This cross-sectional study assessed nursing students’ knowledge and attitudes about Human papillomavirus (HPV) infection and vaccination in Italy. The survey was conducted among a sample of 556 nursing students. Almost all reported that they had heard about HPV infection, while only 36.5% knew the risk factors of HPV infection and that this could be prevented by the HPV vaccine. Those who had heard about HPV infection during their degree program were more likely to know risk factors of HPV infection and that this could be prevented by the HPV vaccine. The majority of students (65.3%) reported that they would be willing to receive the HPV vaccine. Moreover, 91.7% of participants reported that they were willing, as future health care operators, to recommend the HPV vaccine to others. Those who knew risk factors of HPV infection and that this could be prevented by the HPV vaccine, and those who knew that cervical cancer could be prevented by the HPV vaccine expressed this positive attitude about willingness to recommend the HPV vaccine. These results highlight the need to supplement nursing students’ specific education, to improve their knowledge and awareness of HPV vaccination. Human Papilloma virus (HPV) infection is one of the most frequent sexually transmitted infections. In particular, some genotypes can cause cervical cancer and, in addition, they can be responsible for other cancers, such as anal (90%), vaginal (70%), penile (50%), vulvar (40%) and oropharyngeal 26%) . Accordi6% . AccoSince 2008, the HPV vaccine has been included in Italy’s national vaccination program, where it is offered to girls aged between 11 and 12 years . MoreoveTo encourage higher HPV vaccine uptake, the general population requires accurate information about the utility of the vaccine in HPV infection prevention. Indeed, the achievement of vaccinations is related to the awareness of health professionals on this topic. Therefore, health care workers play an important role in health promotion via the provision of correct, complete and comprehensible information. Furthermore, in addition to physicians, other health care workers such as midwives and nurses must be adequately trained in order to offer, depending on their role, appropriate information consistent with maximizing adherence to vaccination and, they are an important population to study their level of knowledge, attitudes and behavior regarding HPV infection and related vaccination .In the literature, several studies have focused on the attitudes and behaviors of at risk groups ,9,10,11 This cross-sectional study was conducted in a random sample of 556 nursing students  who were recruited between February and April 2018, in three Italian universities, two in Campania and one in the Lazio region. In Italy, access to nursing courses is restricted, and all students must pass an exam prior to enrolment. The degree course consists of three years of academic education and is considered as an undergraduate degree program in nursing. The sample was selected using a two-stage cluster method. In the first stage, from a list of all the degree programs in nursing in each University, five degree programs in nursing were randomly selected. Subsequently, a random sample technique was used to recruit nursing students.The directors of each selected school for nursing, before giving their approval, received a letter outlining the study. The survey tool was a self-administered anonymous and structured questionnaire. In each course, an interviewer, gave instructions about the questionnaire to the nursing students, guaranteed the confidentiality of the information provided and the anonymity of all data. Informed consent for participation was requested before completing the questionnaire.The HPV questionnaire was based on a survey implement used in a previously published study, which assessed HPV infection and vaccination related knowledge, attitudes and behavioral intentions among adolescents and young women . Two resThe questionnaire comprised the following five sections: (1) socio-demographic characteristics ; (2) knowledge of HPV infection and vaccination; (3) attitudes towards HPV infection and vaccination ; (4) willingness to receive the HPV vaccine in the future; and (5) need of information about HPV vaccine. Attitudes towards HPV infection and vaccination were measured on a 10-point Likert scale ranging from 1 (not worried) to 10 (extremely worried). Willingness to receive the HPV vaccine in the future was also measured on a 10-point Likert scale ranging from 1 to 10, with a higher score indicating a greater intention to be vaccinated. For each response, the respondents explained their reasons. .In this study, there were four outcomes of interest: (a) knowledge of risk factors  of HPV infection and that this could be prevented by HPV vaccine , (Model 1); (b) positive attitude towards the safety of the HPV vaccine , (Model 2); (c) willingness to receive the HPV vaccine , (Model 3); (d) willingness, as future health care operators, to recommend the HPV vaccine , (Model 4). In all the models, the independent variables included were: gender , age , educational level of at least one parent , at least one parent is a health care operator , have heard about HPV infection during their degree program . The following variables were also included: need of additional information about HPV vaccine  in Model 1; knowledge of risk factors of HPV infection and that this could be prevented by HPV vaccine , knowledge that cervical cancer could be prevented by HPV vaccine  and knowledge that men and women should be vaccinated  in Models 2, 3 and 4; perception of risk of contracting HPV infection , perception of risk of developing diseases caused by HPV , perception of the usefulness of the HPV vaccine in protecting men and women  and positive attitude towards the safety of the HPV vaccine , in Models 3 and 4.p-value of 0.2 for entry and 0.4 for exclusion, based on the likelihood ratio test statistic. Odds ratios (ORs) and 95% confidence intervals (CIs) are presented for logistic regression models; two-sided p-values ≤ 0.05 were considered to be statistically significant. Stata statistical software, version 15  was used for the data analysis [Stepwise logistic regression analysis was performed to evaluate the associations between the independent variables and the dichotomous outcomes of interest. Variables were selected for the multivariate model using a analysis .556 nursing students returned the self-administered questionnaires, giving a response rate of 100%. Almost all the students (96%) reported that they had heard about HPV infection, 30.8% by physicians and 64.9% during their degree program, while 85.6% knew that men and women could contract HPV infection. In terms of knowledge about diseases caused by HPV infection, the values in descending order were cervical (84.7%), penile (31.1%), oropharyngeal (23.9%) and anal (19.2%) cancers, and genital warts (29.9%) .Among the respondents, 36.5% knew risk factors of HPV infection and that this could be prevented by the HPV vaccine. The results of the multivariate logistic regression model showed that those who had heard about HPV infection during their degree program  were more likely to know risk factors of HPV infection and that this could be prevented by HPV vaccine. Moreover, this knowledge was significantly lower in nursing students under 20 years of age  compared to the age group >25. More than two-third (76.8%) knew that cervical cancer could be prevented by HPV vaccine and 53.6% were aware that both men and women should be vaccinated .The mean values for the perceived personal risk of contracting HPV infection and of developing diseases caused by HPV, measured on a 10-point Likert scale, were 4.3 and 4.4, respectively. The mean value for students’ attitudes to the usefulness of the vaccination in men and women, measured on a 10-point Likert scale ranging from 1 to 10 with higher scores indicating high utility, was 6.9 for HPV vaccine for men and 8.4 for women, with 28.1% reporting a very positive views, responding 10, for vaccination in both men and women .In terms of HPV vaccine safety, 20.5% considered it very safe, with a mean total score of 7.4. The multivariate logistic regression showed that those that knew the risk factors of HPV infection and that this could be prevented by the HPV vaccine , those that have heard about HPV infection during their degree program , those that knew cervical cancer could be prevented by HPV vaccine  and those that knew that men and women should be vaccinated  were more likely to think that the HPV vaccine is very safe. Moreover, female participants  were less likely to think that HPV vaccine is very safe .Only 23.9% of respondents reported having undergone HPV vaccination. The majority of these respondents (88.7%) were females aged ≤20 years. In relation to intentions to be vaccinated against the HPV, 65.3% of nursing students responded ‘‘yes’’ on being asked about willingness to receive it. The results of the multivariate logistic analysis showed that those who were more willing to undergo future HPV vaccine were female , and those who considered HPV vaccine useful . Furthermore, students with age ≤20 years  were less likely to undergo future HPV vaccine compared to the age group >25  MoreoverAlmost all the respondents (91.7%) were willing, as future health care operators, to recommend the HPV vaccine to others. The results of multivariate logistic analysis showed that those who knew risk factors of HPV infection and that this could be prevented by HPV vaccine , those who knew that cervical cancer could be prevented by HPV vaccine  and those who heard about HPV infection during degree program  were more willing to recommend the HPV vaccine as future health care operators .In terms of the need for additional information about the HPV vaccine, 88.5% of nursing students declared a need for additional information, particularly from physicians (53.6%) and during their degree program in nursing (55.4%).To the best of our knowledge, this is the first study conducted in Italy on nursing students’ knowledge and their attitudes towards HPV infection and vaccination. This population was selected because nurses play an important role, as health care operators, in health promotion. There is a need to implement knowledge and encourage positive attitudes towards prevention during nursing degree courses. A comparison of the results of this study with those of similar studies is difficult due to the scarcity of studies with the same aims or population.In this survey, almost all the students have heard about HPV infection. The majority of the students also knew that the HPV can cause cervical cancer. The provision of information on HPV during their degree program in nursing may explain this finding. The level of student knowledge in this study was higher than that found in another study, where 89.3% of students in the health sector have heard about HPV infection . MoreoveIn addition to HPV knowledge, we evaluated nursing students’ attitudes towards the HPV vaccine. In our study, 65.3% of students were willing to receive the HPV vaccine in the future and 91.7%, as future health care operators, to recommend the HPV vaccine to others. This finding can be compared with other studies. For example, Shetty et al. reported that 65.2% of students intended to receive HPV vaccine, while a lower level was found when asked about willingness to recommend the vaccine to others (68.3%) . In contIn our sample, only 23.9% of nursing students reported having received the HPV vaccination. This finding is higher to two studies, the first conducted in India and the other conducted in Turkey, in which, respectively, nursing students who had undergone HPV vaccination were only 2.1% and 1.3% ,22.In our study, 62.9% of nursing students reported they had heard about HPV infection during degree program in nursing. Moreover, 55.4% of students stated that the degree program in nursing was one of their preferred sources of additional information about the HPV vaccine. This percentage was higher than that reported in another study, where only 42.1% of students reported that college and university were their main sources of information about HPV vaccination . MoreoveThis survey has some potential limitations. First, this was a cross-sectional study and it is difficult to determine the temporal relationship between the explanatory variables and the different outcomes of interest. Second, it is possible that the nursing students interviewed had favorable attitudes towards HPV vaccination and potentially were more likely to respond to the questionnaire. Third, this survey was based on a self-administrated questionnaire with self-reported information, thus participants could report correct behavior and not that which they deemed incorrect. Besides these limitations, the major strength of this survey was the high response rate, which means the results are representative of the population.The success of the HPV vaccination program is closely related to awareness by health care professionals of the importance of this primary prevention intervention. Therefore, there is a need for education and information programs aimed at medical schools, particularly nursing degree courses, to increase health care operators’ knowledge about HPV infection and their awareness towards HPV vaccination. Moreover, future studies should address educational programs about HPV infection in nursing students and evaluate their effectiveness.


Glass fiber reinforced polyolefin composite materials have many advantages regarding their performance and have been widely used in many fields. However, there are few reports on the simultaneously bidirectional self-enhancement of glass fiber reinforced polyethylene/polypropylene composite pipe. To self-reinforce the pipe’s circular and axial properties simultaneously, short glass fiber reinforced high-density polyethylene/polypropylene (SGF/HDPE/PP) pipes were extruded using a shearing–drawing two-dimensional compound stress field pipe-extrusion device. The effects of the rotating speed of the rotating shear sleeve on the orientation, heat behavior, microstructure, and tensile strength of the pipe were investigated in this paper. The microstructure was observed using scanning electron microscopy (SEM), and the crystal diffraction was analyzed using a polycrystalline X-ray diffractometer (WAXD), the heat behavior was measured using a differential scanning calorimeter (DSC), and the tensile strength was tested using a universal electronic tensile testing machine. The results showed that the shear induction effect induced by the shear rotating promoted the formation of the oriented structure of the crystal plate and SGFs along the circular and axial directions of the pipe simultaneously. Furthermore, it increased the crystallinity of the system, and self-improved the pipe’s circular and axial tensile strength at the same time. Glass fiber reinforced polyolefin composite materials have many advantages such as a high elastic modulus, good mechanical properties, good dimensional stability, excellent electrical performance, short molding cycle, low cost, recyclability, and so on. Therefore, the composites have a wide range of applications in aerospace, automobile and motorcycle, office furniture, building materials, chemical industry, packaging engineering, and other industries. Therefore, it has been studied by many researchers. The glass fiber/polypropylene (GF/PP) composite properties have been improved using nanoplatelets ,2. The rThe properties of glass fiber reinforced polyolefin composites are determined by the performances of glass fiber, a polymer matrix, and the interface between them. The interfacial adhesion between the fiber and resin matrix is critical to the properties of the composites to transfer stress through the interface, thus the interface shear strength determines the potential applications of whole composite materials. However, the surface of glass fiber is smooth with a low surface energy, and the wettability to resin is poor. At the same time, the glass fiber is polar, and with a few exceptions, the polymer matrix is generally non-polar, which leads to a vast polarity difference between them. The above reasons lead to the interface adhesion between the glass fiber and resin matrix not being ideal. Furthermore, it restricts the overall performance of composites. To achieve excellent total properties of composites, the adhesion and compatibility between the fiber and resin matrix are require improvement. Therefore, a lot of research has been done in this area. Zhang Daohai et al. enhanced the mechanical properties of long glass fiber reinforced polypropylene composites using grafted polypropylene with glycidyl methacrylate . The perIt was seen that these studies mainly focused on glass fiber reinforced polypropylene (GF/PP) composites by adding or subtracting or changing the composition of composites. There are few reports studied on the glass fiber reinforced polyethylene/polypropylene blends and their products. In particular, the influence of molding conditions on the structure and properties of glass fiber reinforced polyethylene/polypropylene composite pipes have rarely been reported on.θ is the circumferential stress, σα is the axial stress, t is the pipe wall thickness, D is the pipe diameter, and p is the inside pressure. In this case, the relationship between σθ and σα is given in Equation (3):However, for the thin-walled tube under hydrostatic pressure, which was investigated in this paper, its circumferential stress and axial stress were calculated by Bai et al.  as folloTherefore, for the thin-walled tube under hydrostatic pressure, its circumferential strength should be two times its axial strength to achieve the balance of pipe properties. However, many studies have shown that in the molding process, polymer macromolecules will be arranged and distributed along the flow direction of the melt to form the oriented structure along the route, thus enhancing the strength performance of the product along the path ,25,26. TWhen the melt of GF-reinforced polymer composites is induced by an applied stress, the GF and macromolecule of the polymer under the induction of the stress will be arranged and distributed along the stress direction to form an oriented structure . FurtherThe high-density polyethylene (HDPE) used in this research was type 6100 M and purchased from Beijing Yanshan Petrochemical Co., Ltd. . Its melting index was 0.42 g/10 min. The 30% short glass fiber reinforced polypropylene (SGFRPP) used in this research was granular material and purchased from Chemical Industry Zhonghao Chenguang Research Institute . The mass ratio of innovative raw materials in this study was as follows: HDPE/SGFRPP = 60/40.The pipe extrusion device was developed with an inner diameter of 30 mm and an outer diameter of 35 mm. The melt passed through the circumferential shear stress field and axial tensile stress field successively during extrusion. The rotating of the rotating shear sleeve on the mandrel generated the shear stress field on the material along the circumferential direction of the pipe, and the rotating speed could be adjusted. The reduction of the circular runner section size from the shear stress field section to the die section caused an axial drawing stress field along the axial direction on the material. When the composite melt flowed through the two stress fields, it was subjected to circumferential shear and axial drawing action successively, and then formed into the pipe through the extrusion die. The schematic diagram of the extrusion device is shown in From the feeding hopper to the die, the extrusion temperatures of the plastic extruder  successively were 100, 180, 210, 200, and 180 °C. The temperature of the shear stress field zone was 200 °C. The temperature of the extrusion die zone was 170 °C. The rotating speed of the extruder screw was 20 revolutions per minute (rpm). The rotating speed of the rotating shear sleeve varied from 0 to 25 rpm. When the rotating speed was zero, the extruded pipe was defined as the conventional pipe. When the shear rotary sleeve was rotating, the molded tube was called the reinforced pipe. When the tube was extruded away from the die, it was immediately quenched and cooled to finalize the pipe shape in room temperature water.c is the crystallinity, ΔHf is the latent heat of crystallization melting, and Thin slices of 0.3 mm thickness were cut from the core layer at the location of 1.1 mm away from the surface of the pipe. Under nitrogen protection, the second heating melting behavior was measured using a differential scanning calorimeter  at temperatures ranging from room temperature to 200 °C at a rate of 10 °C/min, and then a delay of more than 3 min at the temperature of 200 °C. The following Equation (4) was used to calculate the crystallinities of PE and PP in the pipe .(4)αc=ΔThe crystal diffraction of pipe was analyzed using a polycrystalline X-ray Diffractometer  under the conditions that the scanning speed was 0.06°/s, the voltage was 45 kV, and the pipe current was 40 mA. The 10 mm × 10 mm samples with entire wall thickness were directly cut from the pipe sample, and their axial directions were marked to distinguish between the axial and circular direction. Then, they were ground flat on both sides for testing.4, H3PO4, and H2SO4 for 24 h. Finally, the samples were cleaned successively with 30% of H2O2, deionized water, and acetone, and dried. The temperature was not more than 45 °C in the process of all operations, and the samples were sputter-coated with gold before the SEM observations.The microstructure of pipe was observed using scanning electron microscopy . The rectangular block samples of 5 mm × 10 mm were cut from the middle of the pipe wall. Then, the samples were roughly ground to flat with sandpaper along the thickness direction. After being refined and polished, the polished surface was soaked in a mixture etching solution of KMnOThe tensile strength of the pipe was tested using a universal electronic tensile testing machine . The stretching velocity during the test was a constant 100 mm/min. The specimen for the circumferential tensile strength test was a circular specimen cut from the pipe samples. Its shape and sizes are exhibited in WAXD characterization was carried out along the axial and circumferential directions of the conventional pipe and reinforced pipe with a rotating speed of 15 rpm. The results in mT) of PE and PP in the reinforced pipe were almost the same as those of the conventional one, as indicated by the results of mT in T) of PE and PP in the reinforced pipe were nearly the same as those of the conventional one too, indicating that their crystal plate thickness uniformity and crystallization rate were virtually the same as each other. However, as shown in c) in the reinforced pipe increased from 54.91% in the conventional tube to 57.68%, a proportional increase of 5.04%. The αc of PP increased from 6.07% to 8.09%, a proportional increase of 33.28%. The results indicate that the rotation of the rotating shear sleeve formed an effective shearing-induced crystallization effect, which accelerated the formation of molecular crystallization of the SGF/HDPE/PP system and improved the crystallization effect of PP especially. The reason for the increases is believed to be that the rotation of the rotating shear sleeve induced the SGF/HDPE/PP system molecules to form a more orderly arrangement structure, especially along the circumferential direction of the pipe. This ordered structure promoted the crystallization of the system molecules. Then, the improvement of crystallinity was helpful to self-improve the mechanical properties of the tube.The DSC analysis test of the conventional pipe and reinforced pipe with a rotating speed of 15 rpm was carried out, and the results are shown in The SGFs and crystal chips in the pipe were observed using SEM. The results can be seen in To investigate the tensile strength of the conventional and reinforced pipe, the axial and circumferential tensile strength tests were carried out. As seen in In this study, SGF/HDPE/PP composite pipes were extruded through a shearing–drawing two-dimensional compound stress field pipe-extrusion device, with the aim to self-improve the circular and axial properties of the tube at the same time. The change of the structure and performance of the pipe after the shear rotary sleeve was stationary and rotated was studied comparatively. The results show that the circumferential and axial strength of the tube could be self-enhanced synchronously via the rotation of the rotating shear sleeve, and in particular, the effect of the circumferential strength self-reinforcement was clear. The axial tensile strength increased from 49.68 MPa for the conventional pipe up to 50.56 MPa for the most robust reinforced tube, a proportional increase of 1.77%. The circumferential tensile strength increased from 18.9 MPa for the traditional pipe to 26 MPa for the most robust reinforced one, a proportional increase of 37.57%. The SEM results confirmed that the crystal and SGF in the reinforced tube had been oriented along the circumferential and axial direction simultaneously. The results of WAXD demonstrated that the orientation degree of the reinforced tube was higher than that of the conventional one, and it had a better orientation effect along the circumferential direction than that along the axial route in the reinforced tube. The results from the DSC analysis showed that the crystallinity of the reinforced pipe was improved and the crystal grain was well refined. As a result, the crystallinity of PE increased from 54.91% in the conventional tube to 57.68% in the reinforced one, a proportional increase of 5.04%. The crystallinity of PP rose from 6.07% in the traditional pipe to 8.09% in the reinforced one, a proportional increase of 33.28%. In this way, the properties of the circumferential and axial strength of the SGF/HDPE/PP composite pipe were self-improved concurrently, and it fully meets the functional requirements for the use of the thin-walled tube under hydrostatic pressure.


The “national meeting effect” refers to worse patient outcomes when medical professionals attend academic meetings and hospitals have reduced staffing. The aim of this study was to examine differences in outcomes of patients with out-of-hospital cardiac arrest (OHCA) admitted during, before, and after meeting days according to meeting location and considering regional variation of outcomes, which has not been investigated in previous studies. Using data from a nationwide, prospective, population-based, observational study in Japan, we analyzed adult OHCA patients who underwent resuscitation attempts between 2011 and 2015. Favorable one-month neurological outcomes were compared among patients admitted during the relevant annual meeting dates of three national scientific societies, those admitted on identical days the week before, and those one week after the meeting dates. We developed a multivariate logistic regression model after adjusting for confounding factors, including meeting location and regional variation (better vs. worse outcome areas), using the “during meeting days” group as the reference. A total of 40,849 patients were included in the study, with 14,490, 13,518, and 12,841 patients hospitalized during, before, and after meeting days, respectively. The rates of favorable neurological outcomes during, before, and after meeting days was 1.7, 1.6, and 1.8%, respectively. After adjusting for covariates, favorable neurological outcomes did not differ among the three groups (adjusted OR (95% CI) of the before and after meeting dates groups was 1.03 (0.83–1.28) and 1.01 (0.81–1.26), respectively. The “national meeting effect” did not exist in OHCA patients in Japan, even after comparing data during, before, and after meeting dates and considering meeting location and regional variation. Out-of-hospital cardiac arrest (OHCA) is a significant public health problem worldwide . In JapaAdequate medical staffing and resource allocation is important to ensure that high-quality care is provided to patients. Off-hours presentation has been associated with worse outcomes among patients with OHCA, acute myocardial infarction (AMI), and those hospitalized in the intensive care unit ,7,8,9. IOne of the limitations of these studies was that the control group was defined as patients admitted with OHCA during the same calendar days in the weeks before and after the meetings ,11,12. FThis study was conducted using the All-Japan Utstein Registry of the Fire and Disaster Management Agency (FDMA), consisting of nationwide population-based data on OHCA patients compiled in accordance with Utstein-style data collection , the det2 area [In 2015, Japan had a population of approximately 127 million people in a 378,000 km2 area . Details2 area . General2 area .EMS personnel at the scene contact an appropriate hospital nearby according to local protocols to request admission of the OHCA patient based on their condition. Receiving hospitals provide resuscitation and emergency care after hospital arrival and post-arrest care, including percutaneous coronary intervention and therapeutic hypothermia according to the attending physician in charge and local practices.Based on the Utstein-style template , the folWe identified annual meeting dates from 2011 to 2015 of three national academic organizations—the Japanese Association for Acute Medicine (JAAM), the Japanese Circulation Society (JCS), and the Japanese Society of Intensive Care Medicine (JSICM)—because medical staff members of these organizations were considered to play a critical role in caring for cardiac arrest patients admitted to hospitals. Each meeting was held for three consecutive days, usually every March, October, and February, respectively; however, the 2011 JCS meeting was an exception, as it was held in August for two consecutive days because the Great East Japan Earthquake had occurred that year. We defined the “during meeting dates” group as patients admitted after suffering from OHCA during the dates of these academic meetings. Meanwhile, the patients admitted with OHCA during the identical weekdays in the weeks before and after the meetings were defined as the “before meeting dates” and “after meeting dates” groups, respectively ,10. For To study differences in outcomes by meeting location, we divided the cohort by whether the meeting had been held in the Tokyo metropolitan area or other places. Of the 15 national congress meetings held over the five-year period, eight meetings were held in the Tokyo metropolitan area . In addition, the cohort was divided into better or worse outcome areas by median one-month survival with favorable neurological outcomes after OHCA, which was 1.9%, during the period from 2011 to 2015, as there was regional variation in favorable outcomes in patients with OHCA across prefectures in Japan .Our primary outcome measure was favorable neurological outcome one month after cardiac arrest, which was defined as CPC scale scores of 1 or 2 . The secp-values. To compare the primary and secondary outcomes among the three groups, we applied a multivariate logistic regression model defining the during-meeting-dates group as the reference group. We obtained adjusted odds ratios (ORs) and their 95% confidence intervals (CIs) after adjusting the following covariables: Age ; gender; type of bystander witness ; type of bystander-initiated CPR ; etiology of cardiac arrest (cardiac origin or noncardiac origin); initial documented rhythm ; public-access AED use; prehospital intravenous fluid; prehospital administration of epinephrine; prehospital advanced airway management; time interval from call to hospital arrival (in one-minute increments); regional variation (better vs. worse outcome areas); and national academic meeting location (Tokyo metropolitan area or others) [p-value of <0.05 was regarded as statistically significant. All analyses were performed with IBM SPSS Statistics 25 .Data are presented as numbers (percentages) for categorical variables and median (interquartile range) for continuous variables. The chi-square test was used for binary variables, and the Kruskal–Wallis test was used for continuous and categorical variables to calculate  others) ,16. A suDuring the study period, 629,471 OHCA patients were registered. Of those, we assessed 554,126 adult patients for whom resuscitation was attempted for eligibility. We excluded 513,277 patients for not being admitted on eligible days, receiving only CPR rescue breathing, unknown information on bystander CPR, or initial documented rhythm, and occurring on 8 or 9 March 2013, which were both before the JCS meeting dates and after the JSICM meeting dates. As a result, we included 40,849 subjects in our analyses, with 14,490 patients in the during-meeting-dates group, 13,518 patients in the before-meeting-dates group, and 12,841 patients in the after-meeting-dates group . Basic cFor primary outcome components, we found no differences in one-month favorable neurological outcomes among patients admitted during, before, and after meeting dates . We founA subgroup analysis, stratifying patients by better or worse outcome areas and dividing the meeting location into the Tokyo metropolitan area and others, respectively, is shown in When looking at alternative definitions of the before- and after-meeting-dates groups, no differences were observed among the three groups regarding favorable neurological outcomes . SimilarIn this nationwide database study, we investigated the “national meeting effect” in patients with OHCA, comparing data among three groups of patients treated during, before, and after national academic meeting dates, considering regional variation of outcomes and meeting locations. No significant differences in favorable neurological outcomes were observed among the three groups.Previously, Kitamura et al. reported no differences in adult patients’ post-OHCA outcomes between meeting and nonmeeting dates during the period from 2005 to 2012 in Japan . AnotherOne of the differences between these studies is selection of the control group, which we divided into the before-meeting-dates group and the after-meeting-dates group to investigate the possible positive impact of a national academic meeting on patient outcomes rather than investigating the hypothesis of worse outcomes during the meeting dates. In addition, we examined the “national meeting effect” using a different study period from the previous study and accounted for regional variation of outcomes and meeting places, which might affect the number and composition of physicians who remain to treat patients or who were on call. Contrary to our hypothesis, no significant differences were observed among the three groups.Generally, annual academic meetings are considered to positively affect patient outcomes by enhancing knowledge of medical staff and performance and promoting research networking and development of guidelines . On the Several important limitations in this study should be acknowledged. First, a weak point of this study was the lack of data on in-hospital treatment, including whether extracorporeal CPR, percutaneous coronary intervention, and therapeutic hypothermia management were performed, which are relevant clinical factors that could affect patient outcomes ,26,27. SWe found no differences in favorable neurological outcomes among OHCA patients admitted before, during, and after relevant national academic meeting dates, even after considering regional variation of outcomes across Japan and meeting locations. Meeting attendance is important for medical professionals to network and share new knowledge, and for hospitals to strive to deliver equitable, high-quality care during meeting dates.


Purpose: The purpose of this study was to examine knowledge, attitudes, barriers, and facilitators for human papillomavirus (HPV) vaccination among Latina mothers of HPV vaccine-eligible children in low-income urban areas, as well as useful strategies to improve HPV vaccination.Methods: The study included 132 Latina mothers of HPV vaccine-eligible children, interviewed in 14 focus groups. Using semi-structured discussions, mothers were asked about their knowledge about HPV infection and vaccine, views toward HPV vaccination, barriers for HPV vaccine initiation as well as completion, and opinions on strategies to improve HPV vaccination.Results: Only 55% of mothers reported having ever heard of the HPV vaccine, 27% of mothers indicated initiating the HPV vaccine, and 14% indicated completing the multi-dose series. Mothers generally lacked knowledge about HPV infection and vaccination, with varying degrees by Latino descent. Health care provider (HCP) recommendation was the strongest barrier/facilitator for HPV vaccination. Useful strategies to improve HPV vaccine initiation and completion that the mothers suggested included strong recommendation from HCPs and addressing side effects and safety concerns. Other useful strategies included community and school-based approaches and the use of text messaging and smartphone technology to educate mothers and send vaccine reminders.Conclusion: The findings provide insight for the development of interventions targeting low-income Latina mothers and the need to improve HCP communication on HPV vaccination. Aragones et al.30 found low levels of knowledge around HPV infection and vaccination and lack of provider recommendation as the main barrier to vaccination. Similarly, Albright et al.31 reported that the most commonly reported barrier among Spanish-speaking parents is when providers do not encourage the initiation of the HPV vaccine or do not explain the necessity of completing the series. These studies, however, describe the knowledge and attitudes of Latina mothers as one single group without investigating potential difference across different descent groups.Only a few studies have recently used qualitative methodology to explore knowledge and attitudes of Latina mothers around HPV vaccination.(1)Assess knowledge, attitudes, and acceptability for HPV vaccination for girls and boys.(2)Identify barriers and facilitators for HPV vaccination initiation and completion identified by the mothers.(3)Examine cultural and other factors that are useful for the development of targeted interventions to promote HPV vaccination among this population.In conclusion, although a few studies have examined knowledge and attitudes toward HPV vaccination among Latina mothers, literature is still lacking in providing an in-depth investigation of the barriers and facilitators, beyond standard survey measures, for both HPV vaccine initiation and completion as well as for both female and male adolescents. Also, very little is known about the differences in knowledge and attitudes among Latina mothers of different descents. Lastly, studies have not investigated mothers' perceptions of useful strategies to improve HPV vaccine uptake among the Latino adolescent population in low-income areas. Therefore, the purpose of this study is to examine knowledge and attitudes toward HPV vaccination among Latina mothers of South American and Caribbean descent in low-income urban areas of the Eastern United States. The study objectives are to:32 Latinos made up 58% of the population in the five zip code areas targeted in this study .This is a qualitative study examining knowledge and attitudes toward HPV vaccination among Latina mothers. The study was approved by Rutgers Institutional Review Board. Study recruitment and data collection occurred in January–December 2015. Participants were recruited from a multi-site community health center and a clinic of an urban community hospital in the Newark/Elizabeth area in New Jersey, through direct invitation, advertisement posters, and word of mouth. To be eligible for the study, participants had to be older than 18 years, self-identify as Latina, and have at least one child eligible for the HPV vaccine . According the 2010 US census data,Fourteen focus groups of Latina mothers were conducted at the recruitment sites with 8–12 participants each, for a total of 132 women. The final sample size was based on achieving data saturation. Twelve of the focus groups were conducted in Spanish and two focus groups were conducted in English, based on the participant's individual choice. Each focus group took 1–2 hours and was audio-taped. Two Spanish-speaking facilitators, who were also fluent in English, conducted the focus groups. The facilitators received training on active interviewing, facilitating discussions, engaging participants, and research ethics. The principal investigator was present during all of the focus groups as an observer and to provide any needed support for the facilitators.33 as well as on other studies on HPV vaccination.34–36 Participants received light snacks and refreshments and a $20 gift card to a local store as an incentive. Because the focus group discussions revealed considerable lack of knowledge regarding HPV infection and vaccination, the focus group facilitators led a brief educational session at the end of the focus group to correct misconceptions and answer any questions. Written information materials about HPV infection and vaccination were also distributed to participants in Spanish and English.The focus group questions, presented in 37 Data from Before the start of the focus group, participants were asked to complete a form providing their demographic information and indicating whether they had ever heard of the HPV vaccine, whether their children had received the HPV vaccine, and whether their children had completed the three-dose series of the HPV vaccine. This study was conducted before the dosing schedule for HPV vaccination was changed in 2016.38 A grounded theory approach was used for coding the data, identifying emergent themes, comparing for similarities and differences, and developing conceptual descriptions of themes.39 Transcripts and meeting notes were reviewed multiple times to identify common concepts and ideas, and consequently derive study themes along with verbatim phrases. Using the process of open coding, significant statements and concepts were identified and grouped together to form themes. A coding scheme was used to identify similarities in responses, conduct group comparisons, and provide quotes supporting the identified concepts and themes. Lastly, the data analysis compared differences and similarities in knowledge and perceptions separately for South and Central American (SCA) mothers and for Caribbean Latina (CL) mothers. Compared with CL mothers , SCA mothers are more likely to be recent immigrants and uninsured, and to be less familiar with the health care system and vaccination guidelines. Therefore, the data analysis identified themes for the entire sample, as well as themes that are different for CL mothers versus SCA mothers. The focus group discussions were transcribed and translated to English, with embedded links to the original transcripts in Spanish, to capture the essence and meaning of the data. Data analysis consisted of thematic content and standard focus group analysis techniques.A total of 132 Latina mothers participated in 14 focus groups—9 groups of SCA mothers (58.3%) and 5 groups of CL mothers (41.7%). The participants' countries of birth included Columbia, Cuba, the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Peru, Uruguay, the United States–Puerto Rico, and Venezuela. See The mothers in the study lacked knowledge about HPV infection, symptoms, and methods of transmission. Most of the women who indicated they had heard of the infection did not know what the acronym stood for, the mode of transmission, and ways in which to prevent it. Only a few mothers were aware of the consequences of the HPV infection, mainly related to cervical cancer. There was also some confusion between HPV and HIV. However, there were varying degrees of knowledge across Latina subgroups. For example, CL mothers appeared more knowledgeable about HPV infection than SCA mothers.But I believe that we are all born with the human papilloma and some develop it and others do not.–SCA motherWhen you have the infection sometimes it is present (obvious) and sometimes it is not present… I mean is that true? My friend said something like this but I'm not sure. I don't even know what symptoms. And when there are no symptoms, how do you know if you have it? I don't know exactly.–SCA motherI know that the contact of this HPV disease is not only by body to body but also by injecting a person that is infected and then vaccinating another person, also they can be infected.–SCA motherThere's different types of HPV… So your body, depending on the type, can fight that virus. For some women. But, if your body doesn't fight it, that's when it can cause cervical cancer.–CL motherIn addition, there was great uncertainty among the mothers in the study related to their knowledge about the HPV infection. Some of the women were unsure of who would be at risk for the infection whereas others were unsure about the transmission. When asked whether the HPV infection affected women, men, or both genders, half of the mothers thought it only affected women whereas half thought it affected both genders.I thought older women got it, some say that only recently in children and that I didn't know, only knew, thought that only women. I also heard that it was the man, that transmitted it to the woman, and that it was in the women that developed but I didn't think that it was the young, but the adults.–SCA motherIt's not only contacted by sexual intercourse there's a lot of other ways that you can contract it. Umm, I not really sure about that [what some of those ways are]… I don't really remember.–CL motherMothers in the study lacked knowledge of how HPV is transmitted. Even though several women were aware that the infection is transmitted sexually, some were misinformed about transmission. Some mothers thought the HPV infection is transmitted by causal contact/touching, through childbirth, exchanging underwear, receiving a blood transfusion, sharing needles, and through use of public facilities. Further, SCA mothers were less knowledgeable and had more misinformation about the HPV infection.[Transmitted] By contact, with another person, that is the person that has it infects the other.–SCA mother[Transmitted] by means of the hands.–SCA motherAnother way of transmitting that disease is by means of the mothers themselves, when they do not take preventive measures in time; they do not take care of themselves. Because of that, then obviously the children are born with the infection. I had a case of a grandchild. My, my daughter-in-law did not get treated in time and when the birth came and the little one was born with that physical problem. And then soon after, ah each one is in treatment.–SCA motherIt [HPV infection] is transmitted by needles.–SCA motherIt can be contracted by exchanging panties [several women agreed]. They also say there that the virus comes and if another person uses it they can catch the virus.–SCA motherI knew that by a blood transfusion.–SCA motherThe bacteria can transmitted in public places such as swimming pools where we all go and get wet in the summer.–CL motherWhen asked to describe the consequences of the HPV infection, mothers who knew about the HPV infection also knew that HPV causes cancer. Although the cancer most often cited was cervical cancer, a few mothers mentioned that HPV leads to oropharyngeal cancer. Further, CL mothers appeared more knowledgeable about the consequences of the HPV infection.If it's not detected in time, it can cause cervical cancer, it can cause oral cancer…There's different strands of HPV. So your body, depending on the strand, can fight that virus…But, if you don't, if your body doesn't fight it, that's when it can cause cervical cancer.–CL motherI believe Michael Douglas, who has cancer of the throat by the same papilloma virus.–SCA mother [a few other women agreed]In addition to correctly identifying that HPV could cause both cervical and oropharyngeal cancers, there were many mothers who believed that uterine and ovarian cancers were caused by the HPV infection as well. Further, a few mothers noted that HPV could also cause genital and oral warts.It shows up like some sort of sores, in the genitals of the person and that she needs to apply some medication for them to disappear, but that is to say, the virus is always there and they can come back at any time.–SCA motherIt's now you hear it more. You hear it on TV, you hear commercials, you know it's more out there now.–SCA mother). A few women said they knew others who were infected with HPV, which prompted them to seek out more information, either by speaking with their child's doctor or by looking it up on the internet.Although most mothers had not heard of the HPV infection, those who had said that they learned about it through their child's health care provider (HCP). In addition to receiving knowledge about the HPV infection from their child's HCP, some women stated that they had heard about the infection in the media, specifically on the internet or on TV commercials  had been vaccinated against HPV. Only 55% of the mothers indicated that they had ever heard of the HPV vaccine, 27% indicated that their adolescent child(ren) had received at least one dose of the HPV vaccine, and 14% indicated that their child(ren) completed the HPV vaccine three-dose series. Results of the bivariate analysis are illustrated in It is against the papilloma virus. And it is a virus that has been detected recently, that produces cancer, said an SCA mother. Although some mothers said that they had heard about the vaccine from the internet or television commercials, most mothers who knew of the vaccine heard about it from their child's HCP. Still others said that they first heard about the HPV vaccine from their peers and/or family members. One of the CL mothers explained:The first time I heard about this vaccine was from an aunt in Texas when my cousin was 12 or 13 and she was commenting that she was taking my cousin to the clinic to get her the papilloma injections because our family has a history of cancer, and it is after that that I started to inquire about the vaccine. In the end I found out that she had given it to her but I didn't pay too much attention because my son was too young then. It wasn't until my son reached 12 years old that the pediatrician examined him and said he needed it. So at the beginning, I heard it from my aunt.In the focus groups, most mothers stated that they had heard of the HPV vaccine and knew that its purpose was to prevent HPV infection and cancer. I believe that many of the diseases from viruses, and of those things that happen to young people is due to a lack of information. And the prevention that they get they do not get it from school, and lamentably, this supposedly developed country, it is a power, but in the Latin American countries, the information is available in the schools and colleges. But here I haven't seen anything. My children are already grown but I have 3 grandchildren and I take care of them and the girl is 10 and has not received any information about that. I think that it is here in this country that the information is lacking, in our country they inform us from foot to head, they are informing us all the time, it is this country which doesn't inform about anything.Some mothers expressed concern that the schools had not informed them of the HPV vaccine and its importance. They explained that although school nurses provide health information to parents about various health topics and particularly vaccinations, they have not had interactions with school nurses in which the HPV vaccine and its importance was mentioned or discussed. One of the SCA mothers explained:Mothers were asked about the HPV vaccination guidelines regarding age, gender, number of doses, and durations between doses. Although some mothers knew that the vaccine should start around age eleven, most thought the vaccine was only supposed to be administered to girls. Only a few mothers knew that the vaccine had three doses and none of the mothers knew the timeframe within which all three doses of the vaccine should be administered.What age? I think I heard it is at nine.–CL motherChildren should be vaccine from nine years on up.–CL motherI thought that it was up to 22 years old or 24 that they could receive it because my daughter is 21 or 22 and, I have not gotten it for her thinking that that was the limit, it is news to me that it is up to 26.–SCA motherHmm, boys or girls? I think only the girls should get the vaccine.–SCA motherI think it is three vaccines, every two or three months. The doctor picked the dates for us. I'm not sure exactly the time between the shots.–SCA motherQuarterly? I think it's less than 6 months, I mean my daughters got it closer than that. I don't remember. I think maybe every 3.–CL motherThe majority of mothers indicated that their child's physician is the main source of information about vaccines, including the HPV vaccine. A few mothers said that they learned about the HPV vaccine from posters and brochures they saw at doctors' offices or health centers. Several mothers indicated that they learned about the HPV vaccine from TV commercials. The majority of mothers indicated that they did not see HPV vaccine advertisements in Spanish magazines.The doctor told us about this vaccine. She told us it was important before they became sexually active, that it helped to prevent infection. I get most of my information about vaccines from the doctor.–SCA motherI would talk directly with my daughter's doctor, not to a friend or someone else. I only trust what the doctor says… I would make this decision talking to the doctor.–SCA motherWell I heard this in the school. They formed a group in the school for mothers with a doctor when my son was in the sixth or seventh grade. It was for mothers.–SCA mothersI heard about it on TV. It was an advertisement on one of the channels in Spanish.–CL motherI have heard about it on the TV commercials, and from mothers of some of my daughter's classmates.–CL motherBecause that is only a protection, that doesn't mean, doesn't mean that you are giving them an open door to go do it.I feel more secure with my daughter, it is not that I tell her the idea that some people are talking about, and that she should go and have sexual relations. This is to prevent something in 5–10 years from now when my daughter gets married and she has to be cautious that her husband, whoever he may be, is not going to transmit this infection to her. At least she will be protected, and maybe after ten years I will tell her because right now she has no idea what this vaccine is for because I just told her that it was to prevent infections like the vaccine for the measles or the flu. I cannot tell her: my daughter it is for you to go and have sex! I say that it is ignorance on the part of those who tell me that I am encouraging her.Overall, all of the mothers were receptive and believed that the vaccine would be beneficial and should be given to adolescents. Most mothers thought that the vaccine should be given to both males and females. Some of the mothers believed that the vaccine should be given around the time of puberty. Specifically, in the case of females, mothers agreed that adolescent girls should receive the HPV vaccine as soon as they began to menstruate. All mothers agreed that giving the adolescents the vaccine was not giving them permission to have sexual intercourse. Two SCA mothers explained:But from what I am hearing I suppose that the parents have to be intelligent and intuitive and they should give it to them before the children start to have sexual relations. The kids in this country start having sex early and it should be given in early adolescence… I think pre-teens. Like twelve. You know what? I'm, I'm going to say either earlier, ‘cause I came home one day and I found… a used condom in my garbage. [My son said] mom it's mine. And it was devastating, devastating to me. Because he was twelve years old.In fact, some of the mothers expressed that because children were having sex at a younger age, they needed all available protection. They felt that the HPV vaccine would be necessary to protect kids in case they become sexually active without their parents' knowledge. One of the CL mothers explained:I say from fourteen on is all right. Another SCA mothers stated, I would say the girls after puberty, after they become young misses .Mothers were asked about other sources of influence on their decision to vaccinate their children, such as religion, friends, and the media. Most mothers indicated that religion usually does not influence their decision whether to vaccinate their child. However, they did state that friends who have had negative experiences with the HPV vaccine would have some influence over their decision. An SCA mother explained:Lack of information was cited as the most common barrier to HPV vaccination. Most mothers indicated that although they were aware of the HPV vaccine, they needed more information, specifically information in their native language, before vaccinating their children. This also included concern about potential adverse and vaccine safety, mainly due to lack of information on these concerns.I believe that many of the diseases from viruses, and of those things that happen to young people is due to a lack of information. And the prevention that they get they do not get it from school, and lamentably, this supposedly developed country, it is a power, but in the Latin American countries, the information is available in the schools and colleges. But here I haven't seen anything. My children are already grown but I have 3 grandchildren and I take care of them and the girl is 10 and has not received any information about that. I think that it is here in this country that the information is lacking, in our country thy inform us about from foot to head, they are informing us all the time, it is this country which doesn't inform about anything.–SCA motherI got it one time only as I was telling my friend, my son fainted and had a little reaction to the vaccine, he fainted, he got some type of attack and I did not go back for the other two doses that followed. That is why am concerned to learn what is going on, what's happening?–SCA motherThe doctor told me to give her the vaccine, I asked my husband and he said get it and the moment that she got it she fainted…When the nurse got scared she called the doctor, they awaked her but before she came to she had some kind of attacks and she woke up crying, with a panic and I felt responsible that she could have gotten something more severe.–SCA motherMothers indicated that another major barrier for HPV vaccination was lack of HCP recommendation. They explained that in most cases their children's HCPs either did not mention the HPV vaccine or presented it as an optional vaccine, providing very little information. A few mothers stated that their children's HCP had negative views about the HPV vaccine, which deterred them from considering the vaccine for their children.The pediatrician said that if I didn't want it, I didn't have to get it. But since the pediatrician has been with us since my children were born. [I asked] What do you recommend? I asked because he speaks Spanish and then he says no.–SCA motherIn addition to identifying barriers to HPV vaccination, mothers were asked about facilitators for HPV vaccination. Most mothers identified HCP recommendation as the strongest facilitator. They explained that the opinion of HCPs and the way they present the HPV vaccine creates great bearing on their decision-making process.I ask the doctor. If he tells me that she needs it and tells me all the reasons why and I ask him all the questions I can think of and I see that it is for her own good, then I say go ahead and give it to her. I like to know what I am exposing my daughter to, and once I know it is to protect her from something then I tell him that I agree and to give it to her.–CL motherThis is to prevent something in 5–10 years from now, when my daughter gets married and she has to be cautious that her husband, whoever he may be, is not going to transmit this infection to her. At least she will be protected, and maybe after ten years, I will tell her because right now she has no idea what this vaccine is for because I just told her that it was to prevent infections like the vaccine for the measles or the flu.–SCA motherAnother facilitator for HPV vaccination was mothers' desire to protect their children from the HPV infection and HPV-related cancers. Most mothers expressed their desire to take on any action to protect their children's health and well-being in the short- and long-term future. One of the SCA mothers explained:The mothers in the study were asked what they thought would be effective methods to improve HPV vaccination among Latino adolescent children. Most mothers indicated that HCP recommendation for the vaccine was the key factor in their decision-making process and would consequently be the most influential way to improve HPV vaccination. To that end, the mothers deemed it necessary for HCPs to provide information about the vaccine and address parental concerns about potential side effects. They also wanted to hear that HCPs recommend and support HPV vaccination. In addition, several mothers thought that HCP recommendation could be supplemented with print materials about the vaccine, such as booklets and brochures.I wouldn't know what Human Papilloma is. What is it? That should be included [in talking to the doctor]. What it is and what are the, the risks and you know, Jennifer [pseudonym for another participant] saying that there's so many strains of it. What are the strains? What can these strains cause in your body, like, we all know maybe it causes cervical cancer but what else? If there's so many strains it's not just cervical cancer. And, and going through the whole routine thing… Me personally, I like to be informed when I go to something, not just, this is what you got to do.–CL motherIf I have to do this, why do I have to do it? What are the benefits, what are the risks? Like, definitely doing some kind of brochure that shows like, everything, and going through it with the community when you educate.–CL motherSeveral mothers indicated that community outreach activities would be helpful in improving HPV vaccination, such as talking to mothers and distributing brochures about the HPV vaccine at community centers or health fairs. Several women also suggested that a school-based approach to educating mothers about the vaccine would be widely effective in increasing HPV vaccine knowledge and awareness among a large number of parents and adolescents. This could be done in collaboration with school nurses or parent–teacher associations or groups.I think this should be included in the sex-education. They talk about when your menstrual comes, and other things, you know. They should start talking about this vaccine too.–CL motherThe [school] nurses should do that but in the school that my son was at, the nurses only spoke English… The nurses in the school are the ones in charge and they should also be giving out information.–SCA motherI think that it is the responsibility of the school to notify the parents that their children are approaching the age where they need to get this vaccine. They should have a program to teach the parents to be involved in the lives of their children. In this case, to inquire of the parents if they know about this vaccine, and if they don't, they should invite them to a meeting. The parent who considers himself responsible for his children will attend that meeting to learn what this is all about.–SCA motherBecause smart phones were widely used among mothers in the study, most mothers expressed interest in using mobile technology, such as apps and text messaging, to learn about HPV vaccination. In addition to using mobile technology to raise awareness about HPV vaccination, most mothers thought it would be beneficial to have mobile technology set reminders for follow-up appointments to improve completion of the multi-dose series of the vaccine. Lastly, several women suggested that would be helpful to set up follow-up visits  immediately after receiving the first dose to improve HPV vaccine completion.It would be helpful to have a text message come, if you have a smart phone with like a link where you can open and read about the vaccine.–SCA motherThere are times with the messages on cell phones when they send you a reminder. There is a way that you press that same message and it gives you the information about the vaccine right there and then.–SCA motherThe way I completed all three doses of the vaccine was because I was called from the hospital as a reminder to come back and complete the vaccine.–CL mother40 This was also evident in other qualitative research that reported low levels of knowledge around HPV infection and vaccination.30 In addition to lack of knowledge, the findings indicate various misinformation about the transmission of HPV infection, such as through childbirth and the use of public facilities. Moreover, this study provides important new information about variations in HPV vaccination knowledge across Latina subgroups. In particular, SCA mothers were less knowledgeable about the HPV infection and its consequences as well as the HPV vaccine, and had more misinformation about the HPV infection and vaccination, compared with CL mothers. Further, similar to the findings of other studies,40 we observed high HPV vaccine acceptability among low-income, Latina mothers. Nevertheless, several mothers in our study expressed the need for more information, such as potential side effects and vaccine safety.This study provides rich qualitative findings on HPV vaccination knowledge and attitudes from low-income Latina mothers from varying Latin American/Caribbean regions. Results show that overall knowledge about HPV infection and vaccination was low among Latina mothers. This is consistent with prior studies suggesting low levels of knowledge about HPV vaccination among Latino parents42 in that HCP's recommendation is the key determining factor in the mother's decision to vaccinate her children. This is also consistent with the findings of other qualitative research, in which Latina mothers reported lack of provider recommendation as the main barrier to HPV vaccination.30 Further, other qualitative research has shown that the most commonly reported barrier among Spanish-speaking parents is when providers do not encourage the initiation of the HPV vaccine or do not explain the necessity of completing the series.31 In addition, the mothers in our study identified their desire to protect their children, which ties to the perceived severity of HPV, as a facilitator to HPV vaccination, which is consistent with other studies.43More importantly, Latina mothers in our study indicated that HCP recommendation is an important factor to getting the HPV vaccine for their children. These findings demonstrate the prominent role that HCPs play is affecting HPV vaccination, through which HCP recommendation is considered the main facilitator; and the lack of HCP recommendation is considered the main barrier for HPV vaccination. This is consistent with other studies18 and 8% have completed the three-dose series.19 Further, our study findings indicate that subgroup variation in knowledge and attitudes within the Latino population may lead to heterogeneous vaccine uptake. To improve vaccine initiation rates among low-income Latina children, culturally appropriate intervention strategies should focus not only on educating all Latinas from varying regions but also on improving provider communication with mothers about HPV infection and vaccination. Our discussions with Latina mothers about acceptable strategies for improving uptake also provide actionable information for increasing uptake in this community. The use of smartphone technology, such as mobile apps and text messaging to educate mothers and send vaccination reminders, is welcomed by the Latina mothers in this study. Several studies44–46 have implemented and evaluated text message and reminder systems and have found them to be an effective way to improve HPV vaccination coverage. However, such interventions may be costly and may require higher levels of literacy, particularly among populations with lower education levels and more recent immigration to the United States. Alternatively, community and school-based outreach strategies may be more beneficial, cost-effective, and easily achievable. Lastly, as is evident from the results of this study, providers play a crucial role in the vaccination decision-making process. Therefore, interventions targeting HCPs on HPV vaccination47–49 present a critical approach to combat disparities in HPV, thereby decreasing the prevalence of HPV-related cancers in the Latina population.Although national data suggest that Latino populations have higher rates of initiation, research in the Greater Newark area revealed that only 21% of Latino adolescents (10–20 years old) have initiated the HPV vaccine,Our study is one of the few that has focused on understanding HPV vaccination knowledge and attitudes among low-income Latina mothers from varying Latin American/Caribbean regions. However, some limitations of the study should be noted. First, we did not collect data on HPV vaccine uptake; therefore, it is unclear whether mothers' reported barriers and facilitators to vaccination matched their actual past and/or future HPV vaccination behaviors for their children. Second, the CDC guidelines were updated from a three-dose to a two-dose completion regimen between the initiation of this study and the completion of data analysis. There is a possibility that this change may affect parental attitudes toward the vaccine. However, knowledge about HPV infection and attitudes toward strategies to reduce barriers to vaccination are less likely to be impacted by the guideline changes. Finally, our study focused on South/Central American and CL mothers recruited from a large community health clinic and an urban, hospital-based clinic. This population may not be generalizable to Latina mothers of different descents and/or in other settings. Despite these limitations, few studies to date have focused on the heterogeneity of Latin American subgroups and the potential variation that may exist in HPV vaccination knowledge and attitudes across subgroups. Our large low-income sample of diverse Latina mothers provides valuable insight to the need for additional research on the heterogeneous Latino population and HPV vaccine uptake.51 However, more research is needed to evaluate whether these strategies can be adapted to effectively improve HPV knowledge and vaccination among Latina mothers of different descents in low-income, urban areas of the Eastern United States. Additional efforts are needed to adapt and accelerate the implementation of evidence-based HPV vaccine promotion strategies in varying settings and for vulnerable subgroups, including diverse Latina mothers in community health settings that serve low-income populations in urban areas.In conclusion, the findings of our study support the need for multicomponent interventions to address low HPV vaccination in all populations, but particularly for low-income, racial/ethnic minority subgroups with compounding social and demographic barriers to health information and HPV vaccination. Our findings suggest that improved provider communication with Latina mothers about HPV infection and HPV vaccination combined with strategies to motivate and remind Latina mothers to vaccinate their children are not only needed but also suggested directly by mothers from these communities. Multi-dimensional HPV vaccine interventions to date have primarily focused on increasing mothers' knowledge about the HPV vaccine, assistance with navigating the health care system to access the HPV vaccine , educating providers about the HPV vaccine and HPV/cervical cancer epidemiology, and using quality improvement techniques to improve provider–parent communication.


Garcinia mangostana L. (Guttifereae), α- and γ-mangostins are known to be major constituents exhibiting diverse biological activities. However, the effects of γ-mangostin on oxidative neurotoxicity and impaired memory are yet to be elucidated. In the present study, the protective effect of γ-mangostin on oxidative stress-induced neuronal cell death and its underlying action mechanism(s) were investigated and compared to that of α-mangostin using primary cultured rat cortical cells. In addition, the effect of orally administered γ-mangostin on scopolamine-induced memory impairment was evaluated in mice. We found that γ-mangostin exhibited prominent protection against H2O2- or xanthine/xanthine oxidase-induced oxidative neuronal death and inhibited reactive oxygen species (ROS) generation triggered by these oxidative insults. In contrast, α-mangostin had no effects on the oxidative neuronal damage or associated ROS production. We also found that γ-mangostin, not α-mangostin, significantly inhibited H2O2-induced DNA fragmentation and activation of caspases 3 and 9, demonstrating its antiapoptotic action. In addition, only γ-mangostin was found to effectively inhibit lipid peroxidation and DPPH radical formation, while both mangostins inhibited β-secretase activity. Furthermore, we observed that the oral administration of γ-mangostin at dosages of 10 and 30 mg/kg markedly improved scopolamine-induced memory impairment in mice. Collectively, these results provide both in vitro and in vivo evidences for the neuroprotective and memory enhancing effects of γ-mangostin. Multiple mechanisms underlying this neuroprotective action were suggested in this study. Based on our findings, γ-mangostin could serve as a potentially preferable candidate over α-mangostin in combatting oxidative stress-associated neurodegenerative diseases including Alzheimer's disease.Among a series of xanthones identified from mangosteen, the fruit of  These beneficial pharmacological profiles of γ-mangostin strongly suggest its therapeutic potential for AD and other neurodegenerative diseases associated with oxidative stress.Even though both mangostins exhibited similar inhibition against γ-mangostin in vivo. It has been previously revealed that memory deficit induced by scopolamine, a nonselective muscarinic receptor antagonist, is associated with oxidative stress [γ-mangostin at dosages of 10 and 30 mg/kg. The memory-improving effects of γ-mangostin at these dosages were quite comparable to that of donepezil, a reference drug. Our results are in alignment with those of a previous report, demonstrating the protective effect of the mangosteen extract on scopolamine-induced amnesia [γ-mangostin to penetrate the blood-brain barrier and reach CNS targets was predicted in vitro using a parallel artificial membrane penetration assay [γ-mangostin could be a promising candidate for therapeutic interventions of AD. To the best of our knowledge, our present study is the first report revealing the neuroprotective effect of γ-mangostin against oxidative neurotoxicity, as well as its memory-enhancing effect in mice.In order to test this possibility, we next conducted a passive avoidance test using a scopolamine-induced amnesia model in mice to investigate the memory-improving effect of e stress , an evene stress , 5. As s amnesia . In addion assay . Taken tγ-mangostin, a xanthone derivative isolated from the fruit hull of mangosteen, exhibited a potent neuroprotective effect against H2O2- or X/XO-induced oxidative neuronal damage. The underlying mechanisms for this neuroprotective action may involve the inhibition of ROS generation triggered by these oxidative insults, antioxidant activities as evident by inhibition of DPPH radical formation and LPO, and its antiapoptotic properties as demonstrated by the inhibition of H2O2-induced DNA fragmentation and activation of caspases. Unlike γ-mangostin, however, α-mangostin neither exhibited neuroprotective activity nor demonstrated antioxidant properties in our study. Moreover, γ-mangostin was shown to exhibit a potent inhibitory effect on β-secretase activity and strongly improved scopolamine-induced memory deficits in mice. Based on our study providing in vitro and in vivo evidences, γ-mangostin may be considered to be a promising candidate in the prevention and treatment of various neurodegenerative diseases including AD.The present study demonstrated that


Those with ≥1 dose  were more knowledgeable about HPV (p = .01). High knowledge scores were recorded for 30% of respondents and were strongly associated with HPV vaccine initiation among both men and women (p < .001) and perceived knowledge among women only (p < .001). Negative attitudes toward HPV vaccine acceptance were associated with low knowledge scores (p = .01) and undervaccination (p < .001). Vaccinated women (n = 95) were over seven times more likely than were unvaccinated women (n = 115) to report positive vaccine attitudes (relative risk = 7.1). HPV vaccination status was not associated with vaccine attitudes among men. HPV knowledge and vaccine uptake remain problematic among college students, and deficits in both are associated with negative HPV vaccine attitudes. Although the knowledge gap is narrowing, HPV vaccination efforts should target young men, as HPV-related cancer morbidity continues to rise in men.The aim of this cross-sectional survey was to assess awareness, knowledge, and attitudes in regard to human papillomavirus (HPV) and vaccination against HPV among college students. From 2015 to 2017, 386 diverse undergraduates were recruited from a south Florida university. A survey, part of which was researcher developed, of HPV awareness, knowledge, and attitudes was conducted. The majority (84%) of participants had heard of HPV, and 70% had favorable attitudes toward vaccination. Only 28% of men and 55% of women had received ≥1 dose vaccine ( Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) in the world , and theHPV is the cause of over 90% of genital warts in men, who experience a longer duration of this outcome and incur more treatment costs than women do. HPV also is responsible for the majority of male anal, oropharyngeal, and penile cancers, creating substantial health and economic burden beyond that of cervical cancer . The dirThe Advisory Committee on Immunization Practices (ACIP) has recommended safe and effective HPV vaccination for girls and women aged 9 to 26 years since 2006 . SubstanHPV vaccine acceptability among men is highly correlated with health-care provider recommendations, although providers more consistently recommend the vaccine for females than for males . Low awaFor college students, given this population’s increased sexual activity and sexual risk-taking, as compared to other age groups, HPV infection constitutes a substantial threat . CollegeThe very-slow-growing HPV vaccination rates leave a large population of college-aged young adults unprotected, despite eligibility to receive catch-up doses up to age 26 years . VaccineA cross-sectional study of university students that focused on students’ HPV-related awareness and knowledge, as well as attitudes and uptake of HPV vaccination, was conducted from March 2015 to February 2017. The university’s institutional review board granted exempt approval status prior to study implementation.The male and female students recruited for this study were from one of the largest institutions of higher learning in the United States. Participating students were enrolled in four sections (semesters) of an undergraduate gender studies course taught by the same instructor from March 2015 to February 2017. This course fulfilled a graduation requirement and was typically populated by students from diverse studies. Students enrolled in undergraduate public health and dietetics courses in January and February 2017 also were recruited. Students aged 18 years or older who were present on the day of data collection were invited to participate by completing a questionnaire. Participants were read a brief statement regarding voluntary participation and consent. Students were not required to answer every item or return the questionnaire to the study team. Students were included in the current study if they were (a) 18 years or older at the time of data collection, (b) registered for the college course in which data collection took place, and (c) present in class at the commencement of data collection.At the time of data collection, the research team explained the purpose of their visit to the class and presented a statement of informed consent. Participants under the age of 18 years were identified and excluded from participation but were welcome to remain in the classroom. Written, self-administered questionnaires were then distributed to eligible participants. The survey took approximately 5 to 10 min to complete. Upon completion, surveys were deposited by each student into a large envelope or box carried by circulating research team members. Participants received tokens of appreciation for their time, such as promotional pens, pencils, lip balm, and condoms.The questionnaire consisted of 34 items. Nine were sociodemographic or descriptive items and 18 items were adapted from the 100-item 2009 University of North Carolina Men’s Health Survey . The remSociodemographic and baseline data  were self-reported. Awareness of HPV was assessed with a single question: “Have you heard of HPV or human papillomavirus before today?” . Participants then indicated how many doses of HPV vaccine they had received as of that day , and, subsequently, if they were not already fully vaccinated, whether they were willing to take the HPV vaccine . Participants also responded to the statement “Before today, I have never thought of getting the HPV vaccine for myself” .strongly agree to strongly disagree with an additional don’t know option. An ad hoc scale, consisting of the five Likert items that specifically addressed vaccination, was developed. This scale was used to gauge participants’ attitudes toward the HPV vaccine, whom they saw as appropriate recipients, and vaccines in general . Items were coded such that strongly agree or agree corresponded to a positive attitude toward that topic. Reliability assessment of the vaccine attitudes scale was conducted with Cronbach’s alpha, with acceptable reliability .Eleven questions concerned beliefs about various HPV-related statements, answered on a 5-point Likert scale that ranged from n/N) when the analyses contain missing data.Participants were then asked to describe their perceived level of knowledge of HPV and the vaccine in answering two separate questions with “Nothing at all,” “a little,” “a moderate amount,” or “quite a lot.” In addition to respondents’ reported self-perceived knowledge related to HPV, knowledge was measured with seven true/false items. A composite knowledge score was created by summing the number of correct responses . When differences were negligible, data were pooled.Categories for items regarding awareness of HPV and number of doses were collapsed into dichotomous outcomes. Likert questions were collapsed into “strongly agree/agree,” “disagree/strongly disagree,” and “neutral/don’t know.” Likert items were reverse scored, if necessary, to allow results to be analyzed together.Correlates of five HPV-related outcomes were explored: awareness, self-perceived knowledge, measured knowledge, willingness to vaccinate, and vaccine beliefs. Sociodemographic characteristics, such as age, sex, race, ethnicity, health insurance status, HPV awareness, and HPV vaccine uptake, were among potential correlates.Differences between men and women in binomial outcome variables were determined using Pearson’s chi-square or Fisher’s exact tests. General linear modeling was utilized to assess sex and age differences in participants’ mean knowledge score and the associations between perceived knowledge and knowledge score. Tukey’s post hoc test identified where significant differences occurred in age differences in the knowledge score. Mantel–Haenszel tests were conducted to determine sex differences in vaccine attitudes among vaccinated versus unvaccinated participants, and risk estimates to indicate the strength of the association were determined.w = 0.5 for tests of independence. Statistical significance was set at p < .05. All analyses were performed using SPSS 20.0  and were predominantly female (70%). Approximately two thirds were Hispanic (66%) and single/unmarried (66%) and over half identified their race as White (59%). Men were more likely to report greater than 10 lifetime sexual partners than women were  completed the survey and were included in the analysis. Three participants were under the age of 18 years and were excluded. Participants had a mean age of 22.3 years (p = .07). The number of lifetime sex partners was not associated with HPV awareness; however, participants who reported being single (46.2%) were less likely to be aware of HPV than those in a relationship were . No significant differences were identified by race , insurance status, or age.Overall, the majority (84%) of participants had heard of HPV; more women were aware of the virus than men were , although this difference was not significant  either had not received any HPV vaccine doses or did not know their vaccination status at the time of the survey. Participants who had received any doses of HPV vaccine were more likely to report having heard of HPV (p = .005). Further, 72% of men had received no or an unknown number of doses of HPV vaccine compared to 55% of women (p = .01). Only 4% of men had all three doses as compared to 26% of women (p < .001). Finally, 45% of men and 27% of women said that they had never thought about getting the HPV vaccine for themselves .Significant vaccination differences between men and women were evident. As shown in SD = 2.1) and women earned an average of 2.5 (SD = 1.9). Further, men (38%) were more likely than women were (24%) to score 0 points (p = .005). Only seven participants (1.8%) answered all seven questions correctly.In response to the question “How much would you say you know about HPV?” (perceived knowledge), 69% of men and 62% of women perceived that they knew nothing or little and even more reported knowing nothing or little about the HPV vaccine (72% men and 67% women). Seventy percent of participants scored low (≤3 correct out of 7) on the true/false knowledge section. There were no significant differences between men and women in overall mean knowledge score; men earned an average score of 2.1 out of 7 . A simple main-effects analysis showed that being in this age group did not have a statistically significant influence on men’s knowledge scores  = 0.13, p = .72). Age was, however, a significant factor in women’s HPV knowledge score  = 11.3, p < .001). Age was further analyzed in women by pairwise comparisons, using Tukey’s post hoc test, which showed that women in the age group of 18- to 20-year-olds (n = 99) had a significantly lower mean knowledge score than the other three age groups did (n = 166), and knowledge progressively increased with age (p <.001).Age was significantly associated with knowledge score; the odds of older students receiving a high score was 10% higher than that of younger students .At least half of the respondents incorrectly identified herpes or AIDS as diseases caused by HPV , with no significant differences by sex. Participants who received any doses of HPV vaccine (47%) or had >10 lifetime sexual partners (46%) were significantly more likely to score high on the knowledge items than others were (p < .001). Only 51% of those with a high score perceived themselves to be knowledgeable. Similar to knowledge score and age, there was a significant difference between men and women. A simple main-effects analysis showed that men’s perceived knowledge was not independently associated with men’s knowledge scores  = 2.6, p = .11). Among women, however, perceived knowledge was significantly associated with HPV knowledge score  = 12.7, p < .001), with women who perceived themselves as knowing moderately/a lot about HPV performing better in knowledge score  than those who perceived themselves to have no/little HPV knowledge did .There was a strong relationship between perceived and actual HPV-related knowledge. Respondents who characterized their HPV-related knowledge as low (77%) earned low knowledge scores (χ2MH(1) = 30.9, p < .001). Vaccinated women were over seven times more likely than unvaccinated women were to report positive vaccine attitudes . This stands in contrast to men, whose vaccination status was not significantly associated with vaccine attitudes .In response to the five-item vaccine attitudes scale, 70% of participants reported positive attitudes toward HPV vaccination, with men and women responding similarly. The number of doses of HPV vaccine received was significantly associated with vaccine attitudes, an association that differed between men and women . Eighty percent of participants with negative HPV vaccine attitudes scored low (<3/7) on the measured knowledge portion of the questionnaire . Of those not vaccinated or undervaccinated (vaccine series initiated but incomplete), 58% were willing to receive the HPV vaccine and 27% did not know whether they wanted to be vaccinated. Participants who had heard of HPV before the day of the survey were more willing to be vaccinated than those who had not heard of the virus previously were .Of the participants who reported negative attitudes toward vaccines, 85% had received either no or an unknown number of HPV vaccinations  compared to those in a 1999 study at a Florida university in which the students were largely oblivious to HPV; only 37% had ever heard of the virus . The disDespite high levels of HPV awareness among undergraduate students in South Florida, both men and women reported disconcertingly low levels of perceived and measured knowledge on the topic. Poor knowledge scores, especially among the youngest participants, who would have the most to benefit from vaccination, confirmed their self-perceptions. Of the men in this study, 38% answered no questions correctly on HPV knowledge. These results are consistent with previous studies that indicated that despite being acutely aware of HPV and HPV vaccination, significant knowledge deficits persist regarding how HPV is transmitted, what diseases result from HPV infection, and how to prevent infection effectively . Of variThe youngest women received significantly lower scores than women in older age groups, similar to findings in previous research on age differences . HPV knoAfter the quadrivalent vaccine was introduced and approved for girls and women in 2006, there was intense marketing from the pharmaceutical manufacturers and health agencies . The manThis study explored attitudes toward HPV vaccination and how those attitudes may be associated with vaccination intentions and behaviors. In this study, over 70% of men had not been vaccinated and only 26% of women and 4% of men had received all three doses of HPV vaccine, despite men reporting similar awareness and knowledge as women. Participants reported favorable vaccine attitudes (70%), yet vaccinated women were seven times more likely to have positive views of vaccination than unvaccinated women were, a distinction not observed in young men. Taken together with the finding that most men had never thought about getting the vaccine for themselves, this suggests that men in this study who did initiate the HPV vaccine may not have received information about HPV or the HPV vaccine at the time of vaccination.The first vaccines approved in 2006 were initially promoted for girls, creating earlier mindfulness of HPV and prevention among them. Previous studies with young men have reported that acceptability of the HPV vaccine has varied from modest (33%–48%) to high 78%; . While vThose with negative attitudes toward HPV vaccination were overwhelmingly uninformed about HPV and were likely to be unvaccinated. This finding parallels recent research that describes HPV knowledge as a predictor of attitudes toward vaccination . The posThe limitations of this study include its cross-sectional nature, which precludes the ability to infer causation or to establish a temporal connection in variables of interest, such as HPV knowledge and vaccine uptake. Self-reported data were collected from the participants, which may subject our results to social desirability and recall biases. The possible effects of social desirability bias, which may decrease the validity of the reported information, are estimated to be minimal in this study. The survey was an anonymous, self-administered questionnaire, which is likely to reduce the respondents’ desire to present themselves in a favorable manner .Self-reported data also can be compromised by the respondents’ memory of events or experiences of interest. Recall bias often can decrease the reliability of information collected . ExistinThese results should be interpreted within the context of the timing of data collection for this survey. The average age of men in this study was 22.6 years. Young men attending college from 2015 to 2017, when this survey was conducted, were most likely already in their mid- to late teens when the ACIP recommendation for males was issued in 2011. Opportunities to receive catch-up vaccination against HPV until age 21 years (or until age 26 for men considered high risk) may have been few for male respondents of this survey. Additional changes to the recommended adult immunization schedule have recently occurred to reflect the Food and Drug Administration’s recent approval of the HPV vaccine for adults up to age 45 years . The ACIThis study used a nonprobability sample. Recruitment was conducted in an urban area of south Florida, a state among those with the highest percentages of Hispanic and foreign-born residents . FloridaDespite these limitations, these results provide evidence that a significant number of young adults in the United States lack accurate knowledge about HPV, the HPV vaccine, and the importance of preventing HPV infection.The results of this analysis suggest that educational interventions should be delivered to increase knowledge and change attitudes toward HPV and HPV vaccination among college students, especially men and freshman women. The college setting provides an optimal environment for education about the virus and uptake of the vaccine. Further, student health centers can assist in removing structural barriers that prevent vaccination among those who are knowledgeable .Future research can integrate these findings to support research aimed at improving knowledge and attitudes regarding HPV among men. Qualitative research can be conducted with at-risk groups, such as men, to inform the design and development of tailored interventions. This would be useful in determining what messages are suitable for this population as well as who provides messages, where messages are delivered, and which approaches should be utilized .To expedite the achievement of state and national vaccination goals, several actions can be pursued at the state level. Florida and other states can review options for the implementation and evaluation of comprehensive sexual education for elementary, middle, and high school students. Many studies have reported support for such programs from both teachers and parents . BecauseIn 2012, Senate Bill 146, which proposed that parents and caregivers of students who are entering sixth grade be given information about HPV, related diseases, and the availability of vaccines to prevent transmission, was introduced in the Florida Senate . UnfortuIf HPV vaccination also were required for college matriculation, dramatic reductions in HPV-related outcomes might be seen. Increased gender-inclusive, targeted information for college students in college clinical settings would reinforce health promotion messages. To remove barriers such as cost and access, college health centers and clinics could determine mechanisms to offer HPV vaccination to students free of charge. The vast majority of the students in this study had health insurance coverage, which includes HPV vaccination, at the time of data collection. The institution at which this study was carried out houses a full-service health center that offers HPV vaccination and also participates in programs designed to reduce monetary costs. Pharmaceutical companies often offer vouchers to institutions such as qualified colleges and universities to, in most cases, completely subsidize such costs, which could cover the costs for uninsured students. Since college health services may be limited in ways they can support undervaccinated students, building capacity for college health centers to expand primary care services and integrate with state immunization registries should be prioritized .At doctor visits off campus, providers could conduct a vaccine eligibility assessment, regardless of sex, at each visit and during general non-STI visits. National vaccine registries and reporting systems should be integrated and intuitive for clinicians, which would help to strengthen vaccine reporting and support vaccine recommendation equality.HPV and HPV vaccine as hot-button terms, participants in this study demonstrated a lack of detailed knowledge about HPV, which, in turn, is associated with negative vaccine attitudes and uptake. Knowledge among young men seems to be slowly improving, yet continued vaccination deficits place an unreasonable burden on women to protect against a virus that increasingly affects men. Improvements in young adults’ awareness, knowledge, and attitudes toward HPV and HPV vaccination are imperative to reach the goal of 80% HPV vaccination coverage to reduce the burden of HPV-related disease in the United States.The majority of the HPV burden is carried among 18- to 26-year-olds across the United States and there is a distinct opportunity for preventive measures to be improved among this group. The findings of this study indicate the need for aggressive targeting of young adults for educational and behavioral interventions, with particular attention to increasing knowledge among both men and women. Despite general awareness of