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Al-leimon A, Al-leimon O, Abdulhaq B, Al-salieby F, Jaber AR, Saadeh M, Jaber AR, Aziziye O, Dardas LA. From awareness to action: Unveiling knowledge, attitudes and testing strategies to enhance human papillomavirus vaccination uptake in Jordan. J Virus Erad 2024; 10:100380. [PMID: 39040683 PMCID: PMC11261058 DOI: 10.1016/j.jve.2024.100380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 06/11/2024] [Indexed: 07/24/2024] Open
Abstract
Purpose Vaccination against HPV plays a crucial role in preventing cervical cancer and related health issues. This study aimed to (1) assess knowledge, awareness, intentions, and attitudes regarding HPV and vaccination among Jordanian parents, and (2) evaluate the efficacy of two intervention strategies in promoting knowledge, awareness, and attitudes towards HPV vaccinations. Methods In study one, a web-based survey was used to collect data from Jordanian parents. In study two, participants were allocated into three groups: video-based intervention, lecture-based intervention, and a control group. Pre-post tests were conducted to evaluate the efficacy of the intervention strategies in promoting knowledge, awareness, and attitudes toward HPV vaccination among Jordanian parents. Results A total of 572 participants took part in the survey. Knowledge levels about HPV and its vaccine were generally low. Intentions regarding HPV vaccination were uncertain for the majority of participants, with 92 % reported as not receiving any guidance from medical professionals about administering the HPV vaccine to themselves or their children. Only 22 % agreed that their children might get infected with HPV at any time in their lives. The pilot randomized clinical trial revealed an improvement in knowledge, awareness, and attitudes towards HPV vaccination in both intervention groups compared to the control group with large effect sizes (eta squared between 0.29 and 0.68). Conclusions Findings highlight the need for increased knowledge and awareness regarding HPV and vaccination. It also supported the potential effectiveness of basic educational efforts in significantly improving knowledge, awareness, and attitudes towards the HPV vaccine.
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Affiliation(s)
- Ahmad Al-leimon
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Obada Al-leimon
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Bayan Abdulhaq
- School for International Training, Brattleboro, VT, 05302, USA
| | - Fadi Al-salieby
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | | | - Mohammed Saadeh
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
| | | | - Omer Aziziye
- School of Medicine, The University of Jordan, Amman, 11942, Jordan
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Luo Y, Liu T, Yang X, Lu M, Kou Z, Xu X. Human papillomavirus vaccination and contributing factors of vaccination intention among adolescents and young adults in China from a socio-ecological perspective: A cross-sectional study. Public Health Nurs 2024; 41:602-616. [PMID: 38554075 DOI: 10.1111/phn.13315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 03/06/2024] [Accepted: 03/20/2024] [Indexed: 04/01/2024]
Abstract
OBJECTIVES Adolescents and young adults are the main target population for human papillomavirus (HPV). The study aimed to investigate school students' HPV vaccination intentions and explore the contributing factors from a socio-ecological perspective. DESIGN A questionnaire survey was conducted in three secondary schools and three colleges in China. SAMPLE A total of 1756 students aged 14-22 years participated in this study. Among the 1756 participants, 182 students have received the HPV vaccine. For the remaining 1574 students, we analyzed their HPV vaccination intentions and the influencing factors. MEASUREMENTS Survey items for sociodemographics, knowledge and awareness of HPV, sexual intercourse and sexual knowledge, subjective socioeconomic status, self-efficacy, eHealth literacy, perceived social support from family, and the availability of HPV vaccine information were measured. RESULTS Only 182 (10.4%) had received the HPV vaccine among the 1756 participants. Among the remaining 1574 students, the majority of the students (1403, 89.1%) were willing to receive the HPV vaccine. Binary logistic regression analysis showed that students who were female, had lower self-efficacy, scored higher on sexual knowledge, believed vaccination preventing related diseases, worried about side effects after vaccination, thought oneself at risk of contracting HPV, had higher family support, knew the availability of the HPV vaccine in Mainland China from healthcare institutions, and with family residence in rural areas were more willing to receive the HPV vaccine. CONCLUSIONS Students had high HPV vaccination intentions while had low vaccination rate. Intrapersonal, interpersonal and institutional or community factors predicted HPV vaccination intention. Public health nurses in communities and schools could target the modifiable factors to promote students' HPV vaccine uptake.
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Affiliation(s)
- Ying Luo
- Qingdao University, School of Nursing, Qingdao, Shandong, China
| | - Ting Liu
- Qingdao University, School of Nursing, Qingdao, Shandong, China
| | - Xiuling Yang
- Qingdao University, School of Nursing, Qingdao, Shandong, China
| | - Mingqin Lu
- Qingdao University, School of Nursing, Qingdao, Shandong, China
| | - Zhiru Kou
- Qingdao University, School of Nursing, Qingdao, Shandong, China
| | - Xiaohan Xu
- Qingdao University, School of Nursing, Qingdao, Shandong, China
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Mendez AJ, Somera L, Badowski G, Mummert A, Castro LJ, Antolin A, Dulana LJ, Sablan D. Knowledge, Attitudes, Beliefs, Practices Regarding Human Papillomavirus (HPV), and Barriers to Vaccination Against HPV Infection: A Cross-Sectional Survey of Guam Residents. HAWAI'I JOURNAL OF HEALTH & SOCIAL WELFARE 2024; 83:54-60. [PMID: 38344697 PMCID: PMC10850866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is linked to several cancers. In Guam, the HPV vaccination rate falls short of the National Healthy People 2030 goal. Only half of eligible Guam teens have received the HPV vaccination series. Additionally, research on Guam HPV vaccination is limited. A cross-sectional survey was conducted, and a representative sample of Guam residents (n=775) was surveyed to examine their knowledge, attitudes, beliefs, practices regarding HPV, and barriers to HPV vaccination. Aggregated scores were calculated for these scale items: attitude, knowledge, subjective norms, and perceived behavioral control regarding HPV. One-way Analysis of Variance (ANOVA) was used to compare the means of the scores and check for significant differences. Binary logistic regression helped to identify significant predictors of HPV vaccination among respondents with children. Significant differences were found for sex, education, income, and ethnicity. Women and those with higher education and income demonstrated higher positive attitudes and knowledge about HPV vaccination. Also, those with health insurance and those who were advised by their physician were more likely to get their children vaccinated. These results will guide the implementation of effective strategies for developing targeted behavioral and other appropriate interventions to increase HPV vaccination in Guam.
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Affiliation(s)
- Ana Joy Mendez
- University of Guam Cancer Research Center, Mangilao, Guam
| | | | | | | | | | | | | | - Dwight Sablan
- University of Guam Cancer Research Center, Mangilao, Guam
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Choi J, Cuccaro P, Markham C, Kim S, Tamí-Maury I. Human papillomavirus (HPV) vaccination in males: Associations of HPV-related knowledge and perceptions with HPV vaccination intention among Korean mothers of boys. Prev Med Rep 2024; 37:102566. [PMID: 38205168 PMCID: PMC10776780 DOI: 10.1016/j.pmedr.2023.102566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Objectives Human papillomavirus (HPV) vaccination rates among males are suboptimal worldwide. In South Korea, little is known about parents' intention to vaccinate boys against HPV. Therefore, we examined the associations of HPV-related knowledge and perceptions with vaccination intention among Korean mothers of boys. Methods From August to December 2021, eligible mothers were surveyed about HPV-related knowledge, perceptions, and intention to vaccinate their sons against HPV. Mothers were categorized into no intention, contemplating, and intention to vaccinate groups. Using analysis of variance, we compared the groups' scores on the scales measuring HPV-related knowledge, attitudes, and beliefs. We conducted a multinomial logistic regression analysis to assess the associations between the variables and vaccination intention. Results Among 361 mothers, 43.9 % had no intention, 60.7 % were contemplating, and 4.4 % intended to vaccinate their sons. The mean percentage of correct answers on the HPV and vaccine knowledge scales were 52.5 % and 62.3 %, respectively. The mean scores on the HPV attitudes and beliefs subscales were significantly different. Higher scores on benefits (OR = 3.04, 95 % CI 1.96 - 4.70; OR = 3.94, 95 % CI 1.54 - 10.70) and influence (OR = 1.48, 95 % CI 1.03 - 2.13; OR = 2.97, 95 % CI 1.44 - 6.14) were associated with contemplating the vaccine and intending to vaccinate sons. Knowledge was not associated with mothers' vaccination intention. Conclusions Public health authorities and healthcare providers in Korea can use the results of this study to implement effective interventions that emphasize the importance of male HPV vaccination and encourage parent-son communication about the vaccine.
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Affiliation(s)
- Jihye Choi
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Paula Cuccaro
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Christine Markham
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sooyoun Kim
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
| | - Irene Tamí-Maury
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston, Houston, TX, United States
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Vu M, Berg CJ, Pham NHT, Tiro JA, Escoffery C, Spring B, Bednarczyk RA, Ta D, Kandula NR. U.S. Vietnamese parents' trusted sources of information and preferences for intervention messaging about HPV vaccination: A mixed methods study. PEC INNOVATION 2023; 3:100189. [PMID: 37521956 PMCID: PMC10371838 DOI: 10.1016/j.pecinn.2023.100189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 08/01/2023]
Abstract
Objective Assess trusted sources of information, perceived message effectiveness, and preferred dissemination strategies regarding adolescent HPV vaccination among U.S. Vietnamese parents. Methods Data came from an observational, explanatory sequential mixed-methods study with U.S. Vietnamese parents of adolescents (408 survey participants; 32 interview participants). Surveys and interviews were conducted in both Vietnamese and English. Mixed-methods data were integrated and analyzed for confirmation, expansion, or discordance. Results Both quantitative and qualitative findings confirm high trust in HPV vaccination information from providers, government agencies, and cancer organizations. Messages perceived as effective emphasize vaccine safety, experts' endorsement, importance of vaccination prior to HPV exposure, and preventable cancers. Qualitative findings expanded quantitative results, demonstrating a desire for evidence-based information in the Vietnamese language and addressing cultural concerns (e.g., effectiveness or potential side effects specific to Vietnamese adolescents, whether parents should delay HPV vaccination for Vietnamese adolescents). Quantitative and qualitative findings were incongruent about whether parents would trust information about HPV vaccination that is disseminated via social media. Conclusion We identified credible messengers, feasible strategies, and elements of impactful messages for interventions to increase adolescent HPV vaccination for U.S. Vietnamese. Innovation We focus on a high-risk, underserved population and integrate mixed-methods design and analysis.
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Affiliation(s)
- Milkie Vu
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, United States of America
| | - Carla J. Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, United States of America
- George Washington Cancer Center, George Washington University, United States of America
| | - Nhat-Ha T. Pham
- College of Arts and Sciences, University of Pennsylvania, United States of America
| | - Jasmin A. Tiro
- Department of Public Health Sciences, University of Chicago, United States of America
- Cancer Prevention and Population Science Program, Comprehensive Cancer Center, University of Chicago, United States of America
| | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, United States of America
- Emory Prevention Research Center, Emory University, United States of America
- Cancer Prevention and Control Program, Winship Cancer Institute, Emory University, United States of America
| | - Bonnie Spring
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, United States of America
| | - Robert A. Bednarczyk
- Cancer Prevention and Control Program, Winship Cancer Institute, Emory University, United States of America
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, United States of America
- Department of Epidemiology, Rollins School of Public Health, Emory University, United States of America
- Emory Vaccine Center, Emory University, United States of America
| | - Danny Ta
- Nell Hodgson Woodruff School of Nursing, Rollins School of Public Health, Emory University, United States of America
| | - Namratha R. Kandula
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, United States of America
- Department of Medicine, Feinberg School of Medicine, Northwestern University, United States of America
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Chen ACC, Kim SW, Ou L, Todd M, Larkey L. Digital Storytelling Intervention to Promote Human Papillomavirus Vaccination Among At-Risk Asian Immigrant Populations: Pilot Intervention Study. JMIR Form Res 2023; 7:e46951. [PMID: 36877658 PMCID: PMC10585432 DOI: 10.2196/46951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 08/15/2023] [Accepted: 08/30/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND The high morbidity, mortality, and economic burden attributed to cancer-causing human papillomavirus (HPV) calls for researchers to address this public health concern through HPV vaccination. Despite disparities in HPV-associated cancers in Korean Americans and Vietnamese Americans, their vaccination rates remain low. Evidence points to the importance of developing culturally and linguistically congruent interventions to improve HPV vaccination rates. Digital storytelling (a specific form of cultural narrative) shows promise as an effective culture-centric health promotion strategy. OBJECTIVE The aim of this quasi-experimental single-group study was to assess the feasibility, acceptability, and preliminary effects of a culturally and linguistically congruent digital storytelling intervention on Korean American and Vietnamese American mothers' attitudes and intention in vaccinating their children against HPV. We also examined if the association between attitudes and intention differed by their child's sex (boy vs girl) and by ethnicity (Korean American vs Vietnamese American). METHODS Participants were recruited via multiple avenues (eg, ethnic minority community organizations, social media, and flyers posted in local Asian supermarkets and nail salons). Web-based, valid, and reliable measures were administered to collect data preintervention and postintervention. Descriptive statistics, paired and independent sample t tests, the chi-square test, and the McNemar test were used to describe the distributions of variables and to examine the differences between subgroups and changes in key variables over time. Logistic regression models were used to examine associations of mothers' HPV- and vaccine-related attitudes with vaccination intention and to explore if the association between attitudes and vaccination intention differed by the target children's sex or ethnicity. RESULTS In our sample of 50 Korean American mothers (mean age 42.8, SD 4.8 years) and 114 Vietnamese American mothers (mean age 41.5, SD 5.4 years), 36% (18/50) of Korean American and 51% (58/114) of Vietnamese American mothers reported that their children received free or reduced-price lunches at school. After the intervention, mothers' attitudes toward HPV and the vaccine (t163=2.49, P=.01) and intention to vaccinate their children improved significantly (X21=18.38, P<.001). The measure of mothers' negative attitudes toward HPV and the vaccine was significantly associated with higher vaccination intention (odds ratio 0.27, 95% CI 0.14-0.51; P<.001), adjusting for background variables (sociodemographic characteristics) and other HPV-related variables (family cancer history, prior HPV education, and HPV communication with health care providers). Findings did not suggest that a child's sex or ethnicity moderated the association between attitudes and vaccination intention. CONCLUSIONS This remotely delivered intervention using digital stories was feasible and acceptable, and showed preliminary effects on promoting Korean American and Vietnamese American mothers' intention to vaccinate their children against HPV. Future research that uses a randomized controlled trial design with a larger and more diverse sample and includes children's vaccination status will help understand the effect of the intervention.
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Affiliation(s)
| | - Sunny Wonsun Kim
- Edson College of Nursing & Health Innovation, Arizona State University, Phoenix, AZ, United States
| | - Lihong Ou
- Edson College of Nursing & Health Innovation, Arizona State University, Phoenix, AZ, United States
| | - Michael Todd
- Edson College of Nursing & Health Innovation, Arizona State University, Phoenix, AZ, United States
| | - Linda Larkey
- Edson College of Nursing & Health Innovation, Arizona State University, Phoenix, AZ, United States
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Wang H, Jiang Y, Wang Q, Lai Y, Holloway A. The status and challenges of HPV vaccine programme in China: an exploration of the related policy obstacles. BMJ Glob Health 2023; 8:e012554. [PMID: 37586782 PMCID: PMC10432676 DOI: 10.1136/bmjgh-2023-012554] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Affiliation(s)
- Huizi Wang
- Department of Nursing, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, Shandong, China
- School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Yujin Jiang
- Operating Room, Shandong Province Maternal and Child Health Care Hospital, Jinan, Shandong, China
| | - Qing Wang
- Department of Outpatient, Shandong Cancer Hospital and Institute Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - YuetMan Lai
- School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Aisha Holloway
- School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
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Lee HY, Xiong S, Sur A, Khang T, Vue B, Culhane-Pera KA, Pergament S, Torres MB, Koopmeiners JS, Desai J. Evaluating Human Papillomavirus eHealth in Hmong Adolescents to Promote Vaccinations: Pilot Feasibility Study. JMIR Form Res 2023; 7:e38388. [PMID: 37338961 PMCID: PMC10337404 DOI: 10.2196/38388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Human papillomavirus (HPV) is a common sexually transmitted infection, causing multiple cancers, including cervical, penile, and anal. Infection and subsequent health risks caused by HPV can be diminished by HPV vaccination. Unfortunately, vaccination rates among Hmong Americans are substantially lower than those among other racial and ethnic groups, despite having higher cervical cancer rates than non-Hispanic White women. Such disparities and sparse literature highlight the need for innovative and culturally appropriate educational interventions to improve HPV vaccine rates in Hmong Americans. OBJECTIVE We aimed to develop and evaluate the effectiveness and usability of an innovative web-based eHealth educational website, the Hmong Promoting Vaccines website (HmongHPV website), for Hmong-American parents and adolescents to improve their knowledge, self-efficacy, and decision-making capacities to obtain HPV vaccinations. METHODS Through social cognitive theory and community-based participatory action research process, we created a theory-driven and culturally and linguistically appropriate website for Hmong parents and adolescents. We conducted a pre-post intervention pilot study to assess the website's effectiveness and usability. Overall, 30 Hmong-American parent and adolescent dyads responded to questions about HPV and HPV vaccine knowledge, self-efficacy, and decision-making at preintervention, 1 week after intervention, and at the 5-week follow-up. Participants responded to survey questions about website content and processes at 1 and 5 weeks, and a subset of 20 dyad participants participated in telephone interviews 6 weeks later. We used paired t tests (2-tailed) to measure the change in knowledge, self-efficacy, and decision-making processes, and used template analysis to identify a priori themes for website usability. RESULTS Participants' HPV and HPV vaccine knowledge improved significantly from pre- to postintervention stage and follow-up. Knowledge scores increased from preintervention to 1 week after intervention for both parents (HPV knowledge, P=.01; vaccine knowledge, P=.01) and children (HPV knowledge, P=.01; vaccine knowledge, P<.001), which were sustained at the 5-week follow-up. Parents' average self-efficacy score increased from 21.6 at baseline to 23.9 (P=.007) at post intervention and 23.5 (P=.054) at follow-up. Similar improvements were observed in the teenagers' self-efficacy scores (from 30.3 at baseline to 35.6, P=.009, at post intervention and 35.9, P=.006, at follow-up). Collaborative decision-making between parents and adolescents improved immediately after using the website (P=.002) and at follow-up (P=.02). The interview data also revealed that the website's content was informative and engaging; in particular, participants enjoyed the web-based quizzes and vaccine reminders. CONCLUSIONS This theory-driven, community-based participatory action research-designed and culturally and linguistically appropriate educational website was well received. It improved Hmong parents' and adolescents' knowledge, self-efficacy, and decision-making processes regarding HPV vaccination. Future studies should examine the website's impact on HPV vaccine uptake and its potential for broader use across various settings (eg, clinics and schools).
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Affiliation(s)
- Hee Yun Lee
- School of Social Work, The University of Alabama, Tuscaloosa, AL, United States
| | - Serena Xiong
- School of Medicine, Washington University in St Louis, St Louis, MO, United States
| | - Aparajita Sur
- School of Public Health, University of Minnesota, Twin Cities, MN, United States
| | - Tounhia Khang
- SoLaHmo Partnership for Health & Wellness, Community University Health Care Center, Minneapolis, MN, United States
| | - Bai Vue
- SoLaHmo Partnership for Health & Wellness, Community University Health Care Center, Minneapolis, MN, United States
| | - Kathleen A Culhane-Pera
- SoLaHmo Partnership for Health & Wellness, Community University Health Care Center, Minneapolis, MN, United States
| | - Shannon Pergament
- SoLaHmo Partnership for Health & Wellness, Community University Health Care Center, Minneapolis, MN, United States
| | - M Beatriz Torres
- Department of Public Health, Mercyhurst University, Erie, PA, United States
| | - Joseph S Koopmeiners
- School of Public Health, University of Minnesota, Twin Cities, MN, United States
| | - Jay Desai
- Minnesota Department of Health, Saint Paul, MN, United States
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Choi J, Markham C, Tamí-Maury I, Kim S, Cuccaro P. Maternal perceptions of vaccinating boys against human papillomavirus (HPV) in Seoul, South Korea: A descriptive exploratory qualitative study. PLoS One 2023; 18:e0282811. [PMID: 36897868 PMCID: PMC10004501 DOI: 10.1371/journal.pone.0282811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/23/2023] [Indexed: 03/11/2023] Open
Abstract
Human Papillomavirus (HPV) vaccination is of paramount importance to reduce HPV-associated cancers in both genders. In South Korea, the prophylactic vaccine is recognized as prevention of cervical cancer with little attention given to male HPV vaccination. The purpose of this study was to explore perceptions of male HPV vaccination and underlying factors for vaccine hesitancy among mothers of unvaccinated boys in Seoul, Korea using a qualitative method. We used a purposive sampling strategy to recruit mothers of unvaccinated middle school-aged boys living in one of the 25 districts in Seoul, supplemented by a snowball sampling approach. We conducted one-on-one telephone interviews with ten mothers using a semi-structured interview guide. Questions probed mothers' views on vaccinating boys against HPV and the reasons for not vaccinating their sons. We found that mothers were hesitant to vaccinate their sons against HPV due to high out-of-pocket costs, fear of side effects concerning the young age of their sons, and low awareness of HPV and HPV vaccine, all of which stemmed from the exclusion of male HPV vaccination in the national immunization program. Sociocultural factors, including vaccination norms, lack of HPV education, and values associated with sexually transmitted infections were also likely to negatively impact mothers' vaccination decision-making. Despite the barriers, mothers were willing to accept HPV vaccination when it was framed as cancer prevention for not only the sons but also their future spouses. In conclusion, reasons for Korean mothers' hesitancy for their sons' HPV vaccine uptake were multifaceted. Healthcare providers' role in emphasizing and conveying the importance of gender-neutral HPV vaccination will be essential to alleviate negative sentiments around the vaccine for boys and reduce their risk of compromised sexual health. As an effective public health strategy, tailored cancer prevention messages should be delivered heightening significant benefits of the HPV vaccine beyond the prevention of cervical cancer.
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Affiliation(s)
- Jihye Choi
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Christine Markham
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Irene Tamí-Maury
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
| | - Sooyoun Kim
- Institute of Health and Environment, Seoul National University, Seoul, South Korea
| | - Paula Cuccaro
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, Texas, United States of America
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Babi A, Issa T, Issanov A, Akhanova S, Udalova N, Koktova S, Balykov A, Sattarkyzy Z, Imankulova B, Kamzayeva N, Almawi WY, Aimagambetova G. Knowledge and attitudes of mothers toward HPV vaccination: A cross-sectional study in Kazakhstan. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231172355. [PMID: 37184051 DOI: 10.1177/17455057231172355] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Although recommended for all member states of World Health Organization, there is no national human papillomavirus vaccination program in Kazakhstan. Furthermore, there are no studies in Kazakhstan that evaluate the mothers' perception of human papillomavirus vaccines. OBJECTIVES This study aims to assess the knowledge and attitudes toward human papillomavirus vaccination among mothers in Kazakhstan and the factors associated with their attitudes. DESIGN A cross-sectional study was performed during the period of December 2021-February 2022. The STROBE guideline for cross-sectional studies was applied. METHODS Paper-based structured questionnaires were filled out by 191 mothers, 141 of whom had daughters. The attitude score was assessed as per the Likert-type scale. The Chi-square and Fisher's exact tests, with a significance value of < 0.05 were used to analyze the relationships between the characteristics of mothers and their attitude scores. RESULTS The following factors were significantly associated with mothers' attitudes toward human papillomavirus vaccination: a place of residence, family income, number of children, and refusal of vaccination for themselves (p < 0.005). Of all participants, only 45% of all mothers, 41% of mothers with a female, and 46% of mothers with male children had positive attitudes toward human papillomavirus vaccination. The child's gender was not a significant determinant. Overall, the level of knowledge about human papillomavirus vaccination was found to be low. The median total score is 0 out of 12 for women who have negative and neutral attitudes toward human papillomavirus vaccines. Among women who have positive attitudes toward HPV vaccines, the median score is around 3 points. CONCLUSION Before the implementation of the human papillomavirus vaccination program into the Kazakhstani national vaccination calendar, comprehensive and adequate information and education campaigns are required on the national level for parents and the population in general.
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Affiliation(s)
- Aisha Babi
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Torgyn Issa
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Alpamys Issanov
- Department of Medicine, School of Medicine, Nazarbayev University, Astana, Kazakhstan
| | - Sholpan Akhanova
- Obstetrics and Gynecology Department, "Keruen Medicus" Clinic, Almaty, Kazakhstan
| | - Natalya Udalova
- Obstetrics and Gynecology Department, East-Kazakhstan Regional Hospital, Oskemen, Kazakhstan
| | | | | | - Zhanna Sattarkyzy
- Obstetrics and Gynecology Department, City polyclinic #6, Astana, Kazakhstan
| | - Balkenzhe Imankulova
- Clinical Academic Department of Women's Health, CF University Medical Center, Astana, Kazakhstan
| | - Nazira Kamzayeva
- Clinical Academic Department of Women's Health, CF University Medical Center, Astana, Kazakhstan
| | - Wassim Y Almawi
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Astana, Kazakhstan
- Faculty of Sciences, El-Manar University, Tunis, Tunisia
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Anuforo B, McGee-Avila JK, Toler L, Xu B, Kohler RE, Manne S, Tsui J. Disparities in HPV vaccine knowledge and adolescent HPV vaccine uptake by parental nativity among diverse multiethnic parents in New Jersey. BMC Public Health 2022; 22:195. [PMID: 35093050 PMCID: PMC8800253 DOI: 10.1186/s12889-022-12573-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 12/20/2022] Open
Abstract
Background Suboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents. Methods We surveyed parents of adolescents (ages 11–18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors. Results Of the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores − 1.7 [− 3.1, − 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics. Conclusions Our findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12573-7.
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12
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Ma GX, Zhu L, Zhai S, Lin TR, Tan Y, Johnson C, Fang CY, Belinson JL, Wang MQ. Empowering Low-Income Asian American Women to Conduct Human Papillomavirus Self-Sampling Test: A Community-Engaged and Culturally Tailored Intervention. Cancer Control 2022; 29:10732748221076813. [PMID: 35193408 PMCID: PMC8874186 DOI: 10.1177/10732748221076813] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Asian American women face disproportionate burden of cervical cancer (CC) than non-Hispanic white women in the U.S. The goal of this study was to assess the feasibility and impact of a culturally tailored intervention to promote Human papillomavirus (HPV) self-sampling test among hard-to-reach Asian American women. METHODS We adopted the community-based participatory research (CBPR) approach to conduct this efficacy study. A total of 156 female participants (56 Chinese, 50 Korean, and 50 Vietnamese) were recruited from community-based organizations (CBOs) in the greater Philadelphia metropolitan area. The intervention components included HPV-related education, HPV self-sampling test kit and instructions, group discussions, and patient navigations, all available in Asian languages. We examined several outcomes, including the completion of HPV self-sampling, HPV-related knowledge, perceived social support, self-efficacy, and comfort with the self-sampling test at post-intervention assessment. RESULTS The majority of Asian American women had low annual household income (62.3% earned less than $20,000) and low educational attainment (61.3% without a college degree). We found significant increase in participants' knowledge on HPV (baseline: 2.83, post: 4.89, P <.001), social support (baseline: 3.91, post: 4.09, P < .001), self-efficacy (baseline: 3.05, post: 3.59, P < .001), and comfortable with HPV self-sample test (baseline: 3.62, post: 4.06, P < .001). CONCLUSION To the best of our knowledge, this is the first intervention study that promoted HPV self-sampling test among Asian American women. Our findings showed that CBPR culturally tailored intervention of self-sampling was highly effective in empowering low-income Asian American women to conduct HPV self-sampling tests.
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Affiliation(s)
- Grace X. Ma
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Cancer Prevention and Control, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Lin Zhu
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Shumenghui Zhai
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Timmy R. Lin
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Yin Tan
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Cicely Johnson
- Hunter College Center for Cancer Health Disparities Research, New York, NY, USA
| | - Carolyn Y. Fang
- Cancer Prevention and Control, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Jerome L. Belinson
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Min Qi Wang
- Department of Behavioral and Community Health, University of Maryland, College Park, MD, USA
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13
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Tung WC, Lin Y, Chao HW, Chen Y. HPV vaccination, information sources, and acculturation among Chinese college students aged 18-26 in the United States. Res Nurs Health 2021; 45:194-204. [PMID: 34549448 DOI: 10.1002/nur.22185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
Human papillomavirus (HPV) vaccination behaviors among Chinese college students (CCS) in the United States are affected by social determinants of health. Using a self-report questionnaire and a snowball sampling technique, this cross-sectional study investigated (a) HPV vaccination practices; (b) primary social networking platforms and preferred means of receiving HPV information; and (c) the influence of acculturation on HPV vaccination, HPV information sources, and social networking use among 213 CCS aged 18-26 in the United States. About half (50.7%) had received one to three doses of an HPV vaccine, and 91.7% had received their first dose. The most popular social networking platforms were WeChat (69.5%), Instagram (58.7%), text messaging (55.4%), and Facebook (47.4%). Preferred means of receiving future HPV information included the internet, online social networking, and health professionals. Participants with high Asian identification (AI) were less likely to receive the HPV vaccine than those with high Western identification. Participants with high AI were more likely to use WeChat for their social networking but less likely to use US-based social media platforms. Acculturation, preferred social networking platforms, and sources and communication of HPV (i.e., health professionals, family members, schoolteachers, friends) influenced participants' HPV vaccination. To promote equity of access to health messages and increase HPV vaccination, future efforts should pay attention to CCS with high AI and incorporate their cultural beliefs and practices. Given that nonprofessionals (e.g., family, friends) were influential factors in HPV vaccination, it is critical to tailor interventions for CCS to the recipients and their social circles.
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Affiliation(s)
- Wei-Chen Tung
- The Valley Foundation School of Nursing, San Jose State University, San Jose, California, USA
| | - Yuting Lin
- College of Nursing, Seattle University, Seattle, Washington, USA
| | - Hannah W Chao
- Department of Integrative Biology and Physiology, University of California, Los Angeles, California, USA
| | - Yinghan Chen
- Department of Mathematics and Statistics, University of Nevada-Reno, Reno, Nevada, USA
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14
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Ma GX, Zhu L, Tan Y, Zhai S, Lin TR, Zambrano C, Siu P, Lai S, Wang MQ. A Multilevel Intervention to Increase HPV Vaccination among Asian American Adolescents. J Community Health 2021; 47:9-16. [PMID: 34232452 PMCID: PMC8738771 DOI: 10.1007/s10900-021-01013-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 12/05/2022]
Abstract
Human papillomavirus (HPV) is the most common sexually transmitted infection in the US. HPV vaccine is a viable source of prevention against high-risk strains that are likely to cause cancer. However, particularly among racial and ethnic minorities such as Chinese Americans, HPV vaccination rates are suboptimal. The goal of this study was to evaluate the effect of a culturally tailored intervention on HPV vaccine uptake in Chinese Americans. We designed and implemented a multilevel longitudinal pilot study to examine the efficacy of the HPV intervention among Chinese American parents/guardians. We recruited 180 participants from federally qualified health center and community-based clinics that serve predominantly low-income Chinese Americans in Philadelphia. Participants were randomized into an intervention group (n = 110) or a control group (n = 70). The intervention group received an HPV specific intervention, while the control group received a general health intervention. The primary outcome was medical record-confirmed receipt of first shot and completion of HPV vaccine within six months of receiving the interventions. Repeated measure ANOVA was utilized to examine the intervention effect on knowledge between intervention and control groups. Knowledge differed significantly, with participants in the intervention group demonstrating the greatest improvement following the intervention. A multivariable logistic regression was used to examine the association between HPV vaccine initiation and study group assignment. There was a significant effect of provider recommendation, parent’s gender, and health insurance status on HPV vaccine uptake. This study demonstrated positive impact of a culturally tailored intervention on HPV vaccination uptake among Chinese Americans.
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Affiliation(s)
- Grace X Ma
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, 3440 N. Broad Street, Philadelphia, PA, 19140, USA.
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, 3440 N. Broad Street, Philadelphia, PA, 19140, USA.
- Fox Chase Cancer Center, Temple University Health System, 333 Cottman Ave, Philadelphia, PA, 19111, USA.
| | - Lin Zhu
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, 3440 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Yin Tan
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, 3440 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Shumenghui Zhai
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, 3440 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Timmy R Lin
- Center for Asian Health, Lewis Katz School of Medicine, Temple University, 3440 N. Broad Street, Philadelphia, PA, 19140, USA
| | - Cristina Zambrano
- Hunter College Center for Cancer Health Disparities Research, 695 Park Avenue, New York, NY, 10065, USA
| | - Philip Siu
- Greater Philadelphia Health Action, Inc., 432 N 6th St, Philadelphia, PA, 19123, USA
| | - Sarah Lai
- Greater Philadelphia Health Action, Inc., 432 N 6th St, Philadelphia, PA, 19123, USA
| | - Min Qi Wang
- School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD, 20742, USA
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15
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Icardi G, Costantino C, Guido M, Zizza A, Restivo V, Amicizia D, Tassinari F, Piazza MF, Paganino C, Casuccio A, Vitale F, Ansaldi F, Trucchi C. Burden and Prevention of HPV. Knowledge, Practices and Attitude Assessment Among Pre-Adolescents and their Parents in Italy. Curr Pharm Des 2020; 26:326-342. [PMID: 31942852 PMCID: PMC7527545 DOI: 10.2174/1381612826666200114100553] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/08/2020] [Indexed: 12/24/2022]
Abstract
Despite infections due to HPV nowadays represent the most common sexually transmitted diseases worldwide with recognized effective and safe preventive strategies, knowledge, attitudes; however, awareness on HPV is considerably low. The present study has two main objectives: 1. To conduct a literature review to analyze the evolution of preventive tools, the complexity of the vaccine choice process, and the challenges posed by HPV vaccine hesitancy and refusal among pre-adolescents and their parents; 2. To assess knowledge, practices and attitudes toward HPV infection and vaccination in a sample of Italian pre-adolescents and their parents. The observational study was carried out through the use of two anonymous and self-administered pre- and post-intervention questionnaires dedicated to the target populations. Between the administrations of the pre- and post-intervention questionnaires, an educational intervention on HPV infection and related diseases, and prevention strategies was conducted. All participants demonstrated suboptimal knowledge and positive attitudes in the pre-intervention questionnaire. Higher levels of knowledge and attitudes were observed among pre-adolescents thatused social networks and had heard of sexually transmitted diseases at home/school/physician and from parents and also who had heard of HPV from General Practitioners, Gynecologists, family members and newspapers. A significant increase in HPV vaccination awareness was observed among pre-adolescents after the educational sessions. Health education programs aimed at increasing knowledge, attitudes and awareness on HPV are needed to implement the outcomes of HPV immunization programs, especially if supported by the physicians involved in counselling and recommendation processes.
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Affiliation(s)
- Giancarlo Icardi
- Department of Health Sciences, University of Genoa, Genoa, Italy.,IRCCS San Martino Policlinic Hospital, Genoa, Italy
| | - Claudio Costantino
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Excellence Specialties (PROMISE), University of Palermo, Italy
| | - Marcello Guido
- Department of Biological and Environmental Sciences and Technologies, Laboratory of Hygiene, University of the Salento, Lecce, Italy.,Inter-University Centre for Research of Influenza and other Transmissible Infections (C.I.R.I.- I.T.), Genova Italy
| | - Antonella Zizza
- National Research Council, Institute of Clinical Physiology, Campus Ecotekne, Lecce, Italy
| | - Vincenzo Restivo
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Excellence Specialties (PROMISE), University of Palermo, Italy
| | - Daniela Amicizia
- Department of Health Sciences, University of Genoa, Genoa, Italy.,IRCCS San Martino Policlinic Hospital, Genoa, Italy.,Azienda Ligure Sanitaria della Regione Liguria (A.Li.Sa.), Liguria Region, Genova, Italy
| | | | - Maria Francesca Piazza
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Azienda Ligure Sanitaria della Regione Liguria (A.Li.Sa.), Liguria Region, Genova, Italy
| | - Chiara Paganino
- Azienda Ligure Sanitaria della Regione Liguria (A.Li.Sa.), Liguria Region, Genova, Italy
| | - Alessandra Casuccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Excellence Specialties (PROMISE), University of Palermo, Italy
| | - Francesco Vitale
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Excellence Specialties (PROMISE), University of Palermo, Italy
| | - Filippo Ansaldi
- Department of Health Sciences, University of Genoa, Genoa, Italy.,IRCCS San Martino Policlinic Hospital, Genoa, Italy.,Azienda Ligure Sanitaria della Regione Liguria (A.Li.Sa.), Liguria Region, Genova, Italy
| | - Cecilia Trucchi
- IRCCS San Martino Policlinic Hospital, Genoa, Italy.,Azienda Ligure Sanitaria della Regione Liguria (A.Li.Sa.), Liguria Region, Genova, Italy
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Chang WH. A review of vaccine effects on women in light of the COVID-19 pandemic. Taiwan J Obstet Gynecol 2020; 59:812-820. [PMID: 33218394 PMCID: PMC7486065 DOI: 10.1016/j.tjog.2020.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
The pandemic situation triggered by the spread of COVID-19 has caused great harm worldwide. More than six million people have been infected, and more than 360,000 of them have died. This is the worst catastrophe suffered by mankind in recent history. In the face of this severe disaster, people all over the world are frightened of the prospect of facing an outbreak or an annual recurrence. However, the development of a vaccine will help control the impact of COVID-19. Women in particular have been more seriously affected by the pandemic. Since the pressure and physical load they suffer are often greater than what men endure, women are more threatened by COVID-19. Though women have a poorer quality of life and work and face worse economic conditions, they also tend to have better physiological immunity than men, which can ease the effect of COVID-19. The early development of a vaccine against COVID-19 is an important issue that must take into consideration women's better immune response to the virus along with the technique of hormone regulation. Relevant research has been conducted on female-specific vaccines in the past, and women's issues were considered during those clinical trials to ensure that complications and antibody responses were positive and effective in women. National policies should also propose good strategies for women to be vaccinated. This could improve consciousness, give women a better vaccination experience, enhance their willingness to vaccinate, and protect them from COVID-19 infection.
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Affiliation(s)
- Wen-Han Chang
- Department of Medicine, Mackay Medical College, New Taipei, Taiwan; Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei, Taiwan; Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan; Department of Emergency, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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