Dessa maneira, o presente trabalho propõe uma técnica cirúrgica com a finalidade de evitar algumas falhas que as técnicas atuais apresentam. Para isso, a técnica de separação-fusão com a utilização de enxerto ulnar autólogo, fixada com um único parafuso, foi realizada e documentada em dois espécimes de cães de 5 kg e 25 kg. Sendo também aplicada a quatro cães de médio porte (30 a 60 Kg), de raças variadas, com sinais compatível com espondilomielopatia cervical, e confirmada com auxílio de exames de imagem. O acompanhamento clínico desses animais variou de um a sete anos. A técnica proposta mostrou-se exequível em espécimes de diferentes pesos. E mostrou-se eficaz nos animais submetidos a técnica proposta, sem intercorrências durante o período de avalição. / Abstract: Cervical spondylomyelopathy (CME) was first described in the 1950s, since then, this neurological disorder has become a challenge for veterinarians. It is a complex disease, with multifactorial causes, resulting from compression of the spinal cord, which leads to the most varied clinical signs. It is known that the prognosis of the patients is directly related to the severity of the symptomatology. Despite the existence of numerous studies in the literature dealing with the therapeutic approach in CME, especially those that are due to invasive methodologies, many doubts remain about the efficacy of these treatments against the various complications of the disease. In this way the present work proposes a surgical technique with the purpose of avoiding some flaws that present techniques present. For this, the technique of separation-fusion with the use of autologous ulnar graft, fixed with a single screw, was carried out and documented in two specimens of dogs of 5 kg and 25 kg. It is also applied to four medium-sized dogs (30 to 60 kg), of different races, with symptomatology compatible with cervical spondylomyelopathy, and confirmed with the aid of imaging tests. The clinical follow-up of these animals ranged from three to seven years. The proposed technique proved to be feasible in specimens of different weights. These was shown to be effective in animals submitted to the proposed technique, without intercurrences during the evaluation period. / Doutor

Background: Cervical cancer may be fatal to women if not identified and treated early. In Iraq, cervical cancer ranks as the 10th most frequent cancer among women between 15-44 years of age, with about 291 new cervical cancer cases diagnosed annually. Cervical cancer can be prevented in two ways: primary prevention aimed at preventing HPV infection through prophylactic HPV vaccinations; and secondary prevention aimed at preventing precancerous lesions from progressing into invasive lesions through screening. Cervical cancer screening is under researched in Iraq. It is clear that Iraq’s years of isolation and disorder has resulted in a loss of research capacity. Aim: To provide evidence–based strategies to establish population based cervical cancer screening services in Iraq. Methods: A mixed methods sequential exploratory design was used; an iterative mixed method approach which included the triangulation of qualitative, quantitative and systematic review methods. Results of all phases were used to develop an emergent theory around the barriers for establishing cervical screening programme and to provide evidence to enhance cervical cancer screening services to be established in Iraq. Findings: The findings from the systematic review indicated significant health inequalities for Arab Muslim women, in that no population-based cervical cancer screening programmes have been implemented in most of Western Asian and Middle Eastern Arab countries. Findings from the qualitative phase revealed gap in theoretical and practical knowledge among the health care professionals regarding cervical cancer screening programmes with a lack of the capacity and infrastructure to establish population based cervical screening programme in Kirkuk, Iraq. Also, results suggest that the health behaviour of women living in Kirkuk is influenced by cultural ‘stigma’ around the word ‘cancer’, in addition to women’s lack of awareness in relation to smear test and cervical screening. Conclusion: Women in Iraq are more likely to be diagnosed at an advanced, rather than early stage of cervical cancer. These women should be targeted by cervical cancer screening and health education programmes. Policy makers need to improve the cervical screening infrastructure and make the cervical screening service more accessible to women. The current opportunistic cervical screening services are insufficient; there is an urgent need to developing cervical cancer intervention programmes.

Introduction Cervical cancer is the fourth most common cancer in women worldwide. An estimated 62,000 cases of cervical cancer occur annually in China, accounting for 12% of global incidence. Virtually all cervical cancers are related to infection by Human Papilloma Virus (HPV): effective HPV vaccines have been developed and vaccination programmes introduced in many countries over the last decade. Given the burden of cervical cancer in China, it is imperative that effective primary and secondary prevention strategies are introduced. Effective introduction of HPV vaccination programmes will require education and information strategies that are informed by a comprehensive understanding of the knowledge, attitudes and beliefs about HPV infection and its relationship to cervical cancer in the Chinese population. Aims and objectives The aims of my thesis are: 1) to systematically review the evidence from the Chineselanguage literature in relation to knowledge of and attitude towards HPV infection and HPV vaccination, and 2) to explore knowledge and attitudes about HPV infection, HPV vaccination and cervical screening amongst teenagers in Heilongjiang province in China. Methods I undertook a systematic literature review using two electronic Chinese databases – the ‘Chinese National Knowledge Infrastructure’ (CNKI) database and the ‘Wanfang’ database. These were searched from inception through November 30th 2012: MeSH terms were applied to both Chinese databases. Manual searching of relevant online journals was also undertaken. Following selection of papers based on pre-determined inclusion and exclusion criteria, quality assessment was carried out using a modified quality assessment checklist, and included studies were classified as good, fair or poor quality. Due to heterogeneity of populations and survey instruments a narrative approach was adopted for data synthesis. I also undertook a questionnaire survey of high-school students in China. Questions were designed based on the Health Belief Model, informed by findings from my systematic review, and refined through cognitive interviews prior to field work in early 2014. The survey targeted students in five public high schools in one middle-income city (Mudanjiang city) and two small counties (Ning’an and Hailin) of Heilongjiang province; 3788 young people aged 14-22 years participated. Descriptive statistical analysis was used to summarise demographic characteristics; initially differences were identified using the chi-square test. Factor analysis was applied to identify attitude patterns and logistic regression analysis models were applied to determine the association between attitude (potential predictors) and acceptability, attitude and levels of knowledge. Results Forty seven articles met my inclusion criteria and were included in the systematic review. All included studies were published between 2006 and 2011; all were cross-sectional questionnaire surveys with sample sizes ranging from 100 – 9,865. The quality of included studies varied considerably. Included populations ranged from the general public, to young people, and health professionals. Awareness of HPV and knowledge of the relationship between HPV and cervical cancer, and of the sexually transmitted nature of HPV, were the main issues examined. Awareness of HPV was low among all non-health professionals groups. Similarly, understanding of the relationship between HPV infection and cervical cancer and of the sexually transmitted nature of HPV was low. However, significant differences in awareness and knowledge were found, based on urban/rural status, ethnicity and age. Uighur women had the lowest awareness and knowledge levels, followed by rural women adults, and teenagers. Acceptability of HPV vaccination varied in terms of the vaccine target recipients (whether adult women, or for their daughters), and between health professionals and the general public). Reported levels of HPV vaccine acceptability (for women adults themselves and for their daughters) were higher in North China compared to South China. Health professionals were less willing to accept the vaccine for their daughters than they were to receiving it themselves. The cost, source and appropriate age for HPV vaccination were also frequently examined issues. Importantly, a high proportion of the health professionals believed that the appropriate age for vaccine was over 18 years old for girls. 3788 participants aged 14-22 years were included in the questionnaire survey, with 54% females and 20% urban students. Overall awareness of HPV was 13.2% and acceptability of the HPV vaccine was 68%. Knowledge levels varied in different content areas; for example 74% of respondents knew that HPV vaccination is not 100% effective against cervical cancer while only 6% knew that poor personal hygiene did not increase the risk of contracting HPV infection. Attitudes towards HPV infection and vaccination were also interesting and novel; the greatest concern about HPV vaccination was minor side effects (72%). The highest-rated source of recommendations about HPV vaccination was parents (66%), while there were concerns expressed about ‘gossip’ in relation to HPV vaccination (51%). No urban/rural differences were found in knowledge and attitudes - gender differences existed, but depended on specific circumstances. Participants who were willing to accept HPV vaccination were more likely to be influenced by others, to report high perceived severity of HPV and cervical cancer, to perceive benefits of HPV vaccination and to score well on knowledge questions. Participants with high knowledge scores for HPV infection and vaccination were more likely to consider HPV infection and cervical cancer to be serious, and were less likely to associate HPV infection with stigma. Participants who had high levels of awareness of HPV infection were more likely to be influenced by others in relation to accepting HPV vaccination. Discussion My thesis has produced new and novel findings in relation to HPV vaccination knowledge, attitudes and beliefs in China. Low levels of awareness and knowledge amongst Chinese people may be influenced by traditional Chinese culture, which perhaps makes people more reluctant to consider issues related to sexual practices. Another possible explanation is that people tended to under-report knowledge of HPV when answering the questions in the survey in order to conform to social norms in China - these topics are highly sensitive in China. High levels of acceptability of HPV vaccines may have also been influenced by ‘ways of thinking’ among Chinese people; their natural inclination is to accept all recommendations for vaccination from government agencies – so they may not have thought hard about this choice. There is optimism in the Chinese population that cancer can be prevented by vaccination – indeed, they are inclined to believe it will prevent disease that can generate serious health impacts in the future. Nevertheless, some Chinese people have conservative attitudes towards the effectiveness of HPV vaccination and some suspicion of the drug companies which produce these vaccines. There were significant methodological issues in my comparisons of Western and Chinese literature. Western literature is more likely to comprise good quality studies – typically there are better-defined sampling frames, more valid and reliable instruments and robust theoretical frameworks. The difference in quality between Chinese and Western literature arises from the stricter rules for reporting and evaluation in western publications and the relatively low publishing standards in Chinese literature. / My thesis also details a number of methodological issues which arose in conducting my questionnaire survey – ideally, I would like to follow up the work I have done with a multi-centre population-based study among teenagers in China (an idea which I will pursue once I return to China). This would hopefully provide better quality information on the influences of factors such as socio-economic status and family background in determining acceptability of HPV vaccination. Nevertheless, my relatively modest, school-based study has, I believe, produced results which add to the information available to health care planners and policy makers in the field of HPV vaccination in China. Conclusion My systematic review is, to my knowledge, the first to identify and synthesise findings about knowledge of and attitude towards HPV infection and vaccination in the Chinese literature – as such, it addresses a gap in currently available evidence. Although there are methodological limitations in Chinese literature (with more poor quality studies), the results still have implications for further health education intervention programmes and health policy. My questionnaire survey was also a ‘first’ in many ways – it explored attitudes towards HPV vaccines based on Health Belief Model among Chinese teenagers and examined HPV related stigma among mainland Chinese teenagers. Low levels of awareness and knowledge and conservative attitudes towards sexually related infections suggest the impact of Chinese traditional culture and a range of other social and financial constraints in China. Hence, there is a great deal to be done before HPV vaccination can be implemented in China – there are educational needs, and in many areas societal and cultural attitudes need to be challenged. Significant changes are also need in government policy and investment – these are major challenges for health care in China, and I sincerely hope my thesis will contribute to these important debates.