Awareness,knowledge and beliefs about HPV,cervical cancer and HPV vaccines among nurses in Cameroon: An exploratory study

Background

While it is known that sub-Saharan African countries face multiple obstacles such as cost in adopting vaccination against human papillomavirus (HPV), the crucial role nurses can play in implementing such programs has not been adequately examined.

Objectives

To investigate the knowledge and awareness of HPV, primary cause of cervical cancer and HPV vaccine among nurses working at four Cameroon Baptist Convention Health Services facilities, and to explore what factors influence nurses’ willingness to inform and recommend HPV vaccine to adolescents and parents attending clinics.

Design and setting

A structured questionnaire survey was administered to a convenience sample of nursing staff working at the four health facilities.

Results

Of 192 eligible nurses 76 (39.6%) participated in the study. There were moderately low levels of knowledge about HPV infection and prevention of cervical cancer, but a moderately high level of knowledge about HPV vaccine. Although 90.8% acknowledged that cervical cancer is directly linked to HPV infection, nearly 32% failed to identify it as a sexually transmitted infection (STI), while 43.4% believed it is an uncommon infection. Willingness to recommend the HPV vaccine was moderate, with 69.7% intentionally initiating discussions with patients about the subject. The most important factors considered when deciding to recommend the vaccine included effectiveness (56.6%) and side effects/safety (11.8%). Cost was less of a concern (6.6%), likely due to the availability of donated vaccine.

Conclusion

Despite high awareness about HPV, more education about the virus, cervical cancer and the vaccine are required to further increase nurses’ willingness to recommend the vaccine and strengthen strategies for reaching adolescents through nurses in Cameroon.     

Update on Vaccination Clinical Trials for HPV-Related Disease

Background

Cervical cancer remains a major cause of cancer death in women worldwide. Moreover, human papillomavirus (HPV)-related disease of the urogenital tract (including preinvasive and invasive cervical, vaginal, vulvar, penile, and anal disease) remains a major cause of morbidity and mortality in the United States and internationally.

Objective

The goal of this article was to review the vaccines available as well as the major Phase III trials of the quadrivalent and bivalent vaccines for the prevention of HPV-related genital tract disease.

Methods

A literature search was performed through PubMed using the terms “HPV vaccination” and limited to clinical trials over the last 6 years. The most relevant and largest scale trials were included in this report.

Results

Prophylactic vaccination has emerged as an important tool that holds promise in decreasing the burden of HPV disease. However, HPV vaccination is known to be largely type-specific. Vaccination is most effective when administered at a younger age and before sexual activity and exposure to HPV. Large trials have been conducted and show efficacy of both the bivalent (HPV types 16 and 18) and quadrivalent (HPV types 6, 11, 16, and 18) vaccine in the prevention of preinvasive lesions and infection with these HPV types.

Conclusions

Future directions include development of more affordable vaccines with extended HPV-type coverage as well as implementation of feasible worldwide vaccination programs.     

Detection of human papillomavirus infection in women attending a colposcopy clinic

Background

Infection by human papillomavirus (HPV) is the main cause of and a necessary factor for cervical cancer. There are more than 100 known HPV genotypes, although HPV genotypes do not all have the same risk of inducing cervical cancer. The main aim of this study is to know the distribution of different types of HPV in women attending a colposcopy clinic for cervical dysplasia.

Methods

We prospectively identified and enrolled a cohort of women followed for cervical dysplasia who were referred to the colposcopy clinic of University Hospital Sant Joan de Déu in Barcelona, Spain, from April 2003 to April 2007. Two cervical scrape samples from each patient were collected for routine cytology and for identification of HPV DNA. During the study period, 2 techniques (Line Probe assay and microarray assay) were used consecutively.

Findings

HPV DNA was detected in 68% of patients (338 of 496 women) with statistically significant differences in positive results according to the cytologic category. Overall, the type distribution showed a predominance of genotype HPV-16 (27% of the total patients) followed by HPV-53 (9.4%), HPV-51 (8%), and HPV-51 (8%). Multiple genotype detection was observed in 35.5% of the patients with HPV infection. HPV-16 was mainly associated with the probable high-risk genotypes: HPV-53 and HPV-66.

Conclusion

The higher prevalence of high-risk nonvaccine genotypes should be considered to increase vaccine efficiency.     

The Australian Experience With the Human Papillomavirus Vaccine

Objective

The goal of this study was to review the current human papillomavirus (HPV) vaccine program and its outcomes to date in Australia.

Methods

This was a review of the published data relating to the introduction and subsequent measurable outcomes of the quadrivalent vaccine, which became part of the Australian national HPV immunization program in 2007. Australia commenced an ongoing, schoolbased, government-funded, HPV vaccination program using the quadrivalent vaccine from April 2007 for adolescent female subjects aged 12 to 13 years, together with a catch-up program for female subjects 13 to 26 years of age from July 2007 to December 31, 2009.

Results

The Australian community (lay and clinical) have embraced the program, resulting in high coverage with >70% for 3 doses in the 12- to 13-year-old ongoing target population. Vaccine effectiveness (outcomes of vaccination in a real-world setting) is already being seen. This effectiveness has been noted in significant reductions in HPV vaccine–related infections in vaccine eligible age female subjects (77% fall in prevalence), rapid reduction of >90% in genital warts (first marker of disease reduction, as well as herd immunity), and reduction in high-grade cervical lesions in this age group. These remarkable changes so soon after implementation of the vaccine in the country occurred faster, and to a greater extent, than anyone could have predicted.

Conclusions

These findings from Australia should encourage other countries to follow suit, with the ultimate aim of translating treatment into reductions in HPV-related neoplasia globally. The greatest success from such an approach will only be realized when prophylactic vaccines are rolled out effectively, with high coverage and at affordable costs, to those areas of the world with the highest burden of disease. To achieve this outcome requires government endorsement and commitment; education of the community at large; realization of the safety, efficacy, and immunogenicity of the available prophylactic vaccines in reducing HPV-related infections and disease, especially neoplasia; and governments procuring vaccines at affordable prices through the various options now available (eg, support from the GAVI Alliance to eligible countries, tiered pricing, negotiation with pharmaceutical manufacturers). We have the tools to reach this goal, and it is time these tools were implemented.     

An Association Between Trichomonas vaginalis and High-Risk Human Papillomavirus in Rural Tanzanian Women Undergoing Cervical Cancer Screening

Objective

The goal of this study was to determine the prevalence of vaginitis and its association with high-risk human papillomavirus (HR HPV) in women undergoing cervical cancer screening in rural Tanzania.

Methods

For the purpose of cervical cancer screening, cytology and HR HPV polymerase chain reaction data were collected from 324 women aged between 30 and 60 years. Microscopy and gram stains were used to detect yeast and bacterial vaginosis. Cervical nucleic acid amplification test specimens were collected for the detection of Trichomonas vaginalis (TV), Chlamydia trachomatis, and Neisseria gonorrhoeae.

Results

The majority of women were married (320 of 324) and reported having a single sexual partner (270 of 324); the median age of participants was 41 years. HR HPV was detected in 42 participants. Forty-seven percent of women had vaginitis. Bacterial vaginosis was the most common infection (32.4%), followed by TV (10.4%), and yeast (6.8%). In multivariable logistic regression analysis, TV was associated with an increased risk of HR HPV (odds ratio, 4.2 [95% CI, 1.7–10.3]). Patients with TV were 6.5 times more likely to have HPV type 16 than patients negative for TV (50% vs 13.3%) (odds ratio, 6.5 [95% CI, 1.1–37]).

Conclusions

Among rural Tanzanian women who presented for cervical cancer screening, Trichomonas vaginitis was significantly associated with HR HPV infection (specifically type 16).     

A Novel Method to Value Real Options in Health Care: The Case of a Multicohort Human Papillomavirus Vaccination Strategy

Background

A large number of economic evaluations have already confirmed the cost-effectiveness of different human papillomavirus (HPV) vaccination strategies. Standard analyses might not capture the full economic value of novel vaccination programs because the cost-effectiveness paradigm fails to take into account the value of active management. Management decisions can be seen as real options, a term used to refer to the application of option pricing theory to the valuation of investments in nonfinancial assets in which much of the value is attributable to flexibility and learning over time.

Objective

The aim of this article was to discuss the potential advantages shown by using the payoff method in the valuation of the cost-effectiveness of competing HPV immunization programs.

Methods

This was the first study, to the best of our knowledge, to use the payoff method to determine the real option values of 4 different HPV vaccination strategies targeting female subjects aged 12, 15, 18, and 25 years. The payoff method derives the real option value from the triangular payoff distribution of the project's net present value, which is treated as a triangular fuzzy number. To inform the real option model, cost-effectiveness data were derived from an empirically calibrated Bayesian model designed to assess the cost-effectiveness of a multicohort HPV vaccination strategy in the context of the current cervical cancer screening program in Italy. A net health benefit approach was used to calculate the expected fuzzy net present value for each of the 4 vaccination strategies evaluated.

Results

Costs per quality-adjusted life-year gained seemed to be related to the number of cohorts targeted: a single cohort of girls aged 12 years (€10,955 [95% CI, –1,021 to 28,212]) revealed the lowest cost among the 4 alternative strategies evaluated. The real option valuation challenged the cost-effectiveness dominance of a single cohort of 12-year-old girls. The simultaneous vaccination of 2 cohorts of girls aged 12 and 15 years yielded a real option value (€17,723) equivalent to that attributed to a single cohort of 12-year-old girls (€17,460).

Conclusions

The payoff method showed distinctive advantages in the valuation of the cost-effectiveness of competing health care interventions, essentially determined by the replacement of the nonfuzzy numbers that are commonly used in cost-effectiveness analysis models, with fuzzy numbers as an input to inform the real option pricing method. The real option approach to value uncertainty makes policy making in health care an evolutionary process and creates a new “space” for decision-making choices.     

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention’s (CDC) Healthy People 2020 target of 80% coverage. Parents’ willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a “bundle” along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action.

• Key messages

• ??Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.

• ??According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.

• ??First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.

• ??It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.

• ??Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.

• ??The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

     

Establishing physician advocates for human papillomavirus vaccination in British Columbia

Objective

To survey general practitioners in oncology (GPOs) in British Columbia (BC) to identify opportunities for them to serve as public supporters of human papillomavirus (HPV) vaccination.

Design

A mailed or online survey.

Setting

British Columbia.

Participants

Forty-two GPOs who worked in the community in BC.

Main outcome measures

Current practices, knowledge, and resource needs concerning HPV, the vaccine, and the HPV immunization program, and the willingness of respondents to be contacted to participate in stated public HPV vaccine supporter activities.

Results

The survey found that 42% of surveyed GPOs were willing to act as public supporters of the HPV vaccine. The survey also identified education needs among GPOs concerning HPV, the vaccine, and the HPV immunization program in BC.

Conclusion

This study found that GPOs in BC are willing to publicly support the HPV immunization program. This study shows that involving physicians in the promotion of public health programs is a viable option that should be further explored and evaluated.     

A Case of Evans' Syndrome Following Influenza Vaccine

Background

Evans' syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia purpura and autoimmune hemolytic anemia with a positive direct antiglobulin test in the absence of known underlying etiology.

Objectives

We present a case of Evans' syndrome following influenza vaccination.

Case Report

A 50-year-old man with no prior medical history developed Evans' syndrome 4 days after receiving influenza immunization. The patient improved following treatment with oral prednisone and intravenous immunoglobulin.

Conclusion

Influenza vaccine is one of the most commonly used vaccines worldwide, with millions of people being vaccinated annually. Despite its wide use, only sparse information has been published concerning any hematological effects of this vaccine. The rarity of such effects supports the safety of using this vaccine.     

Racial/ethnic differences in emergency care for joint dislocation in 53 US EDs

Objective

The aim of the study was to investigate racial/ethnic differences in emergency care for patients with joint dislocation.

Methods

We performed a secondary analysis of the dislocation component of the National Emergency Department Safety Study. Using a principal diagnosis of dislocation, we identified emergency department (ED) visits for joint dislocations in 53 urban EDs across 19 US states between 2003 and 2005. Quality of care was evaluated based on 9 guideline-concordant care measures.

Results

Of the 1945 patients included in this analysis, 1124 (58%) were white; 561 (29%), black, and 260 (13%), Hispanic. One-third of the 53 EDs cared for 51% of minority patients. After multivariable adjustment, black patients were less likely to receive any analgesic treatment (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.51-0.90) or opioid treatment (OR, 0.64; 95% CI, 0.41-0.997), waited longer to receive analgesia (mean difference in time to analgesic treatment, 32 minutes; 95% CI, 16-52 minutes), and were less likely to receive reassessments of pain (OR, 0.49; 95% CI, 0.34-0.70) compared with white patients. There were no ethnic disparities in most of the care measures between Hispanic and white patients. There were no disparities in initial pain assessment, pre- and postprocedural neurovascular assessment, procedural monitoring, or success of joint reduction across the racial/ethnic groups.

Conclusions

Black patients presenting to the ED with joint dislocations received lower quality of care in some, but not all, areas compared with white patients. Future interventions should target these areas to eliminate racial disparities in dislocation care.     

Effect of concurrent radiochemotherapy and chemotherapy on serum proteins for prospective predictors of patients with HPV induced cervical cancer

Objectives

To evaluate the effectiveness of radiochemotherapy and chemotherapy on human papilloma virus induced cervical cancer patients by the estimation of serum proteins and magnetic resonance imaging.

Methods

HPV 16/18 viral DNA was detected in the plasma of cervical cancer patients (n = 50) by PCR using HPV consensus primers. Of the 50 cervical cancer patients, 25 cases undergoing radiation with chemotherapy and another 25 cases undergoing chemotherapy. Levels of pre- and post-treated serum squamous cell carcinoma antigen, soluble CD44, cancer antigen-125 were measured and evaluated the tumour size at pre- and post-radiation based on magnetic resonance images. The effectiveness of treatment was evaluated in terms of protein levels and represented as whisker line graphs.

Results

Of the amplified 50 samples, HPV 16 and 18 strains were identified as 48 and 44%, respectively. Serum protein levels were significantly increased in both pre-treated groups when compared to healthy group. Post-treated (radiotherapy) cervical cancer patients’ shows decreased tumour size when compared to pre-treated groups. Taking consideration of proteins, squamous cell carcinoma antigen, soluble CD44, cancer antigen-125 levels are more decreased in patients treated with radiochemotherapy than chemotherapy alone. The decreased levels of proteins were significantly higher in early stage of the cervical cancer than the advanced stage of cancer patients.

Conclusion

Serum levels of protein markers are more improved in patients treated with radiochemotherapy than chemotherapy hence, radiochemotherapy may be the best choice of treatment with reference to proteins at early stage of cervical cancer when compared to chemotherapy alone.     

The clinical utility of cervical range of motion in diagnosis,prognosis, and evaluating the effects of manipulation: a systematic review

Background

Clinicians commonly assess cervical range of motion (ROM), but it has rarely been critically evaluated for its ability to contribute to patient diagnosis or prognosis, or whether it is affected by mobilisation/manipulation.

Objectives

This review summarises the methods used to measure cervical ROM in research involving patients with cervical spine disorders, reviews the evidence for using cervical ROM in patient diagnosis, prognosis, and evaluation of the effects of mobilisation/manipulation on cervical ROM.

Data sources and study selection

A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted, addressing one of four constructs related to cervical ROM: measurement, diagnosis, prognosis, and the effects of mobilisation/manipulation on cervical ROM.

Study appraisal and synthesis

Two independent raters appraised methodological quality using the QUADAS-2 tool for diagnostic studies, the QUIPS tool for prognostic studies and the PEDro scale for interventional studies. Heterogeneity of studies prevented meta-analysis.

Results

Thirty-six studies met the criteria and findings showed there is limited evidence for the diagnostic value of cervical ROM in cervicogenic headache, cervical radiculopathy and cervical spine injury. There is conflicting evidence for the prognostic value of cervical ROM, though restricted ROM appears associated with negative outcomes while greater ROM is associated with positive outcomes. There is conflicting evidence as to whether cervical ROM increases or decreases following mobilisation/manipulation.

Conclusion and implications of key findings

Cervical ROM has value as one component of assessment, but clinicians should be cautious about making clinical judgments primarily on the basis of cervical ROM.

Funding

This collaboration was supported by an internal grant from the Faculty of Health, The University of Newcastle.     

Human papillomavirus vaccination for boys

Question

In Canada, generally provincial human papillomavirus (HPV) vaccination programs exist for only the female population. What should I recommend when parents and teenage boys ask about male HPV vaccination?

Answer

The quadrivalent HPV vaccine is effective and will reduce the incidence of disease in boys and girls. The quadrivalent HPV vaccination is approved and recommended for both boys and girls in Canada. Public funding for male vaccination is available in Prince Edward Island and Alberta. The remaining provinces and territories will need to consider cost-effectiveness analyses before expanding their female-only vaccination programs to include the male population.     

Survival in Persons With Traumatic Spinal Cord Injury Receiving Structured Follow-Up in South India

Objective

To assess the survival in persons with traumatic spinal cord injury (SCI) receiving structured follow-up in South India.

Design

Retrospective study.

Setting

Rehabilitation center.

Participants

Persons with traumatic SCI (N=490) residing within a 100-km radius of the institute who were managed and regularly followed up by the rehabilitation center between the years 1981 and 2011.

Interventions

Not applicable.

Main Outcome Measures

Survival rates and mortality risk factors. Measures were estimated using the product limit (Kaplan-Meier) method and the Cox model.

Results

The survival rate after SCI was 86% after 5 years, 71% after 15 years, and 58% after 25 years. Survival of persons with complete high cervical injury is substantially low compared with other levels of SCI. Level of injury and extent of lesion (Frankel classification and/or American Spinal Injury Association Impairment Scale) play a significant role in predicting survival of this population.

Conclusions

Survival rates of regularly followed-up persons with SCI from this study show promising results, though survival rates are lesser when compared with studies from developed countries. Better understanding of the predictors, causes of deaths, comprehensive rehabilitation, community integration, and regular follow-up could possibly assist in improving survival rates.     

Effects of Cervical Spine Manual Therapy on Range of Motion,Head Repositioning,and Balance in Participants With Cervicogenic Dizziness: A Randomized Controlled Trial

Objective

To evaluate and compare the effects of 2 manual therapy interventions on cervical spine range of motion (ROM), head repositioning accuracy, and balance in patients with chronic cervicogenic dizziness.

Design

Randomized controlled trial with 12-week follow-up using blinded outcome assessment.

Setting

University School of Health Sciences.

Participants

Participants (N=86; mean age ± SD, 62.0±12.7y; 50% women) with chronic cervicogenic dizziness.

Interventions

Participants were randomly assigned to 1 of 3 groups: sustained natural apophyseal glides (SNAGs) with self-SNAG exercises, passive joint mobilization (PJM) with ROM exercises, or a placebo. Participants each received 2 to 6 treatments over 6 weeks.

Main Outcome Measures

Cervical ROM, head repositioning accuracy, and balance.

Results

SNAG therapy resulted in improved (P≤.05) cervical spine ROM in all 6 physiological cervical spine movement directions immediately posttreatment and at 12 weeks. Treatment with PJM resulted in improvement in 1 of the 6 cervical movement directions posttreatment and 1 movement direction at 12 weeks. There was a greater improvement (P<.01) after SNAGs than PJM in extension (mean difference, −7.5°; 95% confidence interval [CI], −13° to −2.0°) and right rotation (mean difference, −6.8°; 95% CI, −11.5° to −2.1°) posttreatment. Manual therapy had no effect on balance or head repositioning accuracy.

Conclusions

SNAG treatment improved cervical ROM, and the effects were maintained for 12 weeks after treatment. PJM had very limited impact on cervical ROM. There was no conclusive effect of SNAGs or PJMs on joint repositioning accuracy or balance in people with cervicogenic dizziness.     

A Significant Cervical Spine Fracture: Think of the Airway

Background

Airway compromise is a potential complication of significant cervical spine injury.

Objectives

To alert emergency physicians to be aware of possible airway collapse after serious cervical spine injury.

Case Report

We report a case of an 87-year-old man who presented to the emergency department with an unstable cervical spine fracture after a fall. He subsequently developed complete upper airway obstruction from prevertebral soft tissue swelling, requiring a cricothyrotomy after a failed intubation attempt.

Conclusion

Patients with significant blunt cervical spine trauma can be at high risk for upper airway compromise.     

Cost-effectiveness of influenza vaccination of older adults in the ED setting

Objectives

Adults older than 50 years are at greater risk for death and severe disability from influenza. Persons in this age group, however, are frequently not vaccinated, despite extensive efforts by physicians to provide this preventive measure in primary care settings. We performed this study to determine if influenza vaccination of older adults in the emergency department (ED) may be cost-effective.

Methods

Using a probabilistic decision model with quasi-Markov modeling of a typical influenza season, we calculated costs and health outcomes for a hypothetical cohort of patients using parameters from the literature. Three ED-based intervention strategies were compared: (1) no vaccination offered, (2) vaccination offered to patients older than 65 years (limited strategy), and (3) vaccination offered to all patients who are 50 years and older (inclusive strategy). Outcomes were measured as costs, lives saved, and incremental costs per life saved. We performed deterministic and probabilistic sensitivity analyses.

Results

Vaccination of patients 50 years of age and older results in an incremental cost of $34 610 per life saved when compared with the no-vaccination strategy. Limiting vaccination to only those older than 65 years results in an incremental cost of $13 084 per life saved. Results were sensitive to changes in vaccine cost but were insensitive to changes in other model parameters.

Conclusions

Vaccination of older adults against influenza in the ED setting is cost-effective, especially for those older than 65 years. Emergency departments may be an important setting for providing influenza vaccination to adults who may otherwise have remained unvaccinated.     

Correlates for Completion of 3-Dose Regimen of HPV Vaccine in Female Members of a Managed Care Organization

OBJECTIVE: To examine the rate and correlates of completion of the quadrivalent human papillomavirus vaccine (HPV4) 3-dose regimen because nonadherence to the regimen may adversely affect vaccine efficacy.PARTICIPANTS AND METHODS: Female members of Kaiser Permanente Southern California who were 9 to 26 years old, received the first dose of HPV4 between October 2006 and March 2007, and maintained health plan membership 12 months afterward were identified and followed up for regimen completion. We examined the following: (1) demographics/socioeconomic status, (2) primary care physician characteristics, (3) historical health service utilization, (4) women''s health-related conditions, and (5) selected immune-related conditions for their association with completion in 2 age groups: 9 to 17 years and 18 to 26 years. Multivariable log-binomial regression was used to directly estimate relative risk (RR).RESULTS: Of the 34,193 females who initiated HPV4, the completion rate was 41.9% in the 9- to 17-year-old group and 47.1% in the 18- to 26-year-old group. Black race (RR, 0.70; 95% confidence interval [CI], 0.64-0.77) and lower neighborhood education level were associated with lower regimen completion. However, those in the 9- to 17-year-old group who were covered by the state-subsidized program Medi-Cal were more likely to complete the regimen (RR, 1.14; 95% CI, 1.07-1.22). Historical hospitalizations and emergency department visits (RR, 0.92; 95% CI, 0.87-0.96; and RR, 0.96; 95% CI, 0.94-0.98 per visit, respectively) and having a pediatrician were also predictors of noncompletion. A history of sexually transmitted diseases, abnormal Papanicolaou test results, and immune-related conditions (eg, asthma/infections) were not associated with regimen completion.CONCLUSION: These findings suggest that factors such as race or socioeconomic status should be considered when human papillomavirus vaccination programs are being designed and evaluated.CI = confidence interval; HPV = human papillomavirus; HPV4 = quadrivalent human papillomavirus vaccine; ICD-9 = International Classification of Diseases, Ninth Revision; KITS = Kaiser Immunization Tracking System; KPSC = Kaiser Permanente Southern California; PCP = primary care physician; RR = relative risk; SES = socioeconomic status; STD = sexually transmitted diseaseThe quadrivalent human papillomavirus vaccine (HPV4) (Gardasil, Merck & Co, Inc), given in 3 injections, has been shown to be efficacious in preventing cervical cancer and other conditions caused by human papillomavirus (HPV) types 6, 11, 16, and 18.^1,2 However, the 3-dose regimen of the vaccine may impose difficulty for successful HPV immunization in eligible females (ie, 9-26 years old) because of the lack of regular or prespecified health care encounters in these age groups. This may be particularly true in resource-poor settings. In the United States, HPV vaccination is in general not required by state law. As a result, the 3-dose regimen may not always be completed by those who initiate the vaccine. The Advisory Committee on Immunization Practice recommends that the second and third doses be administered 2 and 6 months after the first dose.³ The vaccine label suggests that the 3 doses be completed within 12 months. On the basis of a survey conducted by the Centers for Disease Control and Prevention, approximately 25% of female adolescents between 13 and 17 years of age initiated the vaccine in 2007⁴; however, only one-fourth of these individuals had completed the 3-dose series, potentially because of insufficient follow-up at the time of the survey.⁴ The number of those who initiated the vaccine and actually completed the 3-dose regimen is unclear. Furthermore, whether socioeconomic status (SES) or other health-related factors are associated with regimen completion is unclear. These issues are of public health importance because incomplete vaccination may result in suboptimal disease protection and may jeopardize the cost-effectiveness of the vaccination program. Thus, research addressing these issues is needed to inform clinical practice and future development of HPV immunization programs.To this end, we investigated the rate and correlates for HPV4 regimen completion among those who initiated the vaccine in a managed care population of Kaiser Permanente Southern California (KPSC). A previous study suggested that education level and medical history were predictors for hepatitis B vaccine regimen adherence.⁵ We further explored physician and utilization-related characteristics and examined whether the following factors were correlates for completion of the 3-dose regimen among those who initiated HPV4: (1) demographics and SES, (2) primary care physician (PCP) characteristics, (3) historical health service utilization, (4) women''s health-related medical history, and (5) several immune-related medical conditions (including rheumatoid arthritis, asthma, allergy, and infections).     

Parents’ Sense of Coherence and the Adolescent’s Health and Emotional and Behavioral Adjustment: The Case of Adolescents With Diabetes

Introduction

This study examines parental sense of coherence (SOC) as a resource to health and well-being among adolescents with diabetes.

Method

Participants were recruited by the Juvenile Diabetes Research Foundation and a major pediatric diabetes clinic. Parents of 75 adolescents with type 1 diabetes completed the SOC Questionnaire. Parents and adolescents completed questionnaires regarding the child's physical health, disease self-management, and behavioral problems. Parents and physicians reported adolescent's HbA1c level.

Results

Results showed that parents' SOC was positively correlated to adolescents' physical health and negatively to internalizing problems.

Conclusions

Findings highlight the place of parents in the wellness of adolescents with disease and provide a basis for interventions that enhance adolescents' health and psychological adjustment.