Despite sophisticated technologies for representational fidelity in hybrid meetings, in which co-located and remote participants collaborate via video or audio, meetings are still often disrupted by practical problems with trying to include remote participants. In this paper, we use micro-analysis of three disruptive moments in a hybrid meeting from a global software company to unpack blended technological and conversational practices of inclusion and exclusion. We argue that designing truly valuable experiences for hybrid meetings requires moving from the traditional, essentialist, and perception-obsessed user-centered design approach to a phenomenological approach to the needs of meetings themselves. We employ the metaphor of ‘configuring the meeting’ to propose that complex ecologies of people, technology, spatial, and institutional organization must be made relevant in the process of design. The ‘meetingisation’ of work stems from the increasing need for collective means of social orientation and coordination, especially in post-industrial economies van Vree . Work haTo improve hybrid meeting technologies, we must better understand the special problems of meeting continuity that arise from hybridity itself. These problems are often revealed in practices of inclusion and exclusion of remote participants in hybrid meetings. By inclusion, we mean episodes in which the meeting continuity is disrupted either to organize the participation of a remote user, or to organize meeting tasks around a spatial orientation that accounts for both remote and local participants. By exclusion, we refer to episodes in which meeting continuity is itself organized to accountably exclude remote participants during or following a technological breakdown.Our research question is: How do practices of inclusion and exclusion of remote participants arise in hybrid meetings, especially in the context of technology troubles? We know that when technology troubles arise in the video calls of long-distance relationships, couples aim to maintain conversational continuity rather than fixing technological problems Rintel . Couplescommunication in the meeting to a phenomenon-centered approach to the meeting itself. In so doing, we blend two prior conceptual frameworks  on hybrid meetings and Science and Technology Studies (STS) on ways of approaching understanding shared technologies. We then turn to methods, explaining our analytic methodology of video-based analysis of conversation, the source of nature of our data, and our choice of examples. We then present micro-analyses of three episodes of common technological troubles from a single meeting that lead to practices of inclusion and exclusion. We close with design suggestions that elaborate on how ‘configuring the meeting’ may be possible for diverse social phenomena where technology is a mediator of an activity.HCI and CSCW research on hybrid meetings, distributed across studies about online meetings, remote meetings, virtual meetings, distributed meetings, distributed work, virtual teams, and remote work, has focused on remote participant fidelity and equality of local and remote participation  inspired scholars in STS and HCI to re-consider the development and the use of technologies in bringing together the social and the technical and to take a symmetrical stance towards humans and artifacts. Suchman  notes thLike every socio-technical phenomenon, hybrid meeting experiences are closely linked with the opportunities and limitations designed into meeting software and hardware. Madeleine Akrich , p. 208 In this study, we aim to show how combinations of social, group, institutional, and technological dynamics throughout the meeting lead to practices of inclusion and exclusion of remote participants in order to sustain meeting continuity. These practices, we will argue, demonstrate a need to extend ‘configuration’ from users to the meeting itself.The tools of Ethnomethodology and Conversation Analysis (EM/CA) are common analytic approaches used in HCI when there is a need to understand human action in a technological context Suchman . EM/CA eAchieving continuity in meetings draws on aspects of conversational repair . On the large screen at the front of the room, the video or avatars of two remote participants (RP1 and RP2) and one co-located participant (CP0) were displayed. The reason for the appearance of CP0’s avatar on the screen in addition to remote participants is that he connected to the video call via his personal computer in order to share his screen later during the meeting. A small view of the video from the panoramic camera is shown in the lower right corner of the screen.The meeting was recorded with a standing camera and a hand camera by the observers to capture as much interaction as possible. The positions of the cameras are shown on Figure relevancy to which these episodes attest. For example, in the first episode we observed that the meeting was disrupted to ensure that a remote participant had video on, whereas in the third episode, the meeting was disrupted to ask a remote participant to turn off their video due to apparent network trouble. We selected these episodes from the status round section of the meeting for two reasons. First, interaction among co-located and remote participants was at its maximum in these episodes. Second, the status round itself is usefully complex because managers, moderators, and other participants are frequently attempting to refer and respond to each other. Overall, we are particularly interested in analyzing whether and how requirements and expectations can be constantly negotiated or sacrificed at both individual and collective level in order to accomplish the hybrid meeting.The three episodes of inclusion and exclusion depict how meeting participants tried to repair or give up on remote participants’ inclusion and engagement, even in the same meeting, for the sake of meeting continuity. Meeting continuity, then, is the supposed to be organized and the negotiation necessary to accomplish the meeting practically.The episodes were transcribed using Jefferson’s  system oIn the first episode, the lack of verbal reactions from a remote participant with their video off leads other meeting participants to question the participation of the remote participant and to highlight the importance of video as an indicator of presence. As CP1 begins his status update, he starts talking facing MNG but his gaze shifts to RP2’s place on the screen at the front of the room. RP2’s video is off, so his visual representation is a static image in a circle centered in his area of the grid (Microsoft Teams’ standard audio-only mode). CP1 inclines his head towards the screen and refers to RP2 claiming that he will “steal a little bit of [RP2]’s thunder” . Having received no reaction from RP2 even after all the teasing, MNG summons RP2 one last time (Excerpt 1: 29), but again receives no reaction. She then turns to the co-located participants and reports this obvious lack of response, which could function as a preliminary to proposing excluding RP2 and moving on. However, as she finishes the explanation, RP2’s video appears on the screen. The co-located participants cheer and RP2 utters his first response: “Finally”. As soon as RP2’s video is on, CP1 continues talking again, as if all is resolved.What is particularly interesting about this episode is that a remote participant is mentioned by a co-located participant, but neither a bodily nor a verbal reaction is received. This makes MNG and, after a while, the rest of the participants question the presence or active participation of the remote participant. If his video were on, then the reason for his unresponsiveness could have been understood much easily, and the manager or the facilitator of the meeting could have focused on the connection problem directly to make sure that RP2 could hear them, saving time. However, RP2’s visible presence in audio-only mode but lack of verbal response leads MNG and the co-located participants to probe not only a potential connection problem but also the possibility that the remote participant is not paying attention. While the former is an excusable technical problem out of RP2’s hands, the latter is a more problematic moral problem for which RP2 can be held socially and institutionally accountable. This disruptive moment reveals the social dynamics that have thus far not been evident in the flow of the meeting. Rather than warning RP2 with a domineering attitude, MNG teases RP2 with the proposal that he is part of a younger generation that knows how to use technology in general and is comfortable with video in particular. By proposing that RP2 has no excuse for not turning his video on, she is also reminding him and others of the expected behavior of turning video on in hybrid meetings.Considering this episode as a whole, there are numerous probes into whether the remote participant is still active in the meeting, beginning with CP1’s waiting and ending with MNG’s tease. Although the resolution of the breakdown is acknowledged by all participants with their cheer, it is unclear at which point the participants consider the connection and not the participant’s interest in the meeting as the cause of the problem. RP2’s succinct response “Finally” and the accompanying cheer are performative mutual agreement that there was indeed a technological problem and the elapsed time of teasing and waiting was a struggle for RP2 to find a solution, supported by the frozen video of RP2 while he is saying “Finally”. While the lack of rapport between CP1 and RP2 was the initiating element for the breakdown, when the breakdown is resolved, CP1 continues talking as soon as RP2’s video is on without involving RP2 or receiving/waiting for a response. Since RP2 has already taken enough time and attention from the meeting, neither he tries to, nor do others let him, talk more. Does the video being turned on result in a more inclusive and participatory meeting? At this point, it does not serve an inclusive function. The quest to turn on RP2’s video reveals an unspoken disciplinary requirement of the meeting that participants should be audio-visually present. However, ironically the disruption caused by the attempt to change RP2 from a noticeable absence to a visual presence is also key to the move to sideline him as an active participant, perhaps for fear of further delays. He is included only insofar as he can be accounted for as a passive participant.In the second episode, we observe an inclusive move by the manager treating the physical position of the screen and the placement of the remote participants on it as part of the spatial organization of the co-located participants at the table. When CP3 (located to the right of the screen) finishes their turn, instead of moving to CP4 (located to left of the screen), MNG suggests the continuation of spatial organization with a rhetorical question: “Should we go to the screens now?” This is followed by the verbal approval “Yeah” and nod from CP4, who would otherwise be the next speaker based on the spatial order of the table (Excerpt 2: 4–5). Further assuring the approval, the same participant lowers himself in his chair, limiting his impact as a barrier between the remote and local participants . This treats RP2’s displayed representation on the screen as more accountable than his status as a meeting participant. CP4 begins to talk at the same time as MNG, but stops immediately waiting for her to complete her turn. MNG’s turn is interrupted by a two-second long blaring noise emanating from the room’s speaker, causing CP4 to recoil (Excerpt 3: 9). When the noise finishes MNG picks up her turn from the incomplete word . CP4 then reveals an exacerbated sense of technological objectification of RP2 by ‘revealing’ that he is “feeling quite intimidated” referring to RP2’s big face on the screen behind him, and all co-located participants laugh (Excerpt 3: 16–18). The blaring noise occurs again, this time for 3 s. Someone reacts with the exclamation “Oh ‘allo?!” (Excerpt 3: 21), someone else jokes “Is that a boat?” (Excerpt 3: 23–24), and everyone laughs (Excerpt 3: 25–27). RP2 attempts to start a turn responding to the joke (“No ide-”) but his sound cuts out during his second word (Excerpt 3: 28). Meanwhile, CP0 takes a photo of RP2 and laughs at the “boat” joke as well (Excerpt 3: 29–31). As the co-located participants hear RP2’s voice, MNG says to him “We can hear you” (Excerpt 3: 32), however RP2’s lips move for 6 s without sound (Excerpt 3: 35–36).Three seconds into RP2’s silent turn, MNG and many others call out that they cannot hear RP2 Excerpt 4: 38–40), but his voice then returns. He talks again and can be heard for a while about a “deployment event on Friday” but after 15 s his sound stops, while his face moves (Excerpt 4: 42–48). MNG and CP6 both show their disappointment with a chorus of “We lost you” and waving to RP2 on the screen to get his attention (Excerpt 4: 50–54), but RP2 keeps talking, unaware that his voice cannot be heard. MNG is trying to wave to the screen again and CP4 tells her to wave towards the RoundTable camera, pointing with his finger  and by turning off his video as soon as he hears this concluding move.Although spending one and a half minutes may not be too long for a repair depending on the importance of the status report, this is, of course, the second time that RP2 has faced technological trouble in this meeting. This may well have led MNG to believe that the same problem is recurring and cannot be solved. Even though the participants may not have fully understood or heard enough of RP2’s report, MNG does not offer or ask for alternative communication methods such as switching to a landline call or asking for a typed version through the chat. Instead, she actively shifts to the next participant. This may be a move to ensure that everyone gets equal time for their status report, but time equality is not the same as task equity. Further, although the thought of having already lost enough time due to technological breakdown might be justified, even the co-located participants do not receive equal time in the rest of the meeting. In the end, neither the equality nor equity of talk is ensured, and, as is often the case in hybrid meetings, a remote participant is partially excluded.We have analyzed three episodes in which remote participants are included or excluded in a hybrid meeting in order to continue the meeting and achieve its wider goals. Similar to findings on video-calling practices of couples Rintel , we obseMost of today’s widely-deployed video-mediated communication technologies were not designed to accommodate the needs of hybrid meetings. They draw on the legacy of videotelephony, which was designed to facilitate communication between two or more endpoints. They are not infrastructures for the ‘meeting’ of participants in the sense that they only connect the locations of participants, largely ignoring the problems of mutual engagement across different locations, especially the problem of co-located participant cliques having communicative advantages.As Hollan and Stornetta  argue, dIn the three moments analyzed, we draw attention to the ways in which exclusions and inclusions take place. However, our aim is to go beyond and ask how this could have been otherwise. In discussing the politics of artifacts, Akrich , p. 222 A rough contrast between the analyzed episodes in this paper and previously observed hybrid meetings shows that it is possible to minimize disruptions in settings where the meeting dynamics are either highly ritualized or adaptive to change. While some of this involves meeting participants learning and adopting meeting practices, some aspects of meeting dynamics can be incorporated into technological design. We will explain how this might be achieved with examples based on the episodes above.Currently, successful hybrid meetings depend on meeting practices being adapted to/matching the configuration of the infrastructure. For example, there may be an already known order of talk or an acquired knowledge regarding what to do when certain technological breakdowns occur. In this sense, the success of the hybrid meeting often relies on the previous practice of the participants, which evolves over time to limit incongruities with what the infrastructure allows. We believe that it is possible to take an alternative route to an alignment: making the software adaptable to the meeting needs.One very basic problem in hybrid meetings is that the video and audio fail to reach either or both sides. Given that the network is cause of the problem, it seems obvious that the participants could be notified about a range of network issues. In fact, early IP video-mediated communication systems often did provide this information, although often in ways most suited to experts, and as Quality of Service mechanisms improved, such notifications fell out of fashion. Network adaptation mechanisms such as scalable video codecs have also been in use for a long time , or even accidental noise from remote participants themselves, are both often difficult to identify in meetings with too many participants. Even with noise cancellation to reduce external noise, that the expected behavior for remote participants is to mute their audio unless speaking can be communicated before such a problem emerges, but also aided by better indications of one’s own muted status if one starts to talk or AI-based auto-unmuting using predictive pre-turn behavior tracking.Meetings are more efficient when participants understand how the meeting will be structured. Components that are common in many meetings, such as status rounds, necessitate previous knowledge on how to proceed, for example, when it is the right time to speak. This is not only true for remote participants, but also for co-located ones. It is feasible to inform users of an order of talk that would be more inclusive for the remote participants, and technologically enforce this order through indicators of expected turns, while at the same time allowing flexible control over who is taking the turn when necessary.Letting participants know what technological problems may arise, what the expected behavior is, and, how the meeting will be structured are few of many potential issues that are relevant to the hybrid meeting’s success, as we have identified in three episodes of exclusion and inclusion. While previous research has touched on these issues already, our suggested design implication is to think about these aspects and others as ‘configuring the meeting’ and not just the users. Such a configuration might be possible with questions asked to the organizer in a dialog with the service before the meeting starts or through a self-moderating system feature when there is no facilitator. For example, a hybrid meeting service could let the organizer decide and enter the details of the planned setting, format and other physical and social features of the meeting, which would allow the meeting rules, expectations, and code of conduct to be pre-set and made available to all participants equally before the meeting starts. The potential scenarios and features are endless, and of course we cannot mention all of them, so in this case we will explain what we mean by ‘configuring the meeting’ by re-imagining the status round and brainstorm meeting above as a self-moderating hybrid meeting.In our hypothetical hybrid meeting service, the organizer configures the meeting based on the settings below before the meeting starts Table . The orgAll participants manage turn-taking through the meeting software on personal devices that they have with them. This means that while co-located participants use a shared microphone and camera to interact with the remote participants, they still connect to the meeting service on their personal devices to organize their engagement. The order of talk, which is randomly set, can be seen on personal devices with a number attached to the name of each participant. The service virtualizes ‘jump-in’ talk for both co-located and remote participants. We will explain the features we envision with a specific example.It is C2’s turn in the status round, which is visible on everyone’s personal device. While C2 is talking, C5 wants to jump-in to ask a question. Instead of raising their physical hand, asking for permission verbally, or directly interrupting, C5 clicks the ‘jump-in’ feature on the software and then starts talking immediately. As soon as C5 is done, they ‘jump-out’, letting C2 continue talking. While C2 takes the floor again, R3 wants to jump-in directly to clarify something, which again requires R3 to click on jump-in, which directly mutes C2’s microphone (which is the shared microphone in the conference room) and unmutes R3’s microphone. When R3 is done with the fast comment, jumping-out mutes their microphone and the shared microphone is unmuted again. After C2’s report is complete, they end their section virtually by clicking ‘end turn’, which mutes their microphone and gives the floor to the next participant in the order of talk, unmuting their microphone immediately.As we claim the need for thinking beyond being co-located and taking the diverse meeting dynamics into account, in this example, we imagine a setting where all co-located and remote participants manage turn-taking and jump-in virtually through their own devices. Turn-taking features such as raising hand, thumbs up, fast or slow talk requests as well as fast reactions for approval, already exist in distributed meeting software today, however these features are mostly used by the remote participants and mostly in virtual meetings. In line with previous research (Yankelovich et al. The hypothetical meeting flow we describe in this paper is just an example of configuring a hybrid meeting experience. Different distributed teams or meetings may require diverse settings and features based on their institutional needs and goals. From setting the maximum duration of talk at every jump-in to limiting the number of times a participant can jump-in, there are many physical and social features which could be set and adjusted based on every hybrid or virtual meeting’s goals and dynamics as well as the institutional rules and requirements. While such detailed configuration of hybrid meetings beforehand can also have limitations in practice, causing an increased initial overhead of planning meetings, we argue that it may empower distributed teams to discover and develop more inclusive and effective hybrid meeting set-ups, practices, and routines, enabling them to minimize the time spent on handling breakdowns in the long run.Both commercial and research-based video-mediated communication design processes do involve versions of our suggestions for improving technological state awareness, communicating expected behavior, and communicating meeting formats. However, our aim is also to show such incorporations often forget about peoples’ need for resources to understand the meeting ecology, taking an individualized approach to potential problems. We suggest that the individual user alone should not be ‘configured’ since the meeting itself configures the participants in different ways. Thus, design of hybrid meeting technologies should consider multiplicity of the meetings and meeting needs.Meetings are social phenomena and their dynamic nature goes beyond merely transmitting voice and video, even with sophisticated techniques to improve their apparent fidelity such as eye-tracking or rotating cameras. Being informed of technical states including potential problems, expectations, and how the meeting will be structured are configurable aspects of the meeting that not only empower the users, but are also potential factors that may increase the productivity and inclusiveness of the meeting. Designing flexible hybrid meeting services and hardware for ‘configuring the meeting’ is essential to meeting institutional goals and needs, especially in a post-COVID-19 world in which hybrid workplace attendance is likely to be the new normal.This study explores episodes of inclusion and exclusion practices relevant to common technological and turn-taking problems in hybrid meetings. Our analysis shows that hybrid meetings, like any other meeting, are shaped by the interactions and social dynamics among both participants and the technical infrastructure. Therefore, breakdowns, repairs, or passes emerging in a hybrid meeting are diverse and situational not only in every meeting, but also in every particular episode. We propose that in order to have more inclusive, democratic, and participatory hybrid meetings, there is a strong need for design solutions that are flexibly configurable according to the specific needs, goals, and dynamics of each meeting. This requires treating ‘configuring the meeting’ as the situational phenomenon at the center of the hybrid meeting design rather than an essentialist ‘scripting’ of the user.


TM panel  asked about access, visitation, and felt benefits from green and/or blue spaces. Increasing financial difficulty was associated with less time in and fewer visits to green and/or blue spaces, as well as fewer different types visited. Financial difficulty was also associated with feelings that visits to green and/or blue space had less benefit for maintaining social connection. Working from home was associated with more frequent and longer visitation to green and/or blue spaces, as well as discovery of ones previously unvisited. Working from home was also associated with increased levels of exercise and respite resulting from visits to green and/or blue spaces. Residents of Melbourne, a city of 4.9 million who were in ‘lockdown’ at the time of the survey, appeared more likely to benefit from visits to green and/or blue spaces than residents of Sydney, Australia’s largest city at 5.2 million, who were not in lockdown. Residents of Melbourne compared with Sydney reported consistently increased visitation of, discovery of, and greater levels of various felt benefits derived from green and/or blue spaces, including more respite, connection, and exercise. Comparatively shorter distances to preferred green and/or blue spaces and closure of alternative settings at the time of the survey completion in Melbourne compared with Sydney may provide partial explanation, though more acute responses to experiencing green and/or blue spaces within highly cognitively demanding antecedent conditions posed by lockdown are also plausible and warrant further investigation with other health indicators. These results were robust to adjustment for a range of covariates including preferences for natural settings, which were consistently associated with greater levels of green and/or blue space visitation and felt benefits. Collectively, these results indicate that parallel efforts to generate (or renew) felt connection to natural settings, to increase working from home opportunities, and to mitigate financial difficulties may be important to help maximize the population health benefits of urban planning strategies intended to improve the availability of, and to reduce inequities in access to, green and blue spaces. Benefits felt more commonly by people living through lockdown underlines the role previous investments in green and blue space have played in enabling coping during the COVID-19 pandemic.We hypothesized that visits to green and blue spaces may have enabled respite, connection and exercise during the COVID-19 pandemic, but such benefits might have been inequitably distributed due to differences in financial difficulties, opportunities to work from home, and localized restrictions in spatial mobility generated by ‘lockdowns’. A nationally representative online and telephone survey conducted in 12–26 October on the Social Research Centre’s Life in Australia Unprecedented disruption caused by the COVID-19 pandemic has resulted in millions of people around the world being confined to, and/or working from home . Some maThough many health benefits of contact with natural settings are increasingly recognised and evidence-based ,16,17, sWe hypothesised that (1) those in socioeconomically advantaged positions and/or in (2) occupations permitting working from home during the pandemic may have visited green and/or blue spaces more often and benefitted disproportionately from those visits in comparison with counterparts in socioeconomically less favourable and less flexible and time-poor job circumstances. Furthermore, we also hypothesised (3) people who experienced restricted spatial mobility due to ‘lockdown’ had reduced opportunities to visit and reap benefits from green and/or blue space. In this study, we provide a first look at the situation in Australia using a nationally representative survey conducted in October 2020. Australia’s relatively successful response to the COVID-19 pandemic in comparison to other English-speaking high income countries has included a second-wave of infections in Victoria  and a neTM panel between 12 and 26 October 2020. Members of this panel, aged ≥ 18 y, had originally been randomly recruited in 2016 via their landline or mobile phone using a dual-frame random digit dialling design (RDD) with a 30:70 split between landline and mobile phone sample frames. An alternating next or last birthday approach was used to select respondents via the landline method from households where there were at least two residents in scope. The phone answerer was the selected respondent via the mobile phone method. In each case, invitation to join the panel was for one member per household only. The panel was refreshed in 2018 using mobile phone RDD only and again in 2019 with online-only participants using a G-NAF  sample frame and push-to-web methodology. In each of these cases, refreshment was required to balance demographics of the panel with respect to the Australian population. As of October 2020 the panel included N = 3860 active members located across the following geographical areas: (1) Greater Sydney; (2) Rest of New South Wales (NSW); (3) Greater Melbourne; (4) Rest of Victoria (Vic.); (5) Greater Brisbane; (6) Rest of Queensland (Qld.); (7) Greater Adelaide; (8) Rest of South Australia (SA); (9) Greater Perth; (10) Rest of Western Australia (WA); (11) Greater Hobart; (12) Rest of Tasmania (Tas.); (13) Greater Darwin; (14) Rest of Northern Territory (NT); (15) Australian Capital Territory (ACT).This study involved survey of Social Research Centre’s Life in AustraliaTM panel, survey procedures and sample management protocols, respondent liaison procedures, strategies to maintain co-operation, and detailed examination of the survey questionnaire developed by the researchers. The Social Research Centre’s contact methodology for online panel members involved an initial survey invitation via email and SMS (where available). This was followed by several reminders via email and a reminder SMS. Telephone non-response of panel members took place in week 2 of the survey period and involved reminder calls encouraging completion of the online survey. SMS was also used where available for contacting offline panel members, followed by an extended call-cycle and reminder SMS over the two-week survey period. Messages were left on answering machines and voicemails. Participation was in the English language only. All interviewers and supervisors selected by the Social Research Centre to conduct the survey had received training in the Life in AustraliaTM panel participated in our survey . Completion rates were 78.8% overall, 80.0% for online panel members, and 62.3% for offline panel members. An incentive of a supermarket or department store gift card, direct payment into a PayPal account, or donation to a designated charity was offered to all panel members to the value of AUD $10.00 each. The survey took 15.2 min on average to complete, with mean completion times of 14.9 min online and 22.0 min by telephone. 19.9% of panel members could not be contacted during the survey period and 1.3% of invited members decline participation. Response propensity weights were developed using logistic regression by the Social Research Centre to limit the impact of non-participation on sample representativeness. These weights took into account location, age group, gender, annual household income, citizenship status, language(s) spoken other than English, country of birth, Aboriginal or Torres Strait Islander status, number of adults and children in the household, employment status, marital status, highest education, television viewing and internet browsing habits, smoking and drinking status, general health, life satisfaction, early adopter status, caregiving, disability status, volunteer status, concession card status, and telephony status. Ethical approval for the survey was granted by the University of Wollongong HREC. Approximately 78.8% (N = 3043) of the Life in AustraliaHow long [in minutes] would it take for you to walk to the nearest green space and/or blue space from your home?” Participants were then asked “Is the green space and/or blue space nearest your home the one you prefer to visit locally and most often? [yes or no]” Those participants responding negatively were then asked “How long [in minutes] would it take for you to walk to your preferred local green space and/or blue space from your home?” A variable was derived to record the difference in minutes of walking from home to the nearest green and/or blue space and to that which participants preferred. These questions specified walking as the mode of transport to enable comparisons, even if participants typically selected to travel to natural settings by other means. The typical travel mode to visit green and/or blue space was also asked. A range of questions were asked of participants about their access to green and blue space. Access focussed on walking with the question “In the past four weeks (including the weekends), how often have you visited your preferred local green space and/or blue space? ” To gauge cumulative time spent in natural settings across a week the participants were asked “Approximately how many hours did you spend in green spaces and/or blue spaces in total over the last 7 days?” They were also requested to select different types of natural settings where these visits took place, including playing fields, ovals or bowling greens, small parks, large parks, nature reserves, woodlands or forests, botanic gardens, farmland, mountains, hill or moorland, greenery by a river, lake or canal, a beach, or other. If people reported no visits to preferred green and/or blue spaces in the four weeks prior to the survey date, potential reasons were explored with the question “What are the reasons you have not visited your preferred local green space and/or blue space in the last four weeks?”A second set of questions asked participants about their contact with green and/or blue spaces. Visit frequency was asked using the following question: “Since the COVID-19 pandemic and social distancing began in Australia, to what extent, if at all, do you agree or disagree with each of the following statements? (A) I now visit green spaces and/or blue spaces more often than before the COVID-19 pandemic. (B) Green spaces and/or blue spaces have helped me to stay connected with my neighbours during the COVID-19 pandemic. (C) Green spaces and/or blue spaces have brought me solace and respite in these challenging times. (D) I now walk and/or exercise in green spaces and/or blue spaces more frequently than before the COVID-19 pandemic. (E) I have discovered and visited green spaces and/or blue spaces that I hadn’t had the opportunity to visit before the COVID-19 pandemic”.Finally, participants were asked to reflect on how their use of, and felt benefit from, visiting green and blue space may have changed since the COVID-19 pandemic began in five questions. Answered with a Likert scale , these questions were as follows: “Patterns of green space access, visitation and felt benefits were examined with respect to a range of personal, socioeconomic, and household-level covariates measured in the survey. Personal covariates include gender, age, country of birth , and the 6-item ‘Nature-Relatedness Scale’ (NRS) . A measu and economic status . Given substantial shifts to working from home in Australia during the COVID-19 pandemic, the ‘employed’ category was segmented after survey completion using responses to the following question: “During the last four weeks how often did you work at home? ” Household variables included whether a person was living on their own, with another adult and/or with children, the type of household , whether or not a dog was present in the household, and if the household had access to an outdoor space .Enabling and constraining factors assessed included socioeconomic variables including highest educational qualification, annual household income (AUD $ before tax), perceived financial situation Analysis focussed on a complete-case sample of N = 2697. Frequency tables, percentages and means were calculated to describe each of the green space access and use variables with respect to all covariates. These descriptive statistics were conducted in Stata v.14  using ‘SVY’ to incorporate probabilistic weights to provide nationally representative results. Multilevel logistic and Poisson regressions were then fitted in MLwIN v3.02   estimateThe mean number of different types of nature visited in the last 7 days was 1.6 (95% CI 1.5–1.7). The most popular options were: small parks (40.1%); playing fields, ovals and bowling greens (24.7%); large parks (24.0%); nature reserves, woodlands and forests (20.7%); greenery by a river, lake or canal (18.2%); and beaches (13.0%).Before and after adjustment, the mean number of different types of green and/or blue space visited was lower among the long-term sick or disabled, and those who felt their financial situation difficult. The mean number of different types of natural setting did not vary with age, but was higher among those employed and working from home often or always, with bachelor degree or higher, incomes above AUD 150,000, and with higher nature relatedness scores.Approximately 52.0%  of the sample visited their preferred green or blue space at least once a week in the last 4 weeks . The oddAbout 25.7% of the sample felt they had been able to reconnect with neighbours thanks to visiting nature during the COVID-19 pandemic . Levels Feelings of solace and respite from visiting green or blue spaces during the COVID-19 pandemic were reported by 53.7% . The odds of feeling solace and respite were higher among males, participants working from home, retirees, those with a Bachelor’s degree or higher, and especially with higher nature-relatedness scores. The odds were of feeling solace and respite lower with age, especially among the ≥75 s.Discovery and use of green or blue spaces that participants had not had the opportunity to visit prior to the COVID-19 pandemic was 27.1% of the sample . Higher odds were reported among males, those consistently working from home, and participants with higher nature-relatedness scores. Lower odds were reported with age.Despite being in lockdown, residents of Melbourne reported the highest levels of felt connection with neighbours (35.9%), solace and respite (67.8%), increased levels of walking and other exercise in green and/or blue spaces (52.1%), and discovery of new natural settings (44.6%), compared to peers in most other areas of Australia. Adjusting for individual factors explained about 30% of the geographic variation in increased levels of walking and exercise, and about 61.4% of geographic variation in the discovery of new green and/or blue spaces.Adjusted analysis of the five most populous cities in Australia  indicateAdjusted analysis of the five most populous cities indicated fewer hours spent in green and/or blue space in the last 7 days among people in Adelaide compared to Sydney , but no major differences with other cities. People in Melbourne tended to visit a greater variety of natural settings than their counterparts in Sydney . Odds of visiting preferred green and/or blue space at least once a week for the past 4 weeks were notably higher in Melbourne  and Perth  compared with Sydney.Adjusted between-city analysis with Sydney as the reference group in Compared to Sydney, people in Brisbane , Adelaide  and Perth  had lower odds of visiting natural settings more often since the pandemic began. People in Adelaide reported lower odds that visits to green and/or blue spaces had helped to keep them connected  and lower odds of walking or exercising in them more often , as well as lower odds of discovering new natural settings  compared with Sydney-based participants. Participants in Perth also had lower odds of reporting increases in exercising in green and/or blue spaces since before the pandemic  and discovering new natural settings  compared to people in Sydney.Various findings from our study provide new evidence and indicative avenues for further research on inequities in green and blue space contact and consequences for population health and health inequity during the COVID-19 pandemic and beyond. Evidence was found in support of our first hypothesis with respect to perceived financial wellbeing and education level. People in socioeconomically disadvantaged circumstances tended to visit green and/or blue spaces less often, and feel less benefit from those visits, in comparison to their more affluent counterparts. For example, people reporting financial difficulty spent less time overall and visited fewer different types of green and blue spaces, visited their preferred natural settings less often, and were less likely to feel those visits kept them socially connected compared with financially comfortable counterparts. Moreover, people with university degrees compared to those with less than a year 12 education tended to report better access to, and were more likely to derive respite and social connection from visiting green and/or blue spaces. To what extent these socioeconomic inequities in felt benefits of green and/or blue space are attributable to known socioeconomic differences in the perceived quality of those natural settings ,34, and/to stay connected with… neighbours” if those people did not know their neighbours before the COVID-19 pandemic. This does not dismiss the possibility of new relationships developing. Accordingly, these results indicate the need to examine associations between green space, social capital and related societal issues  in futuIn contrast to our first and second hypothesis, no evidence was found to indicate that Melbourne residents—who were in an extended ‘lockdown’ during the survey—were disadvantaged in terms of access, visitation and felt benefits from green and/or blue space relative to counterparts living in Australia’s four other most populous cities. In fact, Melbourne residents compared to those in Sydney consistently reported increased visits and discovery of new green and blue spaces, and those visits facilitated increased levels of walking and exercise, social connection and respite during the pandemic. From this, we hypothesise that the antecedent condition of the ‘lockdown’ may have generated circumstances in Melbourne wherein experience of visiting green and/or blue spaces became especially acute and meaningful. Such circumstances were likely entwined with closure of other settings where people may usually derive some form of exercise, connection and relief, such as gyms. Another contributing factor is likely to have been that Melbourne residents, compared to those in Sydney, lived closer and were notably more likely to have visited their preferred natural settings at least once a week in the past month, visited a wider range of green and/or blue spaces, and spent similar amounts of time in nature in the past week. Maintenance of visitation despite lockdown is likely to have been facilitated by relatively shorter distances to the nearest green and/or blue space in Melbourne compared with Sydney. Moreover, evidence indicated that Melbourne residents were not only more likely to prefer the green and/or blue spaces nearest their home, but also had shorter distances to walk if they preferred another further afield. Previous work indicates generally more equal distributions of green space across socioeconomic indicators in Melbourne ,36. In sOne more result merits special attention. Participants with stronger preferences towards natural settings consistently reported greater levels of visitation and felt benefit relative to their peers with lower so-called ‘nature relatedness’ scores. Supply side interventions such as urban greening strategies and improvements in access to blue spaces are no ‘one-size-fits-all’ panacea. Previous literature indicates people with more positive attitudes towards natural settings tend to visit parks more frequently ,4. Our rStrengths of the study include a high response rate and a sample with coverage across all states and territories that enabled nationally representative estimates. Coverage of the five most populous cities was also a strength, especially as it permitted comparison of Melbourne, in ‘lockdown’ during the survey, with other cities like Sydney, which was not. The study is limited by cross-sectional design and self-reported data. Some previous research indicates a mismatch between perceived and actual access to green space . HoweverIn conclusion, people with greater socioeconomic disadvantage, such as those experiencing financial difficulty, were less likely to visit green and blue spaces during the COVID-19 pandemic. Even when they did, they were less likely to derive benefits from those visits. People who were able to work from home did accrue benefits from contact with natural settings, especially in terms of respite and exercise, though the lack of reported increase in social connection merits further inquiry. Lastly, rather than being disadvantaged by the experience of ‘lockdown’ with respect to visiting natural settings, residents of Melbourne tended to visit them more frequently and reap greater benefits from green and blue spaces compared with their peers in Sydney. This provides foundation for further research to explore potential felt benefits of green and/or blue spaces for other aspects of health and wellbeing during the COVID-19 pandemic within the context of this ‘natural experiment’. Overall, these findings underline the value of implementing strategies that equalise access to green and blue spaces in so that everyone has opportunities to benefit, while also highlighting that parallel efforts to generate (or renew) felt connection to natural settings, to increase working from home opportunities, and to mitigate financial difficulties may also be important to help maximize the population health benefits for all.


HPV persistent infection is a strong carcinogenic factor that can induce cervical cancer. Investigation of HPV epidemiology and genotype distribution is of great meaning for the development of cervical cancer prevention and control strategies.By using PCR-based hybridization gene chip assay, HPV genotype was detected from 14,185 women that came from HEC  or OGOC (Obstetrics and Gynecology Outpatient Clinics) between 2015 and 2017 in Sichuan area. The epidemiology and genotype distribution as well as the relationship between HPV infection and histology/cytology abnormalities were analyzed.p < 0.05. The prevalence of HPV reached peak at age 41–50 (5.86%) in HEC group, but at age 21–30 (14.74%) in OGOC group. Of all the HPV positive women, single genotype infection was the most common form in both HEC and OGOC group . Three most prevalent HPV types were HPV-52 (5.02%), 58 (3.61%), and 16 (3.24%) in total screening population. Of all the HPV positive women, the top three types were HPV-52 (20.93%), CP8304 (15.32%), and 58 (14.42%) in HEC group, while were HPV-52 (21.14%), 16 (16.34%), and 58 (15.61%) in OGOC group. HPV 52/16/58 accounted for 41.84% of cytology and 56.52% of histological abnormalities.The positivity rate of HPV was 23.84%. The HPV-positive rate of OGOC group (37.62%) was significantly higher than that of HEC group (15.29%), Women in Sichuan area were facing the great threat of HPV infection, especially the women aged between 21 ~ 30 or 41–50 years old. The priority HPV types were HPV 52, 58, and 16 in OGOC group, while were HPV 52, CP8304, and 58 in HEC group. HPV 52/16/58 accounted for the majority of cytology and histological abnormalities. Our analysis was found to be valuable for providing a scientific basis for the prevention and control strategies of cervical cancer in Sichuan area. Cervical cancer is the fourth most common cancer and the fourth leading cause of cancer death for women, with an estimated 570, 000 case and 311,000 deaths in 2018 worldwide, which is a serious threat to female health, especially in developing countries [Human papillomaviruses (HPVs) are non-enveloped, double-stranded circular DNA viruses. To date, over 170 types of HPV have been identified, of which 40 infect the genital tract. Generally, HPVs could be divided into low-risk categories  which were mainly found in the genital warts, and high-risk categories ,the persistent infection of which has been recognized as a strong carcinogenic factor to induce cervical cancer [HPV vaccines have showed a great potential on the prevention of cervical cancer. The prophylactic injection of HPV vaccine can decline vaccine-type HPV infection and substantially lead to reductions in HPV-associated cancers . Howeverhttp://www.stats.gov.cn/). Several studies aimed to investigate the epidemiology and genotype distribution of HPV in this area recent years, however, the results varied a lot [Sichuan, a province in southwestern China, has the fourth largest population in the country, with a permanent population of 83.41 million in 2018 and obstetrics and gynecology outpatient clinics (OGOC) during 2015–2017. We also assessed the relationship between type-specific infection of HPV and the histology/cytology triage, Our study might provide a scientific basis for the prevention and control strategies of cervical cancer in Sichuan area.A total of 14,185 women who participated in HPV screening in HEC or OGOC of Sichuan People’s Hospital were included from 2015 to 2017. The participants were enrolled according to the following selection criteria: (1) was mentally and physically competent; (2) was sexually active women of any age; (3) was willing to undergo HPV testing. The age of the patients ranged from 14 to 78 years old with an average of 39.93 ± 10.38 years.Samples exfoliated cervical cells were collected by using plastic cervical swabs. Each plastic swab was mixed well with 1 ml of specimen transport medium  and store immediately at 4 °C, and finally sent to our clinical laboratory within 1 day for HPV analysis.HPV DNA extraction and genotyping DNA was performed by using Alkaline Lysis Method Kits  and HPV GenoArray Test kit  according to the manufacturer’s protocol , 14 The For cytology test, cervical slides were prepared using Liquid-PREP™ System . The slides were evaluated for cervical cytology by two academic cyto-pathologists of Sichuan Provincial People’s Hospital. Cytological classifications of disease grade were made in conformity to the Bethesda 2001 criteria, including negative of intraepithelial lesion or malignancy (NILM), atypical squamous cells of undetermined significance (ASCUS), atypical gland cell (AGC),low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intra epithelial lesion (HSIL) and invasive cervical cancer (ICC).For cervical biopsies, Digital Electronic Colposcope  was used by specially trained physicians to perform the cervical biopsy tissue collection. The histology results were obtained by two academic Gynecology doctors of Sichuan Provincial People’s Hospital. A diagnosis was assigned to each case, as having NO Lesion, cervical intraepithelial neoplasia grade 1 (CIN 1), CIN 2, CIN 3, cervical cancer (CA).2 test was performed to evaluate the significance of differences between designated groups. All analyses were two-sided and interpreted as being significant at p < 0.05.All statistical analyses were performed using SPSS 22.0 software . Type-specific prevalence of HPV infection and their exact binomial 95% confidence intervals (CI) were calculated. Pearson’s χp < 0.05  was significantly higher than that of HEC group (15.29%), All the participants were divided into seven groups according to their age . The prevalence of HPV reached a peak at 21–30 years and 41–50 years, with a positive rate of 6.70 and 6.42%, respectively. Specifically, the prevalence of HPV reached peak at 41–50 years group (5.86%) in HEC group, but at 21–30 years group (14.74%) in OGOC group (Table p < 0.05).For all the HPV positive women, single genotype infection was the most . Among the multiple infection cases, double genotype infection was the most, and the infection rate decreased significantly as the number of infected genotypes increased  and 6 low-risk types . In our study, the top three prevalent HPV types were HPV-52 , 58 , and 16  in total screening population, which followed by CP8304  and 53. As shown in Table Figure Among the 3382 HPV positive women, 318 were performed cervical biopsy, and 59 women were identified to be histological abnormalities (accounting for 18.55%). The single-genotype infection was still the main infection mode in CIN I , CINII , CIN III  and CA  group. The most common genotypes are HPV 58 (35.14%), 52(27.03%), 16(21.62%) in CIN I group, HPV 16 (70.59%), 52/33, 51/39 in CINIIgroup, HPV 58/16  in CIN IIIand HPV16/18/51/58  in CA group , followed by South America (14.3%), Asia 8.7%), and Europe (5.2%) %, follow–17. The %, and EuConsidering the age of infected women, we found prevalence of HPV infection reached a peak at 21–30 years and 41–50 years group. This double-peak result was also found in other area of China, such as Hangzhou and Chongqing , 23. HowIn our study, among the HPV positive population, we demonstrated that single genotype infection was the most, which were basically consistent with data of Tao et al. .According to HPV prevalence survey, the most prevalent genotype worldwide was HPV 16 (2.41%), followed by HPV 58 (1.25%) and 31(1.07%) , 22–24. Persistent infection of high-risk HPV was a strong carcinogenic factor to induce cervical cancer. In present study, the prevalence of high-risk HPV was 81.41, 88.57, and 100% in ASCUS, LSIL and HSIL, respectively. The top genotypes were HPV52 in ASCUS, HPV 66 in LSIL, and HPV 58 in HSIL. HPV 52, 58, 16 accounted for 41.84% of cytology abnormalities. These results were consistent with the data of He et al., except for the HPV 66, 39 in LSIL, which may due to the bias of sample size [Among histological abnormalities, the prevalence of high-risk HPV were 89.83, 96.30, 100, and 100% in CIN I, CINII, CIN III and CA. The top three genotypes were HPV 58 (21.62%), 5227.03%), and 16(21.62%) in CIN I group, HPV 16 (70.59%), 52/33, 51/39 in CINIIgroup, HPV 58/16  in CIN III and HPV16/18/51/58  in CA group. HPV 52, 58, 16 accounted for 56.52% of histological abnormalities, which was consistent with several studies that investigated the relationship between HPV genotype and histological abnormalities in Sichuan area. These studies demonstrated that HPV 16, 58, 52 infection accounted for a large percentage of histological abnormalities .03%, and.HPV vaccine was introduced to China in 2017. The bivalent vaccine  was available since August 2017, and the quadrivalent vaccine  was available since December 2017 in Sichuan province . Thus, oThere were several limitations in this study. One was the absence of data from other areas in Sichuan province, which meant these results might not represent all women in Sichuan. Second, detailed information of population  was not available for us to evaluate the effect of these characteristics on the prevalence of HPV infection. Third, we have not performed the analysis on the genotypes distribution of per age group, which limited the understanding on the prevalence of HPV at every age stage. Last, the case of cervical cytology or histology abnormalities was limited. Therefore, larger and prospective studies about the mechanism are needed to validate our findings.Women in Sichuan area are facing great threat of HPV infection, especially the women undergoing gynecological clinical symptoms. Women with ages of 21 ~ 30 or 41 ~ 50 years old should pay more attention to HPV infection. The most prevalent genotypes in HEC group are HPV 52/CP8303/58, while in OGOC group are HPV 52/58/16. HPV 52/16/58 accounte for the majority of cytology and histological abnormalities. These data could provide a scientific basis for the prevention and control strategies of cervical cancer in Sichuan area.Additional file 1: Supplementary Figure 1. Prevalence of HPV grouped by age in study population.


The upward trends of vaccine exemptions in Texas are alarming. While HPV vaccine rates in this State are among the lowest nationwide, factors that contribute to the low HPV vaccination uptake among adults remain unknown. In this study, we examined the main reasons for not receiving HPV vaccination among age‐eligible adults.The Texas health screening survey (2018), a multistage area probability design‐based survey of a representative sample of Texas residents, was used to identify 907 eligible adults (age ≥ 18 years) respondents, including 724 women aged ≤ 26 years in 2007 (≤38 years in 2018), and 183 men aged ≤ 21 years in 2011 (≤28 years in 2018). Participants who reported having never received an HPV shot, where asked the main reason for not receiving the vaccine.Overall, 58.5% (95%CI: 55.1‐62.0) of vaccine eligible adults reported having never received the HPV vaccine. The most commonly reported reasons for not receiving it were: did not know about the vaccine (18.5% (14.9‐22.1)), and provider did not recommend (14.1% (10.9‐17.4)). In contrast, commonly perceived reasons such as: safety concerns (7.2% (4.8‐9.5)), lack of insurance (3.4% (1.7‐5.1), and concerns about increasing sexual activity if vaccinated (0.2% (0.0‐0.5)), were less frequently reported.Among vaccine‐eligible adults, safety and sexuality concerns do not appear to be the prime factors underlying low HPV vaccination rates. Rather than emphasizing them, educational interventions should aim at improving vaccine's knowledge, and enhancing provider recommendations on the necessity of HPV vaccination. Among HPV‐vaccine eligible adults, lack of knowledge about the vaccine and lack of provider recommendations are the most commonly reported reasons for not receiving the HPV vaccine. In this population, educational interventions should focus on enhancing HPV vaccine's knowledge and provider recommendations of the necessity and awareness of HPV vaccination. Vaccines to prevent some HPV infections are available for men and women 9 ‐ 26 years of age and are sometimes called the HPV shot, Cervarix, or Gardasil. Have you ever received the HPV shot, Cervarix, or Gardasil? The possible responses were: Yes/No/Don't know. Participants who responded “No” were asked: (b) What is the main reason you have not received the HPV shot/ vaccine? Possible responses were: Provider did not recommend (a), Did not know about the vaccine (b), Vaccine not needed or necessary (c), Not required to get the vaccine (d), Safety concerns (e), Provider indicated could vaccinate later (f), Uninsured or insurance doesn't fully cover shots, or co‐pay or other costs too high (g), Shot could be painful (h), Vaccine not available (i), Difficulty making or getting to appointments/ transportation issues (j), Concern about increasing sexual activity if receive shot (k), Not sexually active (l), Some other reason (m).The main outcomes for this study were: (a) self‐reported receipt of HPV vaccine, and (b) self‐reported reasons for not receiving HPV vaccine. To measure these outcomes, we adapted two validated questions from the National Immunization Survey‐Teen (NIS‐Teen). In the Texas health screening survey, these questions were directed to adult respondents who were or have been eligible to receive HPV vaccination. We first asked: (a) 2.3Covariates were selected based on their potential influence on HPV vaccination uptake, including: socio‐demographic factors of age, ethnicity/race, nativity, educational attainment, marital status, occupation, rurality, and household income; behavioral and mental factors; and health‐related variables such as smoking status, health coverage, vaccination against Hepatitis B virus (HBV), hormonal contraception use, and family history of any cancer.2.4Data were weighted by ICF International, Inc, Fairfax, Virginia using a three‐dimensional raking approach with iterative post‐stratification based on sex, age, and race/ethnicity.33.1Table HPV unvaccinated vs vaccinated respondents were more frequently: aged between 29 and 38 years [36.2% 31.9‐40.5) vs 21.1% (15.3‐26.9)]; males [31.5% (26.7‐36.2) vs [26.7% (19.1‐34.4)], and NHWs [31.5% (27.0‐36.1) vs 27.0% (19.7‐34.3)]. HPV unvaccinated respondents were also more likely to: have a level of education not greater than 12 years [35.1% (30.6‐39.5) vs 27.7% (20.9‐34.4)]; and to reside in rural areas [(39.8% (35.2‐44.4) vs 34.9% (27.5‐42.4)], compared with their vaccinated counterparts.  vs 57.1% (49.4‐64.8)]; have health insurance [62.7% (58.2‐67.2) vs 68.5% (61.3‐75.6)]; be vaccinated against HBV [33.1% (28.7‐37.4) vs 73.7% (67.1‐80.4)]; and have a family history of cancer [50.8% (46.1‐55.4) vs 66.9% (59.7‐74.0)], compared with HPV vaccinated respondents. ); “uninsured or insurance doesn't fully cover shots” (3.4% 1.7‐5.1)); “concerns about increasing sexual activity if receive the vaccine” [0.2% (0.0‐0.5)]; and “difficulty making or getting to appointments, or transportation issues” (0.2% (0.0‐0.4)) ; Reasons for not having received HPV vaccination described according to respondents’ characteristics age, origin of birth, marital status, occupational status, income, residency, use of hormonal contraception, smoking status, availability of health care, vaccination status for hepatitis B, and family history of cancer are reported in the Table 4In this representative sample of adult Texas residents eligible for HPV vaccination, differences in socio‐demographic, health‐related, and behavioral characteristics were assessed between those who reported having ever received the HPV vaccine, and those who had never been vaccinated for HPV. Among eligible respondents who reported having not received HPV vaccination, we examined the reasons why they did not get the vaccine. To the best of our knowledge, this is the first study to assess individual's reasons for not receiving HPV vaccine in the Texas adult population, a state with an alarmingly low HPV vaccine uptake.Texas has experienced a 20‐fold increase in nonmedical exemptions of vaccination for students since 2003 when exemptions for religious and personal beliefs were enacted.HPV vaccination is routinely administered between 11 and 12 years with parental consent (2). However, catch‐up immunization is recommended for both men and women through early adulthood,In our study sample, lack of knowledge about HPV vaccine, lack of provider's recommendation, and perceived lack of necessity, were the most commonly reported reasons for not getting the vaccine. Interestingly, these reasons varied by certain demographics. Among women, the main reason for not getting the HPV vaccine was “did not know about the vaccine”, while among men, it was “not sexually active.” In a study assessing US parents’ reasons for lack of HPV vaccine initiation in their children, “safety concerns” was most frequently reported by parents of eligible girls vs “lack of necessity” by parents of eligible boys.Although the HPV vaccine was FDA approved to prevent cancer over a decade ago, eligible adults still report a lack of knowledge and understanding of its necessity. However, safety concerns, lack of insurance, transportation issues as well as some other concerns were less common in our study sample, suggesting that reasons commonly highlighted in mainstream media, such as anti‐vaccination beliefs including religious objections are not the prime factors underlying individuals’ perception of HPV vaccination in Texas.5Strengths of the study include its large sample size and the representativeness of the adult Texas population. The study is somewhat limited, however, in its ability to detect simultaneous reasons individuals may hold, as the question was framed to assess the “main” reason for not getting the vaccine. Because information about whether or how often eligible individuals visited a healthcare provider was not available, we could not distinguish between respondents with missed clinical opportunities for HPV vaccine recommendation, and those unexposed to provider recommendations. While the self‐report of the vaccine status by study participants could yield a certain level of “misclassification” bias, substantial agreement between electronic medical reports of the vaccine status and self‐reported data were noted for HPV vaccination.6In this study, individual reasons for not receiving the HPV vaccine were assessed among eligible adults. A substantial proportion of age‐eligible adults in Texas reported lack of knowledge or lack of provider recommendation as the main reasons for not receiving HPV vaccine. Rather than emphasizing on safety or sexual activity, educational interventions should focus on the necessity and awareness of HPV vaccination. Providers’ recommendation for HPV vaccine should be reinforced, and further adapted to older age groups.The authors declare no potential conflicts of interest.Concept and Study Design: Fokom Domgue, Shete. Data Analysis: Yu. Interpretation of the data: Fokom Domgue, Cunningham, Yu, Shete. Initial Draft: Fokom Domgue. Critical revision of the manuscript for important intellectual content: Fokom Domgue, Cunningham, Yu, Shete. Obtained Funding and Study Supervision: Shete.The funders had no involvement in design and conduct of the study; analysis and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.TableS1Click here for additional data file.


INK4a/Ki-67 dual stain cytology.Screening of unvaccinated women remains essential to mitigate the high morbidity/mortality of cervical cancer. Here, we compared visual inspection with acetic acid (VIA), recommended by WHO as the most cost-effective screening approach in LMICs, with HPV-based screening, and usage of p16INK4a /Ki-67 (CINtecPLUS®) dual stained slide that was prepared using the ThinPrep® 2000 Processor and evaluated by a pathologist trained in the methodology.We prospectively enrolled women participating in a VIA-based cervical cancer screening program in two peri-urban health centers of Kenya. Consenting women had a VIA examination preceded by collection of a liquid-based cytology sample from the cervix stored in PreservCyt medium (Hologic®). Analysis of all samples included a hrHPV DNA test and evaluation of a p16INK4a/Ki-67 positive transforming infection was 13% (95%CI 2–38).In 701 of a total of 800 women aged 18–64 years, all three investigations were performed and data could be analyzed. The HPV, VIA and dual stain cytology positivity were 33%, 7%, and 2% respectively. The HPV positivity rate of VIA positive cases was 32%. The five most common HPV types were HPV16, 52, 68, 58 and 35. The OR among HIV infected women of an HPV infection, VIA positivity and positive dual stain cytology were 2.6 (95%CI 1.5–4.3), 1.9 (95%CI 0.89–4.4) and 3.4 (95%CI 1.07–10.9) respectively. The sensitivity of VIA to detect a p16INK4a/Ki-67 dual stain cytology as a triage test for HPV positive women in LMICs should be further studied.Primary HPV testing appears feasible and should be considered as a primary screening test also in LMICs. The poor sensitivity of VIA renders it unsuitable as a triage test for HPV positive women. The utility of p16 Cancer of the uterine cervix  is the leading cancer in women in Sub-Sahara Africa . New cerHistorically, the most impressive screening results were achieved in industrialized countries by regular cytological assessment of the cervix using the Pap test , 7. HoweInstead, for low-income countries the visual inspection of the cervix after application of acetic acid (VIA) coupled with subsequent management of abnormalities by cryotherapy is recommended, in what is now commonly referred to as “screen and treat” strategy –16. VIA A hrHPV infection is a necessary factor for cervical cancer development , 21 and INK4a/Ki-67 dual stain cytology has been most extensively studied. This immunocytochemistry test detects cells that have undergone neoplastic transformation in the course of a persistent HPV infection, a stage in the HPV-mediated cervical carcinogenesis that is also called a transforming infection and that correlates morphologically with a CIN2/3 lesion  Version 9.4. Cary, NC: SAS Institute Inc.. For Kappa agreements GraphPad was used  and Moi University, Eldoret, Kenya, and the Institutional Review Board of the Heidelberg University Hospital, Germany.Of the 800 enrolled women, 701 (87.6%) had all three tests  available for evaluation The baseline characteristics are summarized in Table The overall test positivity of HPV, VIA and dual stain cytology were 32.5%, 7.1%, and 2.3% respectively (Table p = 0.0002), age (p = 0.023) and multiparity (p = 0.029) and between positive dual stain cytology and HIV status (p = 0.029). No significant association was found between positive VIA and any of the above risk factors. The odds of an HPV infection among HIV positives were 2.6 times higher than among HIV neg (95%CI 1.5–4.3). The odds of a positive VIA among HIV positives were 1.9 times higher than among HIV neg (95%CI 0.89–4.4). The odds of a positive dual stain cytology test among HIV positives were 3.4 times higher than among HIV negatives (95% CI 1.07–10.9).In logistic regression models including the risk factors ‘age over 30 years’, ‘HIV-infection’, ‘multipara’, ‘hormonal contraception’ and ‘multiple partners’ a significant association was found between HPV infection and HIV status ) and specificity (0.93 (95% CI:0.89–0.96)), the PPV (0.12 (95% CI:0.03–0.36)) performed slightly better but the negative predictive value (0.93 (95% CI:0.92–0.95)) fared worse , only poorly correlated with the HPV test, as nearly 2/3 of VIA positive women had no HPV infection and would thus be overtreated.INK4a/Ki-67 dual stain cytology in order to differentiate common, and often spontaneously clearing HPV infections from persistent, transforming infections, and their morphological correlate, a CIN2+ lesions. When comparing VIA with dual stain cytology we found that VIA only detected a small fraction of transforming HPV infections and only few among them were HPV 16 and/or 18 infections, which have the highest potential to develop cancer.We used p16A primary HPV testing strategy should be considered also in resource-poor countries. Provided its cost-effectiveness is established, dual stain cytology could be a suitable triage test. The assistance of an electronic data system will greatly facilitate such a multi-contact approach.We found a high overall burden (32.5%) of high-risk HPV infections in our study population, similar to results from another study in our Western Kenya region . A numbeThe five most common genotypes in our study were HPV16, 52, 68, 58, 35. Again, the genotype distribution is influenced by the state of the cervical disease, the geographic region as well as by technical issues including the HPV platform used, assay cut-offs and the selection of hrHPV types included in the analysis. In our study we were able to classify the genotype distribution according to the dual stain cytology findings. A strong association of HPV16, 18 and also HPV31, 58, 68 was found with dual stain cytology positive cases consistent with findings of a meta-analysis that compared normal and HSIL cases in East Africa . In the Surprisingly we found a high burden of HPV68, a genotype that is uncommon in epidemiological surveys worldwide. In our study the high proportion of HPV68 was found both in the dual stain positive and dual stain negative cases. Two-third of HPV68 was associated with multiple infections and its frequency was more than 2 times higher in HIV infected women. This is consistent with another study in the same region of Kenya where a high HPV68 prevalence among HIV-infected women was found . A studyThe overall VIA positivity in our study population (7.1%), diagnosed by well trained and experienced VIA nurses was similar to reports from India , CamerooThe dual stain cytology positivity of 1.9% in the HIV uninfected population reflects the expected proportion of CIN2+ lesions in similar unscreened populations , 50. AlsAll but one dual stain positive samples were also HPV positive. Possible explanation for such rarely found case –54 couldThe detrimental effect of an HIV /HPV co-infection is well known , 56. HIVHIV-infected women in our study carried significantly more single and multiple hrHPV types compared to HIV-negative women. Among the currently available HPV vaccines the nonavalent (9v) vaccine would provide additional protection. Given the substantial number of non-9v hrHPV infections among HIV-infected women found by us and others , 61, howWhen comparing the studied screening techniques, the poor agreement between HPV status and VIA diagnosis is striking. Only 32% (16/50) of VIA positive cases were hrHPV positive or two third of women would be overtreated based on the VIA test result alone which is consistent with a study from Cameroon where half of all VIA/VILI-DC positive women had no associated hrHPV infection .INK4a/Ki-67 has a well documented high sensitivity and specificity for identifying the presence of (pre-)cancer [INK4a/Ki-67 positive transforming infections cancer , 62. TheAs primary HPV testing will likely become the standard of care for cervical cancer screening in both low- and high-resource settings, the search for a suitable triage strategy to avoid overtreatment is crucial , 63–65. Dual stain cytology is currently the most extensively studied molecular triage test , 68–70, INK4a/Ki-67 is a very strong but not a definitive predictor of malignant degeneration (high-grade dysplasia). The gold standard for the diagnosis of high-grade cervical dysplasia is a cervical biopsy. Unfortunately, we could not perform colposcopies and biopsies for case ascertainment. Also, we used two different HPV DNA tests in our study, a nucleic acid hybridization test [There were some limitations to this study. p16ion test  and a PCion test . FinallyINK4a/Ki-67 dual stain cytology is an excellent triage test for HPV positive women, its utility for LMICs needs to be further studied.Our findings underscore the superior performance of HPV-based cervical cancer screening over VIA screening in detecting disease at-risk women. When used as triage of HPV positive cases in our high-prevalence setting the positive predictive value of VIA improved, but remained still flawed by an unacceptably low sensitivity. HPV testing should be considered as a primary screening test also in LMICs. P16


Background: Human papillomavirus (HPV) DNA detection in cervical samples is widely used to identify HPV infection; however, there is little detailed evaluation of the characteristics of HPV prevalence by repeated DNA detection in community populations.Methods: Beginning in 2014, a Papanicolaou (Pap) smear and HPV cotesting program was implemented among older women living in the Minhang district of Shanghai. This report uses information from 225,000 participants, who provided person-time data. Of these, 632 subjects had 3 repeated visits and at least one HPV DNA-positive result in the last 5 years.Results: All 16 genotypes of HPV displayed thrice, twice, and once positivity results in 3 repeated tests and differed by proportions among and within genotypes. HPV52 and 58 are the two most dominant genotypes in total and in thrice positive person-time. The thrice positive person-time exceeded 50% in each of HPV58-, 35-, 52-, 56-, 18-, 68-, 31-, and 16-infected women. The single positive person-time ratio ranged from 7.9% (HPV35) to 38.9% (HPV11). Age differed among and within genotypes in thrice, twice, and once positive women. The average age of HPV-free controls was 59.0 ± 7.2 yo, which is close to the median of average ages for thrice and twice positive women and is older than most average ages for once positive women. The percentages of negative results for intraepithelial lesion or malignancy (NILM) for thrice HPV52-, 58-, 16-, 56-, and 59-positive women were significantly lower than the percentage of NILM for HPV-free women.Conclusion: Thrice and/or twice HPV DNA positivity are common in HPV-infected women and tend to occur in older women. It has been established that persistent high-risk human papillomavirus (HR-HPV) infection is associated with high-grade cervical precancer –3. In thHPV persistence is commonly defined as two or more viral DNA-positive time points –11. A reLearning how long an HPV infection will persist has practical significance. Although persistent infection is theoretically determined primarily by the organ HPV infects and the host's immune response, the exact natural history of HPV infection is difficult to reveal owing to the lack of classic dynamic immune processes shown by a virus that causes viremia. Thus, repeated HPV DNA detection could promote the understanding of the duration of virus infection. Under this premise, a study focused on infection persistence is critical in determining the temporal correlation between a given HPV infection and the occurrence of cervical lesions. In addition, an accurate understanding of the duration of virus infection provides a theoretical basis for improving the ability to clear HPV infection by procedures such as loop excision, conization, and cryotherapy.Beginning in 2014, a Pap smear and HPV cotesting program was implemented among older women living in the Minhang district of Shanghai. Among person-time data from 225,000 participants, 632 subjects had 3 repeated visits and at least one HPV DNA-positive result in the last 5 years. This report evaluates the proportions, age distribution, and cervical cytological examination of thrice, twice, and once HPV DNA-positive women.This is a retrospective study focused on older women living in the Minhang district of Shanghai. As we reported previously , the ShaAs we reported previously , all cytAs we reported previously , at the t-test, chi-squared test, or Fisher's exact probability test, as appropriate. All statistical analyses were performed with the aid of SPSS software , and the significance level was set at α = 0.05.Because our participants had 1–3 results for a given variable, person-time was adopted in the statistical analysis. Continuous variables are presented as the means ± standard deviations, and categorical data are presented as frequencies with percentages. Differences between and within groups were evaluated using one-way ANOVA, N = 23,196) assembled in the first half of 2017 were adopted as “controls.” As shown in A community-based screening program with Pap smear and HPV cotesting yielded 225,000 person-time data from 2014 to 2019. A total of 12,706 person-times had at least 1 positive test for any HPV DNA over the 5 years. Among these, 632 subjects with 1,020 person-time data were involved in this analysis . All HPVThe person-times of thrice, twice, and once HPV DNA-positive tests for each strain were calculated. To determine the distribution of thrice, twice, and once HPV DNA-positive rates among strains, the above person-times were divided by total person-time  and plotted in order from high to low thrice and twice positive rates. As shown in To determine the distribution of thrice, twice, and once HPV DNA-positive rates within each strain, the above person-times were divided with the total person-time of each HPV strain and plotted in order from high to low of thrice positivity. As shown in In this report the period duration (last test date – first test date) of thrice and twice HPV DNA positive tests ranged from 2 to 4 years. Since this study is not specially designed to determine the true duration of HPV infection and the time nodes are artificially controlled, we did not pursue further analysis of the period here.The average ages of women thrice, twice, and once positive for HPV DNA were calculated for each strain. One-way ANOVA showed that the average ages differed by strain in both thrice and twice HPV DNA-positive women. The average age of HPV-free controls was 59.0 ± 7.2 yo, which was close to the median of the average ages for thrice and twice HPV DNA-positive women and older than most of the average ages for once HPV-positive women .For HPV66 and 39, the average ages of thrice positive women were significantly greater than those of twice positive women. For HPV66, 11, 16, and 51, the average ages of thrice positive women were significantly older than those of once positive women. For HPV18, 51, and 52, the average ages of twice positive women were significantly greater than those of once positive women. As an exception, for HPV59, the average ages of twice positive women were significantly greater than those of thrice positive women .The percentages of NILM in women who were thrice, twice, and once positive for HPV DNA were calculated by strain. The percentage of women NILM among HPV-free women was 97.8%. For the thrice HPV DNA-positive women, In this report, the distribution trends of thrice, twice, and once positivity for HPV DNA of 12 HR-HPVs , two possibly carcinogenic genotypes (66 and 68), and two LR-HPV strains (6 and 11) were assessed in local older women. Our data shows that thrice and/or twice positivity for a given HPV DNA is highly prevalent in these subjects. For the total 1,020 person-time HPV infection, HPV52 and 58 were the top two strains, constituting 20.3 and 15.3% of person-time in total  and 14.5 and 12.2% of person-time for thrice positivity. When this trend was isolated by strain, thrice positive constitutions exceeded 50% for HPV58, 35, 52, 56, 18, 68, 31, 16, and 33; HPV58, 35, and 52 were the top three strains with >70% thrice positive ratios. The prevalence of once DNA positivity was relatively higher for the two LR-HPVs, 11 and 6. Regarding the age trend, the average age differed by strain in thrice, twice, or once HPV DNA-positive women. In general, the more positive test results women had, the older they were on average for HPV 66, 11, 16, 18, 51, 52, and 39. Although most HPV-infected and HPV-free women were NILM in cervical cytology, the percentages of women with thrice positivity for HPV52, 58, 16, 56, and 59 and women with twice positivity for HPV31 and 51 were significantly lower than the percentage in HPV-free controls.Extrapolating from existing knowledge, once positivity for HPV DNA detected by a reliable approach, might mean a recent acquisition either as a new infection or reinfection, activation of a latent virus, and/or persistent infection . HoweverPostmenopausal women form secondary population peaks of HPV infection due to senescence of cell-mediated immune control and possible new sexual partners , 14, 15.Our previous report showed that 3.9, 7.6, and 5.1% of HPV-positive women displayed cervical cytology of ASC-US, LSIL, and HSIL, respectively. In this report, LSIL and HSIL were rare, and 95.2% of person-time were NILM. This result might benefit from a long-term and continuous screening program for cervical lesions in Shanghai. In addition, a study showed that older women with a long-term HPV infection had no cytological signs and a very small risk of subsequent cervical cancer . AlthougReports have shown that HPV52, 16, and 58 were the top three most dominant HR-HPV genotypes prevalent in local areas, with positivity rates of 23.0 ~ 23.9%, 17.7 ~ 18.0%, and 16.9 ~ 15.7%, respectively  approved the study protocol . The patients/participants provided their written informed consent to participate in this study.LX and LJ: conception and design of study, revising the manuscript critically for important intellectual content, and drafting the manuscript. GH and JX: analysis and/or interpretation of data. All authors: approval of the version of the manuscript to be published and acquisition of data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.