Women’s health in resource-limited settings can benefit from the integrated management of high-burden diseases, such as female genital schistosomiasis (FGS) and human papilloma virus (HPV)-related cervical cancer. In schistosomiasis-endemic countries such as Madagascar, data on FGS and HPV prevalence are lacking as well as preventive measures for both conditions. This study aims to estimate the prevalence of FGS and HPV in rural Madagascar, and to examine associated risk factors to identify opportunities for improving women’s health.CIs).After initial community outreach activities, interested women aged 18–49 years were recruited consecutively in 2021 at three primary health care centers in the district of Marovoay. FGS was detected by colposcopy. Colposcopy images were double-blind reviewed by two independent specialists. A Luminex bead-based assay was performed on cervical vaginal lavage specimens for HPV typing. Crude (CPR) and adjusted prevalence ratios (APR) of associations between selected factors and FGS and HPV positivity were estimated using univariable and multivariable binary Poisson regression with 95% confidence intervals (CI: 56.9–68.1) cases of FGS were detected. A total of 129 women  tested positive for HPV. In total, 80 women  tested positive for both conditions. No association was observed between FGS and HPV positivity, while previous pregnancy  and older age  are showing a negative association with HPV infection compared to no previous pregnancy and younger age groups.Among 500 women enrolled, 302 had complete information on FGS and HPV diagnosis, and were thus eligible for analysis. Within the sample, 189 (62.6%, 95% The results of the study show that FGS and HPV are highly prevalent in rural Madagascar. The concurrent prevalence of these two conditions requires urgent adaptations of public health strategies to improve women’s health, such as integrated services at primary level of care.Theonline version contains supplementary material available at 10.1186/s40249-023-01139-3. Health is a human right and, as such, health care should be accessible to all, regardless of gender, or geographical location. In the African Region, women are more likely to die from communicable diseases and other conditions than women in other regions , 2. AddiFemale genital schistosomiasis (FGS)  and cervSchistosoma haematobium [S. haematobium can also culminate in FGS, leading to ectopic pregnancy, infertility, cervical lesions, and not last, social stigma [FGS is a common consequence of schistosomiasis, a parasitic disease caused, in its urogenital form, by the trematode matobium . The depmatobium , 12. Chrl stigma . The worl stigma . Human sl stigma .Schistosomiasis control strategies in highly endemic areas are mostly based on preventive chemotherapy through mass drug administration (MDA) with 40 mg/kg praziquantel (PZQ) for school aged children . In contColposcopy is also a key clinical diagnostic tool for the prevention and management of CC . CC is tAt the current state of the art, few studies have explored the associations of FGS, HPV infection and CC . Though,Among SSA-countries, Madagascar is one of the countries with the highest prevalence of schistosomiasis –41. CC iS. haematobium [This study is based on data collected in the Boeny region of Madagascar, known to be highly endemic for matobium . To our This cross-sectional study was conducted at three Primary Health Care Centres (PHCCs) in the district of Marovoay in the Boeny region of Madagascar: PHCC of Antanambao-Andranolava , PHCC of Ankazomborona  and PHCC of Marovoay-Ville . Available data from health districts do not allow the classic categorisation based on the degree of urbanisation , althougS. haematobium in the adult population and a population at risk of 25% to acquire FGS [The study area has been selected due to their estimated prevalence of more than 50% of uire FGS . An estiuire FGS . The thruire FGS .Following an awareness campaign from September 2020 to February 2021, enrolment lists were made available at the three PHCCs, where women had four months to express their interest in participating in the study. Women in the study area were contacted and invited to the PHCCs for a gynaecological consultation on a first-come, first-served basis, and the first 500 registered women were enrolled in the study. In order to assess overall adherence to the service, all women who expressed an interest in participating were registered. Eligibility criteria were: (i) aged between 18 and 49 years; (ii) fluent in French or Malagasy; and (iii) voluntary written informed consent. Exclusion criteria for the study was pregnancy.Participants were recruited between December 2020 and February 2021, with examinations and data collection taking place between March and August 2021. Prior to gynaecological examinations and sample collection, six study midwives were trained to perform colposcopy for diagnosing FGS. At recruitment, each participant was assigned a unique identifier to ensure anonymous identification and attribution to each image captured. To each sample, a unique corresponding sample identifier was assigned. Conformity and quality control were performed at laboratory level prior to storage. Background characteristics of the participant, such as socio-demographic information, clinical history, and personal habits were captured in case report form (CRF).® database [All CRFs were checked for missing entries manually by study midwives and researchers following standard operating procedures. Double data entry was used to feed the REDCapdatabase , 47. Qua® collection tubes. Samples were stored according to standard conditions [After insertion of a disposable plastic speculum, the gynecological examination was performed in three steps: (i) cervicovaginal lavage (CVL); (ii) visual inspection; and (iii) image capture. Inspection of the mucosal surfaces was performed with the colposcope based on an adapted protocol from Singer and Monaghan . At eachnditions  before sAll images were reviewed within twelve hours by an experienced gynaecologist. All women suspected of any gynaecological condition different from FGS were invited to the university hospital of Mahajanga for further investigations. Standard treatment for FGS (single dose of PZQ 40 mg/kg) was offered free of charge for all diagnosed pathologies.: (i) abnormal blood vessels; (ii) rubbery papules; (iii) homogeneous yellow sandy patches; and/or (iv) grainy sandy patches on colposcopy. The final diagnosis of FGS was determined by a post-recruitment evaluation of the COLIM revised through a double-blinded assessment of two FGS expert gynecologists (ZR and BR). The presence of one or more FGS signs as described previously was required to define a COLIM as positive. FGS negativity was defined as absence of those signs. Three categories were defined for classification of images: positive, negative, or indeterminate for FGS. Images that received a concordant rating were classified as either negative or positive and were included in analyses. Discordant ratings were classified as indeterminate and excluded from analyses. The presence of one or more FGS sign as described previously was required to define a COLIM as positive. FGS negativity was defined as no presence of those signs.At the PHCCs, women were considered positive for FGS if the study midwives identified one of the four cervicovaginal manifestations described in the WHO FGS atlas : (i) abnThinPrep media was centrifuged at 3300 × g for 10 min to pellet the cervical exfoliated cells. After removing the supernatant, DNA extraction was performed using the Qiagen BioRobot EZ1 with the EZ1 DNA tissue kit according to the manufacturer's instructions . DNA was eluted in 100 μl of elution buffer [CVL were analyzed at the International Agency for Research on Cancer (IARC) in Lyon, France. There, a standardized methodology aimed at identifying all HPV strains has been established and used for worldwide HPV surveillance –53. Sampn buffer , 54.The presence of HPV DNA was detected using a type-specific E7 PCR bead-based multiplex genotyping assay . The E7-MPG assay utilizes HPV type-specific primer pairs targeting the E7 region of 19 probable/possible high-risk (pHR) or high-risk (HR) HPV types  and two low-risk HPV types (HPV-6 and -11), plus primers for the amplification of a b-globin sequence . 10 μl oFollowing PCR amplification, 10 μl of each reaction mixture were analyzed by MPG using the Luminex technology as described previously  . BrieflyOverall and type-specific HPV prevalence was estimated as the proportion of patients who tested HPV DNA positive for a given HPV DNA type.® v.4.2.2 [. Continuous variables were described using means (with standard deviation) and medians (with interquartile ranges). Categorical variables were presented as frequencies and percentages . Only complete cases were considered for analyses.All analyses were conducted using R v.4.2.2 . ContinuCIs). Presence and combinations of possible FGS symptoms were described among FGS positives and negatives.Positivity rates of FGS, HPV and their co-presence were reported as proportions with exact 95% confidence intervals  was described. Univariable and multivariable binary Poisson regression  were performed to derive crude and adjusted prevalence ratios with 95% Ethical approval was obtained from the National Ethics Committee of Madagascar (ref. no. N°052-MSANP/CERBM) and the Ethics Committee Hamburg State Medical Chamber, Germany (ref. no. PV7309).All participants were informed of the aims and procedures of the study in Malagasy language. Participation in the study was voluntary, and informed consent for participation was obtained from the participant by signature or, in the case of illiteracy, by thumbprint in the presence of an independent witness. In all cases, participants had the right to refuse to participate and to withdraw informed consent at any time without giving reasons. No financial incentives were given for participation in the study. Diagnosed pathologies were treated according to national guidelines and free of charge.n = 7), technical problems (n = 4) such as power failure, because the woman was uncomfortable with the procedure and refused (n = 4), or because of religious or cultural beliefs (n = 2). CVL could not be performed in 12 cases because the woman was menstruating or otherwise bleeding (n = 7) or less frequently because of religious or cultural beliefs or fear of the procedure (n = 5). Among the images captured via colposcopy 63 images were not interpretable because of poor image quality  or because of lack of ID correspondence. After double-blinded revision, a total of 112 COLIMs were excluded from the analysis because a consensus between FGS positive or negative classification could not be reached. After CVL quality control 302 corresponding COLIMs and CVLs were obtained with complete data on both FGS and HPV acquisition.A total of 673 women expressed interest in taking part in the study Fig. . Among tn = 89) of participants had completed secondary school or higher, while in the rural community of Antanambao-Andranolava (ATA), 75.0% (n = 83) of participants had completed primary school.A total of 302 women were considered for analysis. The median age of the participants was 31 years (IQR: 25–37) (Table n = 237) of the participants were self-employed and the most common occupation among the women was farming with 57.0% (n = 173) (Table n = 95) of employed participants in the rural community ATA were farmers, only 34.0% (n = 48) in the urban community MVY were employed in this sector. While in the rural community almost all participants were employed with 99.0% (n = 110) in ATA and 92.0% (n = 46) in Ankazomborona , in the peri-urban community 12.1% (n = 17) were unemployed. Across all sites 76.0% (n = 228) of participants reported that their husbands as the main contributors to the family income  of participants in the peri-urban community MVY reported to never have had treatment with PZQ, 54.1%  participants from the rural community ATA and 44.0% (n = 22) of the rural community AKZ reported to have been treated with PZQ prior to our study (Table n = 137) participants reported a previous miscarriage. None of the participants had been vaccinated against HPV (Table While 87.2% (n = 17) reported to be smokers, whereas only 1.0% (n = 1) in the rural community AKZ, and 1.7% (n = 2) in the rural community AA reported to be smoking. Alcohol consumption was reported to be 34.8% in MVY, 26.0% (n = 13) in AKZ, and 20.7% (n = 23) in AA  was reported in the area  of participants were tested positive for FGS. The lowest rate was observed in the peri-urban community MVY, where 52.0% (n = 73) of the women were tested positive for FGS. In the remaining site in the rural community ATA, 69.0% (n = 76) of the women were tested FGS-positive. Three cases of suspected pre-cervical cancerous lesions were described but none of the cases was diagnosed with CC.In total, an FGS prevalence of 62.6%  were tested positive for HPV. The highest HPV positivity rate was reported in the rural community AKZ . The lowest rate was observed in the urban community MVY, where 40.0% (n = 57) of women were positive for HPV. In the rural community ATA 44.0% (n = 49) of the women were FGS-positive.In total, 42.7% of women (n = 23) reported a low to probable high risk of HPV infection and 82.0% (n = 106) had a high-risk infection.In addition, of all HPV infections, 18.0%  tested positive for both FGS and HPV infection. The highest rate of co-infection was found in the rural community AKZ with 36.0% (n = 18), and the lowest in the peri-urban community MVY . The third study site, the rural community ATA, reported 31.0% (n = 34) co-infection with FGS and HPV acquisition. No cases of CC were diagnosed in our study population.In total, 26.5% (n = 118) of women with FGS had at least one of the symptoms, 37.6% (n = 71) of the FGS-positive women had no symptoms. Among the FGS-negative participants, 74.3% (n = 84) presented symptoms, and 25.7% (n = 29) had no symptoms. Pain was the most frequently reported symptom as in 12.2% (n = 23) for FGS positive participants and 14.2% (n = 16) for FGS negative participants. The third most frequently reported set of symptoms was the presence of vaginal discharge, pain and itching in 9.0% (n = 17) of FGS positive women, and 14.2% (n = 16) for FGS negative women. Bleeding was reported in 7.9% (n = 15) for FGS negative women, and 11.5% (n = 13) in FGS positive women. The symptom “vaginal discharge” was reported 6.9% (n = 13) by FGS positive women, and 6.2% (n = 7) by FGS negative women.All participants were asked for the presence of the four most common symptoms of FGS . Figure Crude and adjusted prevalence ratios (CPR and APR) were estimated for associations with selected risk factors for FGS  and more prevalent in the rural community AKZ , when compared to the rural community ATA  compared to no previous pregnancy (P > 0.05). In relation to no symptoms, increasing numbers of symptoms were associated with FGS as follows: lower prevalence in women with one symptom , two symptoms , and with three or more symptoms  , when compared to women with no previous pregnancy  and for the age group 35–44  as well as for the age group 45–49  when compared to the age group 18 to 24.Prevalence was reduced in the age group 25 to 34 , the age group 35–44 , as well as for the age group 45–49  when compared to the age group 18 to 24.There is a lower tendency for FGS-HPV co-infection among the age group 25 to 34  while secondary education appeared as an APR of 1.41 (95% CI: 0.70–2.86)   is positive for the viral infection in the age range 18 to 24 years, still in higher age groups high positivity rates can be observed, suggesting a high risk for the subsequent development of CC or genital warts .0% is po, while tnobody is safe until everyone is safe”.Our study shows a high concomitant presence of the two conditions (26.5%) but no evidence of association. Additional studies would be beneficial to confirm or further explore the role of FGS in HPV infection clearance but also the role of HPV in FGS progression and cure. Interestingly, in our study population, none of the women interviewed were vaccinated against HPV Table . In MadaIn our study, the majority of the population affected by FGS and HPV lives in rural areas. If for FGS this can be easily explained through the lack of access to clean water  for HPV Notably, there is a lower association of HPV infection with previous pregnancy , which does not allow to sufficiently explore the effects of FGS and HPV on CC cancer onset and prevalence, since it normally occurs at older ages . AdditioOur study highlights the high prevalence of FGS and HPV infections and important gaps in their management among women in Madagascar. There is an urgent need to establish services that can align Madagascar’s public health agenda with that of the global health community. Strengthening primary health care services to address FGS and HPV can improve overall women's health in Madagascar, and in other contexts with similar epidemiological profiles and resource availability.Additional file 1: Table S1. Regression analysis FGS.Additional file 2: Table S2. Regression analysis HPV.Additional file 3: Table S3. Regression analysis FGS and HPV.


Nymphaea caerulea (Nymphaeaceae), is a water lily found globally in lakes and rivers. With its long history of use in Egyptian culture, blue lotus has been associated with spiritual rituals and health benefits. Nowadays, blue lotus is still consumed as a tea or tincture to induce relaxation and heightened spiritual awareness. In this study, six authentic N. caerulea extracts from trusted sources and eleven commercial products were analyzed using gas chromatography−mass spectrometry (GC-MS). Authentic blue lotus extracts were produced in industrial settings. Overall, the extracts were a mixture of aliphatic hydrocarbons, aromatic alcohols, fatty acids, phenyl derivatives, diterpenoids, phytosterols, and stigmastanes. Apomorphine and nuciferine, which are responsible for psychoactive effects of the blue lotus flower, were virtually absent from the authentic blue lotus extract. Although blue lotus has a long history of use, the safety data on the plant and its extracts is limited; however, together with the analytical data, the available information does not indicate major safety concerns for the topical application of authentic blue lotus flower concrete or absolute when diluted as a fragrance ingredient.Blue lotus, also known as  Nymphaea caerulea Savigny (Nymphaeaceae). It is an aquatic perennial plant that grows globally along rivers and lakes at altitudes ranging from sea level to 2700 m asl [N. caerulea is a recognized synonym of N. nouchali var. caerulea (Sav.) Verdc. [N. caerulea are its characteristic feature. Blooming in September until February, the flowers are presented in a star-like pattern when fully open, measuring about 15–20 cm in diameter. The flowers close in the afternoon after opening in mid-morning and can be found in a range of colors, such as blue, white, and pink, with blue being the most common.Blue lotus, water lily, and Egyptian lotus are common names of 00 m asl . N. caer) Verdc. . The floNymphaea species were revered as the epitome of holiness and beauty in ancient Greece and Rome. Based on its regional distribution, the plant is classified into tropical and hardy water lilies [N. caerulea is reputed to have calming and soothing effects. In Ayurvedic medicine, it is used for a variety of health-related issues [N. caerulea is a rich source of different secondary metabolites such as anthocyanins, anthraquinones, fatty acids, flavonoids, leuecoanthocyanins, phenols, coumarins, tannins, and triterpenoids [N. caerulea flowers and nine isolated compounds can be used as a natural solution for oxidative stress. The blue lotus flower has been chiefly utilized in relation to relaxation and sleep in modern times. At high doses, some users might experience hallucinations and euphoria [N. caerulea and compare the composition to the commercial products available in the U.S. market. Moreover, we assessed the safety of N. caerulea extracts.Blue lotus has long-standing historical and cultural significance. Drawings and paintings of the blue lotus flower were reported on Egyptian papyri and tombs from the 14th century B.C., indicating its use in shamanistic rituals and health-related practices ,4. Nymphr lilies . Blue lor lilies ,7. In trd issues . The famrpenoids ,10,11,12rpenoids . Becauserpenoids ,16. Accoeuphoria . Intereseuphoria ,19. Litteuphoria . These pN. caerulea extracts can be described as floral, fruity, sweet, fig-like, leathery, and slightly herbaceous. The volatile fraction ranged from 38.7–65.1% of the total extract. N. caerulea extracts. Overall, the extracts were a mixture of aliphatic hydrocarbons, aromatic alcohols, fatty acids, phenyl derivatives, diterpenoids, phytosterols, and stigmastanes. The chemical makeup of the flower is quite complex. Fossen and coworkers identified seven flavonoids and five anthocyanins, including three acylated anthocyanins from the methanolic extract of the flower [N. caerulea live flower contained benzyl acetate (10.4%), pentadecane (15.5%), 6,9-heptadecadiene (40.1%), and 8-heptadecene (15.3%) as the main components [Authentic blue lotus extracts were produced in industrial settings. The average yields were 0.18% and 0.09% for the concrete and absolute, respectively. The aroma of e flower ,21. Agnimponents . When thmponents .Alkaloids are mainly found in lotus leaves ,25. NuciCitrus oil, Lavandula oil, and Geranium oil addition, respectively. It was hard to recognize which oil was added to C8-C11. Furthermore, there is evidence that herculyn D was used as a fragrance fixative in C4, C8, and C9, as indicated by the presence of abietic acid derivatives.Eleven commercially available blue lotus products were purchased online. Interestingly, the aroma varied greatly between the commercial products and none of these products resembled the original aroma. More than 150 compounds were identified from the obtained products . All of N. caerulea is not GRAS classified, and no published safety data were found on the plant or the extracts as a whole. However, the plant has a long history of use. The safety data for all constituents present at 1% and above are presented in N. caerulea (water lily) flowers using GC-MS and reported four main compounds: 6,9-heptadecadiene (40.1%), pentadecane (15.5%), 8-heptadecene (15.3%), and benzyl acetate (10.4%). This is different from our GC-FID results, except that the main compound, 6,9-heptadecadiene, was identified as the most abundant compound, although at a substantially lesser concentration in the flower extracts.As these are absolute and concrete materials, they may contain an unknown and significant portion of nonvolatile compounds. As such, quantification through GC-FID may not be accurate and compounds present in the absolute and concrete may not be detected and therefore not evaluated as part of this assessment. Since the safety of unidentified compounds cannot be guaranteed, this presents an unknown safety risk.Of the 28 compounds investigated (making up 85.43% of the concrete and 80.52% of the absolute), safety information was not found for 10 compounds (making up 27.29% of the concrete and 25.11% of the absolute) including 6.9-heptadecadiene, n-pentacosane, tetrapenol, 3--heptadeca-8,11-dien-1-yl)-5-methoxyphenol, 2-nonadecanone, heptacosane, benzyl linoleate, methyl cholesterol, benzyl linolenate, and benzyl hexadecanoate. We were able to gather safety information for the remaining 18 compounds (making up 58.69% of the concrete and 56.68% of the absolute) including n-tricosane, benzyl alcohol, tetradecanol, heneicasane, nonadecane, pentadecane, oleic acid, E-squalene, linoleic acid, γ-sitosterol, palmitic acid, phytol, E-β-farnesene, ethyl stearate, stigmasterol, hexadecyl acetate, ethyl linoleate, and ethyl palmitate. According to the data available from CIR, all of the assessed compounds, except two, were found to be at concentrations considered safe in accordance with current usage practices, as indicated in w/v) in an enamel extraction tank with continuous stirring for 12 h. After soaking, the hexane was discharged and filtered with 120 mesh stainless steel mesh. The collected extracts were allowed to settle for 4 h, then filtered. The solvent was then recovered by heating with jacketed steam. The extract was concentrated under atmospheric pressure with a spherical concentrator until all of the hexane was evaporated. The concentrated extract is called concrete. To prepare the absolute, the blue lotus concrete was dewaxed with 95% ethanol  in a stainless-steel barrel, stirred carefully, and placed in the freezer for more than 12 h. The resulting extract was filtered and the floral was separated. The filtrate was concentrated under low pressure in a spherical concentrator until all of the solvent was evaporated. Samples of both the concrete and absolute were tested for solvent residue. Eleven commercially available blue lotus oil products were purchased online (Amazon and Etsy). The product labels of these samples contained the information listed in Authentic blue lotus absolutes and concrete samples were prepared using industrial extraction methods. Cultivated blue lotus plants were collected from Hainan and Guangdong, China . The plan-alkanes with those reported in databases  using the Lab Solutions GCMS post-run analysis software version 4.45 .Authentic and commercial samples were analyzed using a gas chromatograph coupled to a mass spectrometer QP2010 Ultra  with electron impact (EI) mode with 70 eV, as previously described . The comE. purpurea essential oil was carried out using a Shimadzu GC 2010 equipped with a flame ionization detector , as previously described [Analysis of escribed , with a LCMS-grade methanol, LCMS-grade water, and HPLC-formic acid were purchased from Sigma-Aldrich . Nuciferine and apomorphine were purchased from Cayman Chemical . Stock solutions of each standard at a concentration of 10 ppm were prepared by diluting the powder in methanol. Nuciferine and apomorphine were quantified using a NEXERA UPLC system  equipped with a mass spectrometer  as previously described ,25. The The safety assessment of blue lotus extracts was conducted by applying standard toxicology and risk assessment methods using the analytical results , publishn-tricosane (8.03 ± 0.18%), and benzyl alcohol (7.58 ± 0.85%), while the main constituents of the authentic absolute were 6,9-heptadecadiene (11.05 ± 1.53%), benzyl alcohol (10.46 ± 1.42%), and tetradecanol (5.32 ± 0.74%). Surprisingly, none of the investigated commercial products resembled authentic extracts in aroma or composition. Nuciferine and apomorphine were found in traces or were absent, respectively, from the studied authentic extracts, suggesting that the risk of psychoactive effects associated with these compounds would be virtually absent for a small dose of either of these extracts applied topically. Other than the psychoactive effects associated with nuciferine and apomorphine, the available safety data from the literature are limited and do not show major safety concerns for the authentic extracts. Surprisingly, none of the investigated commercial products resembled authentic extracts in aroma or composition.In this study, we analyzed the chemical composition of six authentic blue lotus extracts and eleven commercial products. The extracts were a mixture of aliphatic hydrocarbons, aromatic alcohols, fatty acids, phenyl derivatives, diterpenoids, phytosterols, and stigmastanes. The main constituents in the authentic concrete were 6,9-heptadecadiene (11.95 ± 1.65%),


Action Plan to eliminate cervical cancer by 2030, with promotion of the HPV vaccination for school-aged girls as a critical step. Despite this, implementation of the vaccination has been patchy, with very low coverage among eligible girls. To address this, from December 2021 to December 2022, a demonstration project was launched in Shenzhen, Guangdong Province, to promote the inclusion of HPV vaccine in local immunisation programme and to address existing barriers to implementation. Using multiple sources of data, this article presents a case study of the demonstration project, analysing its impact on rolling out HPV vaccination among eligible girls and identifying any challenges encountered during implementation. The demonstration project has shown promising results in increasing the HPV vaccination rate, promoting public awareness and acceptance of the domestic HPV vaccine, and establishing a model for quickly scaling up the vaccination at the municipal level. The success of the project can be attributed to several factors, including strong governmental commitment, sufficient funding, multi-sectoral collaboration, ensured vaccine accessibility and affordability, improved vaccination services, and effective health education and communication strategies. Lessons learned from Shenzhen can provide valuable insights for future advocacy and implementation of the vaccination in other areas of China, but challenges must be addressed to achieve universal coverage. These include addressing vaccine hesitancy, expanding the programme to cover a broader age range, and ensuring consistent quality of vaccination services in primary care facilities. Overcoming these challenges will require innovative strategies, public-private partnerships, and sustained funding and resources. Future research should focus on evaluating the long-term effectiveness of the vaccination programme and identifying contextual factors that may impact its implementation in different settings. Overall, the effective control of cervical cancer in China will rely on the “political will” to ensure the incorporation of preventive interventions into policies and universal programme coverage.Cervical cancer is a major public health concern in China, accounting for almost one-fifth of the global incidence and mortality. The recently prequalified domestic bivalent human papillomavirus (HPV) vaccine offers a practical and feasible preventive measure. In response to the global call for action, the National Health Commission issued an  Cervical cancer is a major public health concern worldwide, with an estimated 604,000 new cases and 342,000 related deaths reported annually by the World Health Organization (WHO) . China aAction Plan to Accelerating the Elimination of Cervical Cancer (2023–2030), which aims to eliminate cervical cancer by 2030 [Action Plan sets stepwise targets for HPV vaccination, including promoting the vaccination of eligible girls through pilot programmes by 2025 and rolling out the programmes by 2030.Persistent infection of high-risk human papillomavirus (HPV) is closely associated with cervical cancer, with over 95% of cases caused by the infection . ScalingSince its initial adoption in Jungar Banner, Ordos, in 2020 , HPV vacCervical cancer prevention scholars have suggested that conducting research on implementing HPV-based preventive strategies and advocating for their adoption by addressing the existing barriers could lead to significant benefits in reducing the burden of HPV-related diseases . From DeA more focused and sustained advocacy effort to address the challenges hindering uptake of HPV vaccination has the potential to significantly reduce the burden of cervical cancer . In ordeWork Guidelines for Free HPV Vaccination for Eligible Girls (2022–2024), with the overall goal of vaccinating 90% of girls by the age of 15 by 2030. The Work Guidelines stipulated that, starting from September 2022, all girls entering Grade 7 and aged below 14 would receive free and voluntary HPV vaccination services, and two doses of the domestic bivalent vaccine must be completed before the girls reach age 15.The policy advocacy described above was successful. On January 11th, 2022, the Shenzhen Municipal Health Commission, Education Bureau, Department of Finance, and Women’s Federation jointly issued the Work Guidelines emphasised the importance of “governmental leadership, multi-sectoral collaboration, and social mobilisation” in achieving the goal, and established the responsibilities for all participating departments .The ts Table . To ensu“Funding is not an issue thus we are able to make such a commitment. The Livelihood Project is a strong commitment that the government makes to the people.” Different from other Category 2 vaccines in China , the dom“If the vaccination is carried out in schools, one team consisting of one doctor and one nurse is sufficient. In the past, we used to vaccinate around 1000 students with the flu vaccine in one morning, with a team capacity of 200–250. Therefore, it is feasible for us to vaccinate an additional 100 girls with the HPV vaccine in one afternoon. Additionally, since we are able to efficiently transition between schools, it is possible for us to complete the vaccination in our community.“ (A director of school-based vaccination in a vaccination clinic)Shenzhen has a well-established vaccination system, with years of experience and a sound service infrastructure in place. Over the past years, the city has gradually improved its vaccine usage management and vaccination services, as well as the information system  for vaccine circulation and administration. At community level, tight collaborations have been established between schools and primary care facilities, such as Community Health Service Centers (CHSCs) and district hospitals, which provide centralised vaccination services for school-aged children. These services include annual flu vaccinations and emergency vaccinations for diseases such as chickenpox. To facilitate effective coordination, communication channels, often utilising WeChat groups, have been established between schools and primary care facilities. In this partnership, school doctors play an active role in identifying eligible students and coordinating vaccination schedules with local vaccination clinics. They also actively engage with parents and guardians to obtain consent for vaccination and provide information about the importance of immunisation. This strong partnership has contributed to the smooth delivery of HPV vaccination services. As mentioned by a director of school-based vaccination:“We, as the management agency, have opened a dedicated query channel for the HPV vaccination programme on the information platform. This means that through the query channel, we can check the vaccination status of each school and primary care facility.” (A director of the HPV vaccination programme in a District CDC)SVIS has been in use since 1997 and undergone several updates. The information system is known for its good logic validation performance, and both health workers and the public are proficient in using it. To facilitate implementation of the free HPV vaccination programme, a separate section has been added to SVIS, which simplifies the process of importing and using the vaccination data. This section clearly displays the vaccination status in different clinics and schools, providing crucial data for analysing vaccination situations and making arrangements for future work. According to a programme director:During the promotion of HPV vaccination, health education played a pivotal role in raising awareness among the general public and in schools , 24. The“For the HPV vaccine, we already have a project for adolescent health and development, so the cooperation between schools and the healthcare system is quite close. I just need to incorporate this into my adolescent health project, and we already have a platform and a foundation to work from.“ In addition, the city’s Adolescent Health and Development Programme has established connections with schools, which facilitates the integration of HPV vaccination into existing school-based health education programmes. As pointed out by a programme director:Collaborating with the Municipal Education Bureau, the project team conducted a survey in June 2022 to assess the knowledge and acceptance of the HPV vaccine among parents of eligible girls, shortly before their daughter entered Grade 7. This survey was an important tool in promoting the vaccination and increasing adherence. The results showed that out of the 2856 parents surveyed, only 3.4% reported their daughters had already received any HPV vaccine. However, an overwhelming 97.3% of them expressed willingness to accept the HPV vaccination services provided by the government for their daughters, and 91.6% agreed that their daughters would receive the domestic bivalent HPV vaccine.In 2022, the project team organised five training sessions for primary care practitioners on cervical cancer prevention, which included interpretation of provincial and municipal policies, programme process, HPV vaccination, data input, quality control, cervical cancer screening, and mental health promotion for women who tested positive. Due to indoor gathering restrictions during the COVID-19 pandemic, all the training sessions were conducted online, reaching over 1000 trainees. At the end of each session, a questionnaire was distributed to assess the practitioners’ knowledge of and attitude towards HPV and HPV vaccine. This survey aimed to identify potential barriers to implementing the free HPV vaccination for eligible girls and collected baseline data for future evaluation of capacity building programmes. The findings, as published elsewhere , revealeWork Guidelines. The rapid roll out of vaccination coverage acts as a testament to the successful implementation of the free HPV vaccination programme.The free HPV vaccination officially began in October 2022, with a total of 60,524 eligible girls (aged below 14 in Grade 7 and never vaccinated for HPV before) registered according to data from the Education Bureau. The implementation process is illustrated in Fig. “Initially, we anticipated a 60% coverage rate and procured 36,000 doses. When we realised this quantity was far from sufficient, we decided to administer the second dose as the first, as the second dose is administered six months later. We will procure more doses for the second dose as needed.“ (A director of the HPV vaccination programme in a District CDC)Nonetheless, certain limitations must be acknowledged. Centralised procurement of the vaccine can lead to supply chain and distribution challenges, potentially resulting in delays in the roll out of HPV vaccination. As noted by a programme director:χ² = 153.309, P < 0.001). Moreover, among those unwilling to accept the vaccination services, 56.1% expressed a preference for imported or higher-valent vaccines, 10.9% were concerned about the vaccine’s safety and side effects, and 8.4% had little to no knowledge of HPV vaccine and HPV vaccination.In addition, vaccine hesitancy among parents presents a significant barrier. Using an adapted 8-item Vaccine Hesitancy Scale (VHS) , the surCervical cancer is a highly preventable and treatable disease, yet it remains the world’s fourth most common gynaecologic cancer  and poseSince 2020, pilot HPV vaccination programmes have been initiated in a number of cities, offering free HPV vaccines or vaccination subsidies for school-aged girls. The present case study highlights several critical factors contributing to the success of implementing the free HPV vaccination for eligible girls in Shenzhen, including strong governmental commitment backed with sufficient funding, active participation of multiple governmental departments, available and affordable vaccines, high-quality vaccination services, and improved public awareness. Comparing to implementation strategies adopted in many other parts of China, which mainly focused on provision of free vaccines and education to adolescents and their parents , 24, 32,Work Guidelines focused on vaccinating girls aged below 14 in Grade 7, potentially missing those who started school early. Moreover, centralised procurement of the HPV vaccine at the provincial level of Guangdong, as opposed to city-level procurement in Jinan and Chengdu, could have resulted in delays and logistical challenges in distributing the vaccine efficiently to vaccination clinics, impacting Shenzhen’s ability to rapidly reach a higher coverage.However, when compared to cities like Jinan and Chengdu, where over 90% of eligible girls were vaccinated within 2 months , 15, SheWhile case studies in this domain remain limited, this in-depth analysis of Shenzhen’s experience offers a valuable reference point for understanding the intricacies of implementing the HPV vaccination for eligible girls at local level of China. Lessons learned from the demonstration project can provide valuable insights for future advocacy and implementation in other areas of China, particularly those have not yet initiated the vaccination. To begin with, given the rapid increase in the HPV vaccination rate among Grade 7 girls in Shenzhen after the municipal government began actively addressing it, it is imperative for local health agencies, professional societies, and non-governmental organisations to engage in more active, advocacy-oriented outreach to stimulate policy and funding attention. This aligns with findings from a policy analysis conducted in 2019, which suggested that the lack of powerful advocates and health professionals’ mobilisation skills hindered the feasibility of universal HPV vaccination in Shenzhen . AdvocacAdditionally, strong governmental leadership and effective coordinating mechanisms are essential for achieving policy goals . For theFurthermore, Shenzhen’s experience underscores the importance of combining public educational initiatives with community outreach, such as the “Expert-into-School”, to enhance awareness and acceptance of HPV and HPV vaccine among parents, students, and school administrators. Targeted messages and tailored approaches effectively addressed specific concerns and misconceptions related to the domestic vaccine. Moreover, integrating health education on HPV into existing school-based sexual health curriculum through collaborations between schools and public health agencies proved instrumental in rapidly increasing positive attitudes towards the vaccination programme within a short time. This is consistent with experiences in other cities, as demonstrated in Zhang and colleagues’ multi-center intervention follow-up study, where a “Train-the-Trainer” approach significantly increased HPV-related knowledge and vaccine acceptability among adolescents .The demonstration project also highlighted several challenges that must be addressed to further implement and sustain the progress. Firstly, vaccine hesitancy among parents and guardians due to concerns about the domestic vaccine’s safety and efficacy, coupled with limited knowledge about HPV vaccination, remains a significant obstacle. Notably, a recently published systematic review on HPV vaccination promotion interventions by Escoffery et al. emphasised the need to expand promotion efforts beyond educational interventions . In thisSecondly, expanding the HPV vaccination programme to achieve universal coverage is a major challenge. Currently, the vaccine is only free for Grade 7 girls aged below 14, which leaves out many adolescent girls who are at risk of HPV infection. Moreover, girls who do not attend school are unable to access the vaccine, which limits the programme’s reach and effectiveness. To address these challenges, there is a need to develop innovative strategies to catch up with girls who missed the vaccine, especially those from vulnerable populations, and to expand the programme to cover a broader age range . This coThirdly, the applicability of Shenzhen’s experience to other areas of China is uncertain due to differences in economic development levels and healthcare systems. In an earlier health policy analysis, Chen et al. suggested that introduction of the HPV vaccination for eligible girls in Shenzhen was shaped by local legislative environment, economic development level, and social norms on immunisation and sexuality . TherefoLastly, ensuring consistent quality of vaccination services in primary care facilities is crucial for the success of the HPV vaccination programme. Given that practitioners in private facilities had relatively poor knowledge of HPV and HPV vaccine, measures should be taken to ensure that they receive adequate training and resources to provide high-quality vaccination services. Future research should examine the drivers and obstacles to implementing the HPV vaccination for eligible girls at the primary care facility level, which will inform the design and testing of intervention strategies to optimise implementation. Such strategies could include targeted training and education programmes for practitioners, the establishment of quality assurance mechanisms, and incentivisation .Action Plan for the elimination of cervical cancer must be followed by a series of ongoing, transparent, and operable policy initiatives combined with institutional and investment actions. Overall, the successful implementation of the free HPV vaccination for eligible girls in Shenzhen has demonstrated the significance of a comprehensive approach, combining effective policy advocacy, adequate financing, strong governmental leadership, multi-sectoral collaboration, secured vaccine accessibility and affordability, improved vaccination services, as well as public health mobilisation. Shenzhen’s experience underscores the critical role of voluntary school-based vaccination programmes in achieving the national and global goals of cervical cancer elimination and provides a valuable reference for other regions in China that are working to improve their cervical cancer prevention strategies.Effective control of cervical cancer relies not only upon the availability of effective and affordable screenings and vaccines, but also on the “political will” to ensure that these interventions are incorporated into policies and that programme coverage is equitable and universal . To achi


BackgroundIn this study, we aimed to evaluate the knowledge and awareness about cervical cancer, human papillomavirus (HPV) and its vaccine among women living in the western region of Saudi Arabia.MethodologyUsing a cross-sectional online survey, this study assesses the knowledge and awareness level of HPV and the risk factors of cervical cancer among women living in the western region of Saudi Arabia. The design of the questionnaire is based on several earlier studies in different populations.ResultsThe total completed responses include a sample of 624 that was subjected to statistical analysis; the analysis showed that only 34.6% were aware of HPV. Participants who belonged to the 21-30 and 31-40-year-old groups had comparatively more awareness than other age groups (p<0.001). Most (83.8%) believed that it would cause cervical cancer. Less than half (45.8%) knew that there is a vaccine against HPV infection. When we assessed the willingness to receive the vaccine, it was found that 75.8% were willing to take it.ConclusionsThe study found that women in the western region of Saudi Arabia have limited knowledge of cervical cancer and HPV and its vaccine. There is a need to educate and promote awareness of HPV and its complications for women in the western region of Saudi Arabia. Human papillomavirus (HPV) is considered a sexually transmitted virus and is strongly linked to many types of cancer, such as cervical, ovarian, and vaginal . HPV hasThe upper cervix (endocervix) is lined with a simple columnar epithelium, and the lower cervix (ectocervix) is lined with stratified squamous epithelium. At the junction between them, there is a high chance of the occurrence of metaplastic changes; therefore, most of the cervical cancers arise from within this site. The hazard of HPV infection corresponds to the highest levels of metaplastic activity. The highest metaplastic activity occurs in puberty and the first pregnancy and decreases after menopause .The most prevalent cancer that affects women’s health is cervical cancer, which is the fourth most prevalent cancer among women in the world. According to the World Health Organization (WHO), cervical cancer is the second most prevalent cancer among women residing in less developed regions, with a reported 604,000 new cases in 2020. Approximately 342,000 cases died from cervical cancer in 2020, about 90% of these deaths occurring in less developed regions .In Saudi Arabia, around 6.5 million women over 15 years old are at risk of developing cervical cancer, according to the World Health Organization . The estConsistent evidence shows that the authorized bivalent and quadrivalent HPV vaccines containing HPV16 and 18 antigens defend against HPV infection, and precancerous cervical lesions correlate with these types while individuals are not yet exposed . For theIn this study, we tried to assess the knowledge and awareness level about cervical cancer, the mucosal type of HPV and its vaccine among women living in the western region of Saudi Arabia.Study designA quantitative and descriptive cross-sectional study was done.Study participantsThe study targeted every female aged between 18 and 50 years in the western region of Saudi Arabia. The exclusion criteria were men and women living in the eastern, middle, south, and northern regions of Saudi Arabia.Study instrumentsA pre-designed online questionnaire was used. The questionnaire was distributed randomly via social media and delivered to (703) women during the period from September 2020 to January 2021. We invited them to participate in the survey, and the purpose of the study was explained to them before sharing in the study. The questionnaire consisted of four parts and covered the data about participants' socio-demographics . In addition, it contained questions about participants' awareness about cervical cancer, papillomavirus (HPV) , and acceptance of HPV vaccination .Data analysisThe data were analyzed by the SPSS program version 23 . Qualitative data are expressed as a number and percentage, and quantitative data are expressed as the mean and standard deviation (SD). A suitable statistical test will be used accordingly. P-values <0.05 are considered significant.Ethical considerationsThis study obtained ethical approval from the Research Ethical Committee at Taif University, KSA (No. 42-0017). The questionnaires were anonymous, ensuring confidentiality.This study was done to assess the awareness and knowledge about human papillomavirus (HPV) among the adult female population residing in the western region of Saudi Arabia. The total completed responses include a sample of 624 that was subjected to statistical analysis. The age distribution of the participants showed that 29.6% were 18-20 years old, 48.4% were 21-30 years old, and 13.1% were 31-40 years old. The majority of the participants (83.7%) had educational levels at the graduate level or more, and 73.6% of the participants were single  were aware of HPV, and hence, the assessment of knowledge related to HPV and associated factors were done only among these participants. When we assessed the relationship of the level of awareness with the participants’ different socio-demographic characteristics, there was no statistically significant association seen except for age. The 21-30-year-old and 31-40-year-old participants had comparatively more awareness than the other age groups (p<0.001) . There was no statistically significant association observed with the participants’ educational level and marital status , 30.5% mentioned that they are against vaccines, 32.5% believed that this vaccine is not necessary, and 15.9% reported that they are unsafe Table .When we assessed the relationship of willingness based on the knowledge level, it was found that 94.8% of the participants who had "good" knowledge were willing to take the vaccine, which showed a statistically significant relationship (p=0.001) Table .The present study explored the awareness and knowledge regarding human papillomavirus (HPV) infection and willingness to accept vaccines for it among adult females in the western region of Saudi Arabia. We found that the awareness about HPV in these females was significantly less (34.6%), and out of this, approximately one-third had only good knowledge regarding the infection and the risks involved. A recent study conducted in four Arab countries  has reported poor awareness (26.1%) compared to our study findings . In anotAccording to the WHO’s health statistics report, females aged between 35 and 44 years are at an increased risk of getting cervical cancer . In thisThis study finding shows that there is a need to promote awareness and educate Saudi women regarding HPV and its complications. Even though vaccination is an effective way of preventing infection, other preventive strategies, such as lifestyle modifications, proper sex education, abstinence from sexual intercourse, and the use of barrier contraception methods should also be emphasized when educating the public. Healthcare professionals have a crucial role to play in educating and motivating patients to institute and achieve HPV vaccination. An annual national HPV awareness campaign could be organized, targeting both parents and young females.This study set out to assess the evaluate the knowledge and awareness about cervical cancer, human papillomavirus (HPV) and its vaccine among women living in the western region of Saudi Arabia. This study has identified that women in the western region of Saudi Arabia have limited knowledge of cervical cancer and HPV and its vaccine. Therefore, it is crucial to increase women's awareness of cervical cancer and HPV and the importance of its vaccine through an awareness campaign.


Background: Research on the relationship between posttraumatic stress disorder (PTSD) and sexual dysfunctions (SD) has clearly recognized the association among these conditions. The main objective of this research was to compare the levels of the overall and the level of certain domains of sexual functioning among veterans with and those without PTSD. Methods: Two hundred and fifty veterans with PTSD and 187 veterans without PTSD were included in the comparative study. The following assessments were conducted: LEC-5, PCL-5, ITQ, IIEF, PEDT, and MINI. Results: Veterans with PTSD had significantly higher levels of all types of SD in the PTSD group compared with the non-PTSD veterans. Veterans with PTSD more frequently experienced psychiatric and somatic comorbidities and use of medication that may contribute to the occurrence and severity of SD. Conclusions: The present study emphasized that SDs are an important issue among patients with PTSD. The study comprehensively accounted for conditions that may contribute to the occurrence and severity of SD among veterans with PTSD. Future directions of the research that could further improve the healthcare of the patients were indicated.  The rates of sexual dysfunctions (SDs) among patients with posttraumatic stress disorder (PTSD) are much higher than in the general population, varying from 8% to 89%, respectively. The interesting finding made so far has been that studies reporting the low prevalence were mainly based on the numbers of diagnoses observed from medical files, whereas those showing the high prevalence were based on direct interviews and questionnaires . What caSD among veterans with PTSD have been almost totally neglected in research until an increase of interest occurred in recent years. Veterans have been regularly exposed to multiple traumatic experiences, but studies have shown that SDs are much more prevalent among veterans with PTSD than in veterans without PTSD, or in the general population ,11,12,13What kind of SDs are related to PTSD? Studies have so far revealed the association of PTSD with overall sexual function, as well as impairments in the specific domains of sexuality, such as activity, desire, arousal, orgasm, and satisfaction with sexual life ,18. The Comorbidities with psychiatric and somatic conditions, and the use of a variety of medications are very common among veterans with PTSD. Some of those conditions carry a significant burden for the worsening of sexual functioning ,21. RegaAlmost 30 years after the Homeland War in Croatia 1991–1995), veterans still suffer from numerous health problems. In recent periods, case reports  and rese, veteranA total of 437 war veterans participated in this study. The group of veterans with PTSD (N = 250) was recruited from a pool of patients referred from the Referral Center for PTSD of the Ministry for Health of the Republic of Croatia within the Clinical Hospital Center (CHC) Rijeka. The control group consisted of comparable male combat veterans without PTSD (N = 187). Target sampling  was usedExclusion criteria were active psychosis, and moderate or high suicide risk, measured using the Mini-International Neuropsychiatric Interview (MINI) for DSM-IV , and defAssessments included clinical interviews and self-report questionnaires. Three psychiatrists and 2 psychologists performed the interviews with the participants. A sociodemographic questionnaire was created for the study purposes. The assessment was usually completed in one session, with an average of 2 h. The study was approved by the Ethics Committees of the Faculty of Medicine, University of Rijeka. All participants were informed of the purposes and procedures to be undertaken in the study and were given detailed information on the risks and benefits. Written informed consent was obtained from all participants included in the study. PTSD symptoms were assessed with the PTSD Checklist (PCL-5) and Criterion A . PCL-5 iTo assess the presence of war-related traumatic events we used the Life Events Checklist for DSM-5 (LEC-5) , a self-Two measures were used to assess sexual function. The International Index of Erectile Function (IIEF)  was usedTo assess the presence and severity of PE, we used premature ejaculation diagnostic tool (PEDT) ,45. PEDTThe Croatian version of the Mini-International Neuropsychiatric Interview (MINI) for DSM-IV , was usep ≤ 0.05.Data was analyzed with Statistica software, version 12  and were presented as N (%), M (sd), or median as appropriate. Results on the dependent variables  did not meet assumption of normal distribution as assessed using the Kolmogorov–Smirnov test and boxplots. To examine between group differences, we used the Mann–Whitney U test, chi-square test, and Fisher’s exact test for variables with small cell sizes. To calculate the extent of correlation between the variables of interest we used the Spearman coefficient. Probability significance was set as p < 0.001), more likely to be in a relationship (PTSD n = 218 (87.2%), non-PTSD n = 175 (93.6%)); Fisher’s exact test p < 0.001), to have a medium economic status (PTSD n = 158 (63.3%), non-PTSD n = 150 (80.2%), χ2 = 14.678, p < 0.001), and to have a higher level of education (PTSD n = 20 (8.1%), non-PTSD n = 41 (21.9%); χ2 = 16.846, p < 0.001) compared to veterans with PTSD.The average age of war veterans included in the study was 53.7 (SD = 6.27) years, with the range from 44 to 65 years. respectively. Most of them were married (66.6%), with secondary education (77.2%), and perceived their economic status as medium (70.6%). Veterans without PTSD were 3.7 years older on average  compared to the non-PTSD group, with a median of 26.5 months compared to the median of 18 months in the period from 1919 to 1996, respectively. The average duration of active participation in the Homeland War was 27.1 (18.98) months, ranging from 1 month to 70 months, respectively. The average intensity for the overall PTSD symptoms among war veterans was 38.7 (sd = 24) within the range from 0 to 80, respectively. As expected, veterans with PTSD had a significantly higher intensity of the overall PTSD symptoms  compared to veterans without a provisional diagnosis of PTSD . Both groups met the criteria for at least one war-related traumatic event and have had high exposure as assessed by Criterion A. However, the PTSD group was deployed significantly longer  in the overall sample (n = 433). The average score for orgasmic function was 6.7 (sd = 3.25), , sexual desire 5.6 (sd = 2.47) , intercourse satisfaction 7.6 (sd = 4.55) , and for overall satisfaction 7 (sd =2.32) , respectively. Although there is no clear classification of the level of dysfunction for the domains on the IIEF other than erectile dysfunction, the results are comparable to those provided by the authors of the IIEF. Rosen et al.  reportedTo assess for the association between PTSD and SD, we compared two groups in different domains of sexual functioning . Veteranp < 0.001). More than half of the veterans without PTSD experienced no erectile dysfunction at the time of measurement compared to 19.8% veterans with PTSD  veterans had sought psychiatric help, with 10 of them having done so during the war.Participants without PTSD did not meet the criteria for any psychiatric comorbid disorders measured using the MINI. Among participants with PTSD, the most common comorbid psychiatric disorders were current (n = 50), lifetime major depressive episode  , and panic disorders (current and lifetime 29.2%). Current suicidality (low suicide risk) was present in 6 (2.4%) veterans. At least one of the other anxiety disorders was present in 45 (18%) participants . Nine participants (3.6%) reported alcohol use disorder and six (2.4%) had drug-related disorders in the last year. Three participants were classified with antisocial personality disorder, and one with an eating disorder. None of the participants were classified with a current psychotic disorder although two have lifetime psychotic disorder. p < 0.001) and diabetes (n = 38 (15.2%) vs. n = 13 (7%), respectively; χ2 = 7.06, p = 0.008) compared to the non-PTSD group. There was no significant difference observed in the disorders of lipoprotein metabolism (n = 20 (8%) vs. n = 14 (7.5%), respectively; χ2 = 0.843, p = 0.843) or hyperplasia of the prostate (n = 6 (2.4%) vs. n = 4 (2.1%), respectively; Fisher’s exact test p = 1) between the groups. Significance of differences were confirmed using the Fisher’s exact test.The most common self-reported non-psychiatric diseases in the overall sample were diseases of the circulatory system , followed by endocrine, nutritional, and metabolic diseases , and diseases of the musculoskeletal system and connective tissue . When it came to the diseases that have already been recognized as significantly related to SD, the most commonly self-reported in our sample was essential hypertension, which affected 153 (35%) participants, followed by diabetes mellitus , diseases of lipoprotein metabolism , and hyperplasia of the prostate . Some of the conditions known to influence SD were rarely present in our sample: sleep apnea (four), malignant neoplasm of testis (two), epilepsy (two), other hypothyroidism (four), multiple sclerosis (one), Parkinson’s disease (one), and autoimmune thyroiditis (one), respectively. Veterans with PTSD were significantly more likely to have had essential hypertension (n = 107 (42.8%) vs. n = 46 (24.6%), respectively; χ2 = 15.576, In the PTSD group, 94.8% of participants used at least one psychotropic drug, compared to only 14 (17.5%) of non-PTSD participants. Among those who were taking psychotropic medication, 36 (14.6%) had a single drug, 76 (30.9%) had a combination of two psychotropics, 75 (30.5%) had a combination of three psychotropics, and 59 (24%) had a combination of four or five psychotropics, respectively. The average number of psychotropic drugs in the PTSD group was 2.59 (median = 3), and in the non-PTSD group 0.1 (median = 0).The most common psychotropics in the overall sample were anxiolytics, with 202 (46.2%) participants taking at least one anxiolytic therapy. Furthermore, 133 (30.4%) participants used at least one antidepressant, 73 (16.7%) of them used at least one hypnotic and sedative, 90 (38.5%) used at least one antiepileptic, and 63 (14.4%) at least one antipsychotic, respectively. Only three participants had used drugs in addictive disorders (such as methadone). There was a large discrepancy observed between psychotropic medication between the groups .The most common self-reported non-psychotropic medication was related to cardiovascular therapy (31%), followed by medications for the musculoskeletal system (12.8%). When it came to drugs that were previously recognized as related with SDs, the most common was antihypertensive therapy, with 116 (26.5%) participants using at least one antihypertensive. At least one lipid-modifying agent therapy was used by forty-six (10.5%) participants, drugs used in diabetes by twenty-six participants (5.9%), H2 blockers by six, antihistamines by five, corticosteroids for systemic use and immunosuppressants by two, and drugs for erectile dysfunction by only one participant. Differences in non-psychotropic drugs with a frequency of at least five are presented in Correlation coefficients between SDs and variables presenting sociodemographic data, comorbidity, drugs used, PTSD symptom severity, and war deployment duration are presented in The most important finding of this research was that veterans with combat-related PTSD experienced significantly more frequent sexual difficulties than the veterans without PTSD in all varieties of impairments in the specific domains of sexuality , as well as in the overall personal satisfaction and satisfaction with intercourse. As the DSM-5  providesRegarding the level of SD in both groups of participants, the scores on the IIEF permitted the classification of the severity for erectile dysfunction as severe, moderate, and mild or no dysfunction. The scores in our sample indicated that veterans with PTSD were significantly more likely to have severe and moderate erectile dysfunction compared to non-PTSD veterans, while the frequency of mildly occurring sexual difficulties was similar. Previous research showed consistent results in that participants with symptomatic PTSD exhibited significantly more severe symptoms related to erectile dysfunction ,48.The results revealed that participants from the PTSD group experienced extensive comorbidities with depression, anxiety disorders, and to a lesser extent, substance-related disorders. Unlike them, participants without PTSD did not meet the criteria for any psychiatric comorbidity disorders. It has been well-known that patients with PTSD commonly experience comorbid psychiatric conditions. The data from epidemiologic surveys have indicated that depression, anxiety disorders, and substance-related disorders are the most prevalent comorbid psychiatric disorders among PTSD patients, and in turn, all of them increase the risk for SD ,31. KotlSeveral physical conditions influence sexual functioning. In our sample, essential hypertension and diabetes mellitus were the most prevalent in the overall sample and were significantly more frequent among veterans with PTSD than among those without a PTSD diagnosis. Hypertension appeared to be associated with all types of SD, and diabetes mellitus only with premature ejaculation. High blood pressure has already been confirmed as a risk factor of SD . PossiblAlmost all participants with PTSD used at least one psychotropic drug. In comparison with the non-PTSD group, those with PTSD used them five times more frequently. The most common psychotropics in the overall sample were anxiolytics followed by antidepressants. The overuse of anxiolytics in the same post-conflict setting has already been reported , as wellThe most common non-psychotropic medication was antihypertensive therapy, and it appeared to be related with all types of SD except for PE. La Torre et al., in their review found that most of the studies recognized antihypertensive drugs with a key role in sexual dysfunctions induced by cardiovascular drugs. There is also evidence suggesting that older antihypertensive drugs  have a more negative impact on erectile function when compared to newer agents .What could be implications of the findings on the quality of healthcare? It could be the raised awareness of the issues of the SD and PTSD comorbidities among the healthcare providers and users. Professionals may strive to overcome the personal reasons to question patients about their sexual functioning, as the research strongly confirms that patients with SD want their doctors to initiate talks about sexual health . This reThis research had strengths worth noting. The participants’ index trauma was assessed, expanding our understanding of the extent to which trauma type may moderate the relationship of PTSD with sexual functioning. Comparisons with the matching control group of veterans with the same traumatic experiences but without the satisfied required criteria for the diagnosis of PTSD allowed more firm conclusions to be made about the association between PTSD and SD in the veteran population. The study comprehensively accounted for the psychiatric and physical comorbidities, and the use of all varieties of medications that may contribute to the occurrence and severity of SD among the veterans with PTSD. The data related to SD were systematically collected as they covered a broader range of possible sexual health problems as well as perceived sexual satisfaction. This study had several limitations. The study was limited to male veterans, and thus the findings cannot be generalized to the general population or the female population. Data were cross-sectional and did not allow insights in causation. The study relied on self-reports and was therefore subject to participant bias. Self-reports of sexual functioning may be under- or overreported due to stigmatization.The present study showed that veterans with combat-related PTSD experienced significantly more frequent sexual difficulties than veterans without PTSD. The study comprehensively accounted for psychiatric and physical comorbidities, and the use of all varieties of medications that may contribute to the occurrence and severity of SD among veterans with PTSD. These results are a relevant contribution to the rising body of research that should pave the way for the improvement in the healthcare of veterans with co-occurring PTSD and SDs. Future direction of the research that could improve the healthcare of the patients should be focused on identifying the most important factors that prevent recognizing and diagnosing SD among patients with PTSD. Widening the research on other groups of traumatized people would further contribute to the generalizability of the results. On the level of primary healthcare, research could be focused on getting more qualitative data from patients regarding the context of trauma and the nuances of SDs. Longitudinal research could enable better insights to be obtained in the dynamics of development and the course of comorbidity of SDs and PTSD.


The host factors that influence father-to-child human papillomavirus (HPV) transmission remain unknown. This study evaluated whether human leukocyte antigen (HLA)-G alleles are important in father-to-child HPV transmission during the perinatal period. Altogether, 134 father–newborn pairs from the Finnish Family HPV Study were included. Oral, semen and urethral samples from the fathers were collected before the delivery, and oral samples were collected from their offspring at delivery and postpartum on day 3 and during 1-, 2- and 6-month follow-up visits. HLA-G alleles were tested by direct sequencing. Unconditional logistic regression was used to determine the association of the father–child HLA-G allele and genotype concordance with the father–child HPV prevalence and concordance at birth and during follow-up. HLA-G allele G*01:01:03 concordance was associated with the father’s urethral and child’s oral high-risk (HR)-HPV concordance at birth . HLA-G allele G*01:04:01 concordance increased the father’s oral and child’s postpartum oral any- and HR-HPV concordance with an OR value of 7.50 (95% CI: 1.47–38.16) and OR value of 7.78 (95% CI: 1.38–43.85), respectively. There was no association between different HLA-G genotypes and HPV concordance among the father–child pairs at birth or postpartum. To conclude, the HLA-G allele concordance appears to impact the HPV transmission between the father and his offspring. Human papillomavirus (HPV) infection is furthermost known as an accountable factor for the development of cervical cancer in women ,2. HowevEven though HPV infection is one of the most common sexually transmitted infection, non-sexual routes of transmission, such as vertical and horizontal transmission and autoinoculation, have emerged ,10,11,12The father’s role as a source of HPV infection to the newborn is less known. As HPV DNA has been isolated from vas deferens, seminal fluid, and spermatozoa ,17, the Even though different modes of transmission have been identified, a child’s early-life exposure to HPV infection and genetical and immunological co-factors that facilitate the susceptibility to an infection remain mostly unexplored. Human leukocyte antigen G (HLA-G) is one of those immunological co-factors that is supposed to impact the natural history of HPV as well as other viral infections. In general, HLA-G molecules take part in innate and adaptive immune responses and immune escape in cancer progression ,19 and iThe Finnish Family HPV (FFHPV) Study is a longitudinal cohort follow-up study conducted at Turku University Hospital and University of Turku, Finland. At baseline, a total of 329 families with pregnant women (in their third trimester), fathers-to-be and later their newborn offspring participated in the original study. All families with a minimum of 36 weeks of pregnancy were recruited during their regular obstetrics clinic visit at the hospital. Families were followed up for six years to assess the dynamics of HPV infection between family members as described in detail previously [eviously . The preHPV genotyping Semen, urethral and oral scapings from the fathers and oral scrapings from the newborns were collected for HPV testing with a Cytobrush  as described earlier [ earlier . Fathers earlier .HLA-G typing DNA from father’s and newborn’s frozen whole blood samples were extracted for HLA-G typing by using the MagNAPure 96 System (Roche). Determination of HLA-G alleles was performed by direct DNA sequencing exploring exons 2–4 (1718 bp) of the HLA-G gene regions as described before [d before .STATA SE15.1  was used for all statistical analyses. The study cohort included 134 father–child pairs, 132 fathers and their 134 offspring (two pairs of twins), both parties having HLA-G allele determination available. Only those HLA-G alleles and genotypes that were identified both among the fathers and children and were ≥3% prevalent among fathers and/or children were included in the analyses. HLA-G alleles were explored both in high- and low-resolution groups. HLA-G concordance for a specific HLA-G allele was considered if a father and his child both had at least one specific allele; in other words, HLA-G allele concordance was defined if both parties were heterozygous or homozygous for this allele. If one party had an allele and the other did not have the allele, the pair was counted as HLA-G discordant for the allele.In low-resolution analyses, only one allele group G*01:01+  was available, while there were four low-resolution genotype groups: 01:01+/01:01+, 01:01+/01:03+, 01:01+/01:04+, and 01:01+/01:06+. In low-resolution analyses, HLA-G allele concordance was divided into four groups by number of shared alleles .In HPV genotyping analyses, HPV species were classified as either LR or HR groups . MultiplIn assessing HPV concordance, only those father–child pairs who had an opportunity for HPV infection  were considered. Any-, LR- or HR-HPV concordances were defined if a father and his offspring both were detected positive for any-, LR- or HR-HPV, respectively. HPV prevalence among father–child pairs was calculated as HPV positive  if at least one party, father or child, had at least one positive  HPV sample.Unconditional logistic regression was used to determine the associations (OR) between (1) within father and his child shared HLA-G alleles or genotypes and (2) father–child HPV concordance and prevalence. In high-resolution HLA-G allele analyses, the father–child pairs with both parties being negative for these specific alleles served as a reference, whereas in low-resolution group analyses, HLA-G allele discordant father–child pairs served as a reference. A significance level of 0.05 was used (two-tailed), and 95% confidence intervals (CI) were calculated.n = 114) of the fathers, and 85.8% (n = 115) of children had the allele. The second most common allele was G*01:01:02; 36.4% (n = 48) of the fathers and 32.8% (n = 44) of the children had the allele. The most common HLA-G genotype among the fathers and children was G*01:01:01/01:01:01 in 37.1% (n = 49) and 36.6% (n = 49), respectively, which was followed by G*01:01:01/01:01:02 in 23.5% (n = 31) and 21.6% (n = 29), respectively. n = 99) of pairs shared at least two common alleles , which was followed by other alleles that were shared between 2.2% (n = 3) and 22.4% (n = 30) among the pairs. The most commonly concordant genotype between father–child pairs was the G*01:01:01/01:01:01; 25.4% (n = 34). Overall, 37.3% (n = 50) of the father–child pairs had any concordant HLA-G genotype.The mean age of the fathers was 28.8 years (range 19–46 years). Among fathers and their offspring, overall, nine different HLA-G alleles with 19 different genotype combinations were identified. Only those seven alleles and five genotypes that were ≥3% prevalent and were identified in both among the fathers and the children were included in the analyses. The most common HLA-G allele found among fathers and newborns was the wild-type G*01:01:01; 86.4%  were compared to those pairs with discordant HLA-G alleles . The father–child pairs with both parties missing the allele served as a reference. Sharing of different alleles was compared to the HPV concordance of father’s three anatomical baseline (before birth) HPV status  and child’s oral HPV status at birth and postpartum, as seen in The association between father–child HLA-G allele sharing and the common HPV prevalence of fathers and/or children is shown in The acquisition of HPV infection in early life is supposed to be facilitated by many complex immunological, genetical and epigenetical co-factors . The fatThe role of HLA-G in vertical HPV transmission is even less studied. To our knowledge, there is only one previous study with the same Finnish Family HPV cohort that has evaluated the HLA-G and vertical mother-to-child HPV transmission . In thatHLA-G in vertical HIV transmission is more studied than HLA-G in vertical HPV transmission. Several studies have shown HLA-G polymorphism to influence the risk of mother-to-child HIV transmission ,27,28,29One study has shown an association of the HLA-G*01:04:01 allele with vertical mother-to-child HCV transmission; G*01:04:01 was significantly higher in HCV-positive children than HCV-negative children (22.5% vs. 6.8%) . InteresIn this study with a cohort of fathers and their newborns, we identified only nine different HLA-G alleles. To date, overall, 117 HLA-G alleles have been identified  . The relWe showed HLA-G concordance with certain specific alleles to have an impact on father–child HPV concordance , but whether it indicates HPV transmission from father to child is questionable. We showed that the type-specific father–child HPV concordance was associated with HLA-G allele G*01:04:01. HLA-G*01:04:01 father–child concordance was related to the father’s oral and child’s postpartum oral any- and HR-HPV concordance. In this case, HPV type-specific concordance was seen in two father–child pairs with HR-HPV genotypes 33 and 70  and 9.86 (95% CI 1.49–65.12), respectively. This finding is suggestive for vertical father-to-child HPV transmission in this case. Interestingly, in the study with the same Finnish Family cohort including mother–child pairs, discordant mother–child HLA-G allele G*01:04:01 increased the risk of the child’s oral LR-HPV infection at birth .According to our results, HLA-G*01:01:03 allele father–child concordance relates to the father’s urethral and child’s oral HR-HPV concordance at birth. Controversially, when a child’s oral HPV status was determined postpartum, an association between G*01:01:03 allele discordance and the father’s urethral and child’s oral HR-HPV concordance was seen. Moreover, HLA-G allele G*01:01:03 discordance seems to increase the risk of the father’s urethral and/or child’s oral any- and HR-HPV positivity at birth, whereas G*01:01:03 concordance was associated with the higher risk of father’s oral and/or child’s oral HR-HPV positivity at birth. This contradiction remains unexplainable assuming that biologically HLA-G allele discordance is supposed to reduce the risk of infection at any anatomical site. Therefore, we investigated separately the fathers’ HPV prevalence at baseline (before birth) and children’s HPV prevalence at birth; G*01:01:03 allele discordance seemed to increase solely the father’s urethral any- and HR-HPV positivity but not the child’s oral HPV positivity at birth. G*01:01:03 allele concordance lost statistical significance when the fathers’ oral HR-HPV prevalence and children’s oral HR-HPV prevalence at birth were explored separately; thus, it did not show an impact on one or the other’s oral HR-HPV prevalence alone. Interestingly, in our recently published study, we found the presence of men’s allele G*01:01:03 to associate with an increased risk for urethral HR-HPV infections .Allele G*01:06 concordance was associated with the LR-HPV prevalence of fathers’ semen and urethral and/or children’s oral HPV at birth. When we explored this association by fathers’ and children’s prevalence alone, G*01:06 concordance was not associated separately with the father’s semen or child’s oral LR-HPV positivity at birth. However, G*01:06 concordance increased the father’s urethral LR-HPV positivity but not the child’s oral LR-HPV positivity at birth, when the prevalence of fathers and children was analyzed separately. Interestingly, the study of the Finnish Family cohort with mother–child pairs showed that G*01:06 mother–child discordance increased the child’s oral LR-HPV positivity but had no impact on the mother’s site .The main limitation of this study is that we could not stratify analyses by HPV genotype due to the relatively low sample size of fathers and newborns. A small sample size of fathers and children with uncommon HLA-G alleles may reduce the detection rate of significant associations between father–child HLA-G allele concordance and father–child HPV concordance. In addition, especially for the perinatal period, newborns might be also exposed to HPV from siblings and other caregivers. These covariables were not considered in this study. In addition, as the study cohort represents the Finnish population, which has a restricted gene pool, the findings of this study may not be generalized to other populations.For many, it is still questionable whether a child’s HPV status at birth represents passive HPV contamination or a true infection. However, a recently published study with the FFHPV cohort showed that part of the newborns born to seronegative mothers showed seroconversion to HPV6, HPV11, HPV16 and HPV18 recorded after birth . AccordiThis is the first study to our knowledge to evaluate the association of the father–child HLA-G allele and genotype concordance with the father–child HPV prevalence and concordance at birth and during the perinatal period. According to our results, father–child concordance of certain HLA-G alleles appears to have an impact on father–child HPV concordance and prevalence in the perinatal period. However, father–child HLA-G genotype concordance did not show such an impact. Due to a relatively low sample size, we could not evaluate the results by genotype-specific HPV concordance. Thus, the results are approximate and should be further validated by larger studies, with HLA-G and genotype-specific HPV data, in the future.To conclude, father–child HLA-G concordance might play some role in father–child HPV concordance and prevalence at birth and during the perinatal period of life. The regulatory role of HLA-G in a child’s susceptibility to HPV infection and the role of the father in the transmission chain need further investigations.


About ECEMECEMwas initiated by Rudolf Groner (Bern), Dieter Heller(Bayreuth at the time) and Henk Breimer (Tilburg) in the198 to provide a forum for an interdisciplinary group ofscientists interested in eye movements. Since theinaugural meeting in Bern, the conference has been heldevery two years in different venues across Europe until2021, when it was planned to take place in Leicester butwas cancelled due to the COVID pandemic. It was decidedto hold the meeting in Leicester in August 2022 instead,and as an in person meeting rather than an online orhybrid event. Incidentally, the present meeting is thethird time the conference has come to the English EastMidlands, now in Leicester following previous meetingsin the neighbouring cities of Derby and Nottingham.here..The sites of previous ECEMs and webpages can be found


In general, the findings suggest that encouraging frequent participation in recreational angling could be a dual method strategy for promoting relaxation and positive mental health, as well as encouraging increased levels of physical activity in those with mental health issues.Exposure to aquatic environments  can lead to improved mental health and well-being. One meaningful way to spend time in blue spaces is through recreational angling, although limited scientific literature exists on this topic. The present study aims to examine the relationship between recreational angling and mental health and well-being in a sample of UK adult male anglers. A cross-sectional online survey asked questions about demographic characteristics, participation in recreational angling, physical activity levels, diagnosis of psychiatric disorders, and mental health and well-being. Relationships between angling status  and mental health variables were determined using regression models adjusted for age. In total, 1752 participants completed the survey. The regression models found that those who took part in angling more regularly had reduced odds of having depression ( There is a considerable evidence base that demonstrates the impact of exposure to aquatic environments, known as blue spaces, for improved mental health and well-being . These bIn 2019, an estimated 2.0% (approximately 1.25 million) of people had participated in some form of recreational angling in blues spaces across Great Britain , making Despite the popularity of recreational angling and its potential utility to address the rising levels of mental health problems in the UK ,10, therTherefore, the aim of this paper is to examine the relationship between recreational angling and mental health and well-being in a sample of UK adult male anglers. This has the potential to inform targeted mental health interventions, future research, and public health policy.A cross-sectional study design was utilised. Participants were recruited from October 2021 to January 2022 via an online survey  that wasParticipants were asked to provide demographic variables including age, country they live in, ethnicity, relationship status, presence of disability, employment status, household income, smoking status, and alcohol consumption.Participants were asked if they had any of the following diagnosed psychiatric disorders: anxiety disorder, depression, bipolar disorder, schizophrenia, or ‘any other psychiatric disorder’. Other questions included whether they have had any suicidal thoughts, have attempted suicide, or have deliberately self-harmed themselves.Overall well-being was assessed using the Warwick–Edinburgh Mental Well-being Scale (WEMWBS), which consists of 14 questions on a Likert scale. Total scores ranged from 14 to 70, with higher scores indicating greater levels of mental well-being. The WEMWBS is well validated across several populations ,18,19. SParticipants were asked if they participated in angling and, if so, asked how often they took part  as well as how long they would participate in angling during a normal session .Participants were asked how long they sat each day as well as how much time they spent watching a screen. Participants were also asked how long they engaged in moderate  and vigorous  physical activity on an average day as well as how much time they typically spent outdoors.p < 0.05.SPSS version 28.0  was used for conducting analyses. Descriptive categorical data are presented as numbers (percentage/%) and continuous data as medians (25th–75th interquartile range/IQR) unless stated otherwise. To determine if fishing status was associated with mental health and mental well-being outcomes, a logistic regression was conducted for dichotomous variables , and a linear regression was conducted for continuous variables . Regression models were chosen as they are robust against non-parametric data. All regression models were adjusted for age. Statistical significance for regression analyses was set at Originally, a total of 1792 participants completed the questionnaire; however, we only received a small number of female respondents (n = 40). Therefore, we only analysed the males in the sample (n = 1752). Also in p < 0.05) with how often participants took part in angling included the presence of depression, schizophrenia, suicidal thoughts, and deliberate self-harm. These significant regressions stated that the odds of having depression were 1.172 (95% CI: 1.078 to 1.273), schizophrenia were 1.879 (95% CI: 1.177 to 2.997), suicidal thoughts were 1.162 (95% CI: 1.072 to 1.260), and deliberate self-harm were 1.166 (95% CI: 1.034 to 1.314), and they were less likely the more frequently participants took part in angling. In terms of the normal length of an angling session, the only significant relationship was with suicidal thoughts (odds ratio: 0.678 95% CI: 0.521 to 0.882), which conversely suggested that the odds of having suicidal thoughts were higher the longer the normal length of an angling session was.Regarding the logistic regression models displayed in p < 0.05) with how often participants took part in angling included the WEMWBS, BDI, and BAI scores. These significant regressions showed that mental well-being was higher  and that depressive symptoms  and anxiety symptoms  were lower the more frequently participants took part in angling. In terms of the normal length of an angling session, the only significant relationship was with the BDI score , which conversely suggested that depressive symptoms were higher the longer the normal length of an angling session was.Regarding the linear regression models displayed in The main aim of the current study is to examine the relationship between recreational angling and mental health and well-being in a sample of UK adult male anglers. The results highlight that in terms of age-adjusted regression models, those who took part in angling more regularly were almost 17% less likely to report being diagnosed with depression, schizophrenia, suicidal thoughts, or having deliberately self-harmed compared to those taking part in angling less regularly. Also, those who took part in angling more regularly compared to those who did not were more likely to score highly on the WEMWBS  and were less likely to score highly on the BDI and BAI (and therefore experience fewer depressive and anxiety symptoms). However, despite most results for the age-adjusted regression models being non-significant, suicidal thoughts and depressive symptoms were higher in those reporting a normal angling session lasting a longer period of time compared to a shorter period of time. Finally, this sample reported taking part in high levels of moderate and vigorous physical activity.Given the potential health benefits of spending time in blue spaces ,2, the fPutting the main findings into context, it is important to note that the prevalence of some aspects of mental health issues was higher when compared to the general UK population . ExampleA survey conducted by Sport England in 2012 found that the drivers of satisfaction for general angling participants included the release and diversion as well as social aspects . The keyAnother notable finding was that anglers reported taking part in 2.5 h/day of moderate–vigorous physical activity. Some of this specific activity is likely to be accumulated while angling, with estimated metabolic equivalent (MET) values for general angling activity being 3.5 METs, fishing from a riverbank being 3.5 METs, and fishing in a stream while in waders being 6.0 METs . HoweverThe strengths of this study include recruiting a large sample size of male recreational anglers, using validated questionnaires to measure different facets of mental health such as anxiety and depressive symptoms. However, there are also limitations to consider. A cross-sectional study design was utilised, meaning causal relationships cannot be established between the different aspects of mental health and angling behaviour. Future research should utilise longitudinal designs to more accurately determine the association between mental health and recreational angling. Future research could also control for additional relevant covariates, such as education status and household income . This would help to further explain the associations between mental health and recreational angling. The normal length of an angling session was measured categorically, with participants only having four possible answer options. In combination, two of the options were chosen by only 0.8% of the sample. This limited the utility of this question, as an open answer option would have allowed for more of a spread of possible answers, and therefore, would have allowed to more definitively determine whether a longer time spent in a normal angling session promoted better mental health and well-being. This is likely to have resulted in some of the spurious results suggesting more time spent in a normal angling session was related to higher levels of suicidal thoughts and higher depressive symptoms. The views of those who were less digitally literate may have been missed due to using an online survey format . The oveIn conclusion, this study has highlighted that those who took part in angling more regularly were less likely to report being diagnosed with depression, schizophrenia, suicidal thoughts, and having deliberately self-harmed compared to those taking part in angling less regularly. Taking part in angling more regularly also resulted in higher mental well-being and fewer depressive and anxiety symptoms compared to taking part less regularly. However, it should be noted that the anglers in this cohort appeared to have higher levels of diagnosed anxiety disorder, diagnosed depression, and suicidal thoughts than the general UK population. With this particular cohort self-reporting high levels of moderate–vigorous physical activity, this would suggest that encouraging participation in angling could be a good dual method strategy for both promoting relaxation and good mental health, as well as encouraging increased levels of physical activity within those with mental health issues, such as those experiencing suicidal thoughts. However, it will be necessary for future research to more clearly understand the exact mechanisms which explain the association between recreational angling and mental health. In addition to more traditional exercise prescriptions, such as walking and gym-based exercise, developing public health initiatives focused on promoting angling could provide a viable additional physical activity option for those with mental health issues.