Both corporate identity and corporate social responsibilities are of strategic importance to companies’ reputation and competitiveness. From a social constructivist view, identity is constructed in discourse. Therefore, this study sets out to investigate how corporate identity is discursively constructed in corporate CSR communication. Taking Starbucks as an example, this corpus-assisted study explores how Starbucks deploys nomination, predication, and intensification strategies and the corresponding linguistic resources to discursively construct itself and its main stakeholder groups in the CSR reports from the perspective of Discourse-Historical Approach to Critical Discourse Analysis. Also, how Starbucks addresses or presents issues in which scandals or problems reside is investigated. The findings show that Starbucks explicitly constructs itself as the supportive care-taker of the partners, faithful deliverer of good customer experience, powerful helper of poor farmers, and CSR-conscious selector of suppliers, who takes a strongly committed and proactive CSR stance through the discourse. However, behind such discursive construction are the hidden ideologies and corporate agenda of a capitalistic nature, with Starbucks veiling the power dominance and unequal power relations. This study not only contributes to the understanding of the discursive construction of corporate identity, but also helps raise peoples’ awareness of the power game at play behind the corporate discourse. The word identity is rooted in the Latin attribute idem, which means ‘the same,’ and later nominalized as identitas, meaning sameness. It is used to designate the particular characteristics by which a person or an entity becomes recognizable . Once a To construct a favorable corporate identity, companies have begun to devote themselves to an ever-growing trend in the business practices, that is, corporate social responsibility (hereafter CSR). Stimulated by the deterioration of the environment and the proliferation of social problems, peoples’ environmental and social consciousness has become all-time awakened. Therefore, more than ever before, companies are under enormous pressure and scrutiny from various stakeholder groups, including but not limited to governments, NGOs, interest groups , investors, and consumers. Companies are deemed as corporate citizens responsible for the sustainability of not only the economy, but also the society and the planet earth. Indeed, research has found that consumers attach great importance to a company’s CSR practices e.g., , providiIn terms of the construction of identity, research in various fields like anthropology, linguistics, sociology, history, and psychology, to name a few, has firmly established and acknowledged the essential role of linguistic strategies and discourse processes in the construction and negotiation of identities . In thisIn this study, corporate identity is considered to be discursively constructed in the corporate communication with hidden ideologies at play. In particular, the corporate identity in the CSR dimension is discursively constructed in the company’s annual CSR reports, whose aim in disclosing the company’s CSR information is to construct a positive identity, manage the corporate image and engage in dialogs with the stakeholders .Therefore, it is this study’s objective to investigate how a company use discourse strategies and linguistic resources to construct its identity in the CSR reports and to reveal the hidden corporate agenda behind.This study intends to conduct and present a case study of Starbucks. The reasons are manifold. First, seen in the restaurant industry or coffeehouse industry, or as a combination of both, Starbucks comparatively stands out and is unquestionably world-renowned. Second, it has enjoyed a high CSR profile in its own industry and has appeared on many CSR-related ranking lists, which can more or less affirm its CSR achievements. Third, it is one of the pioneers in publishing annual CSR reports, starting as early as 2001, which guarantees a relatively sizable corpus for analysis.As a global coffee and food retailer, Starbucks has established stores in more than 80 countries and regions. In terms of CSR reputation, it has ranked eighth in Fortune’s ranking of the Most Admired Companies 2022, and has remained one of the top 10 in this ranking for many years. One of the attributes of reputation this ranking evaluates is social responsibility to the community and the environment. In addition to this, Starbucks is on the Dow Jones Sustainability Index and included in many other Environment, Society, and Governance-related lists, such as Barron’s 100 Most Sustainable US Companies, Forbes’ America’s Best Large Employers, and Sustainalytics’ Global Sustainability Index. Moreover, it is ranked on Ethisphere’s World’s Most Ethical Companies list for 12 years in a row. All these official rankings demonstrate that Starbucks’ CSR efforts are world-widely acknowledged, rendering a relatively positive corporate identity in terms of CSR.In its own industry, it is also perceived to be taking the lead in CSR. According to Restaurant Business magazine , consumeHowever, despite the high ranking in terms of CSR and the consumers’ impression of its greenness, Starbucks also has been criticized for some of its CSR practices. In particular, its tax avoidance in the United Kingdom , the allThe most important vehicle for corporate communication on its CSR performance and plans is the annual CSR report. In terms of corporate reporting on CSR, Starbucks issued its first official CSR report as early as in 2001, making it one of the pioneers who provided a stand-alone annual corporate report specifically focused on CSR. Moreover, along with each report, there is also an independent assurance report from Moss Adams, serving as an endorsement and external audit on Starbucks’ CSR disclosure in the report.To examine Starbucks’ discursive construction of its corporate identity in the CSR dimension, it would not be as informative to disregard the industry context. With regards to Starbucks’ products and services, it can be identified as belonging to the coffee industry as well as the restaurant industry. A briefing on the CSR concerns of these two industries would be insightful for the analysis of Starbucks’ identity construction in its CSR reports.Nowadays, the coffee chain is buyer-driven, as international traders, retailers and major coffee roasters become powerful actors in the coffee chain . As a coBesides the challenges placed on the farmers, the coffee industry also faces sustainability challenges regarding the environment, e.g., the harmful production practices and the ‘technification’ of coffee cultivation which has a negative effect on the local fauna . The cofWithin the restaurant industry, environmental issues and green awareness have attracted growing interest, with more and more consumers becoming environmentally concerned and ecologically conscious about their choices . FollowiFrom what has been provided, the most important stakeholder groups that are affected by the production of coffee are the environment and the farmers, and the consumer trend for coffee industry as well as restaurant industry is ethical consumption and green practices. Responding to these growing trends, Starbucks has been working closely with coffee farmers and promoting sustainability through reusable cups, recycles, LEED-certified building and other environmentally friendly practices . DespiteIn this light, some green practices of companies have been doubted and have been regarded as a kind of green marketing  following the recommendation in the edited book of CDS views the use of language as a ‘social practice’ that is both determined by social structure and, at the same time, contributes to stabilizing and changing that structure . TherefoTwo key concepts are integral to CDS, namely, ideology and power. To begin with, ideologies in CDS are the ‘worldviews’ which constitute ‘social cognition’ , p: 258,Within CDS, there are different approaches, and five major approaches are identified . Based oAccording to A note should be made that “strategy” means a more or less intentional plan of (discursive) practices adopted with the aim to achieve a particular linguistic, social, political, or psychology goal. And they are located at different levels of linguistic organization and of different complexity . Also, tvia which conclusions can be made) and the perspectivization . While nomination, predication, and intensification/mitigation strategies can be explored in a quantitative way by using corpus tools to generate results based on the frequency of linguistic devices, argumentation and perspectivization can hardly be explored in the same way.Therefore, this study mainly explores three discursive strategies in detail, that is, nomination, predication, and intensification/mitigation strategy. The reason is that this study interests itself more in the most frequent linguistic devices used for Starbucks’ identity construction in its CSR reports, rather than the argumentation schemas  form. Then, a manual cleaning of the texts was conducted to exclude the following elements in the corpus: 1. captions for any illustrations or photos; 2. tables, diagrams, and figures; 3. the independent report (in the form of a letter) produced by a third party; 4. the section “About the report”; 5. the Mission Statement and Guiding Principles that occur in almost all the reports; and 6. hyperlinks. The total word count of the corpus is 208,444, and the word count for each year’s report is shown in This study combines quantitative and qualitative methods for the advantages of such an approach  Green Power Partnership. (2006)1. Starbucks is one of the founding members of the Sustainable Coffee Challenge… (2017)2. That’s why Starbucks as the largest buyer of CSR-related resourceStarbucks is the largest buyer of East Timor’s highest-quality Coffee. (2004)3. Starbucks is the number one purchaser of renewable electricity in its sector on the EPA’s Green Power Partnership National Top 100 list. (2006)4. Starbucks as a gathering place and as a good employerStarbucks is a gathering place, a place to connect, a barista offering a cup of coffee with an outstretched hand. (2012)5. Starbucks is a best place to work. (2013)6. We now turn to the other frequent verb collocates of Starbucks, which can give us a clue as to what actions are ascribed to Starbucks as an agent. Based on the actions, we can assign a role to Starbucks. A manual examination of all the concordances of the verb collocates are done, generating the following summary of identity:Starbucks as an environmental-conscious purchaser:purchased considerably more certified organic coffee in fiscal 2005 than in the previous year. (2005)7. Starbucks Starbucks as a CSR projects/initiatives launcher:launched two initiatives to improve our recycling rates. (2002)8. In fiscal 2002, Starbucks Starbucks as a provider of funds for CSR causes:provided financial support to 42 environmental organizations across North America. (2012)9. Starbucks Starbucks as a supporter of CSR causes/community:supports nonprofit organizations in our communities with cash contributions and product donations. (2004)10. As a company, Starbucks After the verb collocates are examined, we now turn to the most frequent noun collocates for Starbucks as pre-nominal modifiers, which can show us what Starbucks is associated with in the CSR reports. Listed below are the identity statements that can be summarized from the noun collocates. Due to limit of space, not all collocates will be illustrated with an example.Starbucks is about the stores.Starbucks is about coffee.Starbucks is about business.Starbucks is about growth.Starbucks is about making CSR commitment:Starbucks is about experienceStarbucks Experience. (2003)11. It’s the coffeehouse experience – a third place between work and home – that connects customers to coffee in an inviting, enriching environment that is comfortable and accessible. We call it the What is worthy of note is that in (11), a unique term is coined---the Starbucks Experience. This is arguably the most auspicious way for identity construction through nomination. The Starbucks Experience can be understood as a metaphor: Starbucks is a third place for connecting people. A third place is a term frequently mentioned on Starbucks’ website and incorporated in Starbucks’ mission statement and vision. Indeed, this is the identity that Starbucks constructs to set itself apart from the rivals. It has made ongoing and various attempts to brand Starbucks coffeehouses as a “third place” by encouraging patrons to engage in diverse social networks . And in As the semantic prosody often reveals whether a word is associated with positive or negative evaluations, it is of interest to look into the semantic prosody of ‘Starbucks’ so as to shed some light on its identity construction. A collocate list for ‘Starbucks’ is generated, which results in a total of 994 collocates appearing no less than five times within five slots before and after the node word. Then, a manual examination of all the collocates is conducted, leading to the identification of the adjectives, adverbs, and nouns with evaluative meaning. Among all the collocates, only 48 are identified as having explicit evaluative meanings, among which 33 are associated with positive connotations and 5 with negative connotations, as is shown in From the table, we can see that the semantic prosody of ‘Starbucks’ is overwhelmingly positive, which is in congruence with the Pollyanna Effects found in corporate communication . That isTo be noted, the coding of the positive/negative association is dependent on the context in which the collocates appear, instead of merely by the dictionary sense of the word itself. For example, the adjective ‘aggressive’ is often associated with a negative connotation. However, from its specific use in the context, it is decided that this collocate contributes to the positive prosody. As is shown in (12), positive evaluation is assigned to the use of ‘aggressive’ because in the context, it is employed to show Starbucks’ highly ambitious goal, which constructs an identity that is bold, audacious, and forceful in pursuing CSR.aggressive goals for C.A.F.E. Practices, reflected in the amount of coffee we plan to purchase from participating suppliers. (2005)12. Starbucks has set In the same manner, the noun collocates which are neutral in themselves  are classified as having positive connotations based on their use in the context. For instance, in (13), ‘impact’ is used in juxtaposition with ‘benefit’ in parallel grammatical structure, so the latter is intended to be interpreted in the same light with the latter. In this way, through deliberate wording, ‘impact’ is invested with positive connotations, which is conducive to the construction of a positive identity for Starbucks. And in (14), ‘change’ is used to testify Starbucks’ constant commitment to CSR in the sense of adopting strong corporate governance practices, which, again, contributes to the construction of a positive corporate identity.impact and provide more benefit to communities around the world. (2006)13. Starbucks contributions will have greater change demonstrates Starbucks ongoing commitment to strong corporate governance practices. (2007)14. This Also worth mentioning is that, there are only five collocates with negative prosody among all the collocates for ‘Starbucks,’ and no adjective or adverb collocates showing negative connotations are identified. Among the noun collocates associated with negative connotations, three detonate external factors beyond the manageability and influence of the company . And the rest detonate things within Starbucks’ control , for which proactive efforts are promised.Also, concordances for ‘challenges’ are manually examined to determine the source of the challenges presented in the CSR reports. And the results indicate that they are presented as being posed or brought about by factors external to the company, with ‘Starbucks’ being constructed as the innocent victim who actively tries its best to cope with these challenges, see (15) and (16). In these cases, an identity of a courageous company who is subject to the challenging external world but takes an active role in living up to the challenges are discursively constructed.challenges to Starbucks and the communities we serve. (2008)15. The difficult business climate in fiscal 2008 and beyond has brought challenges for Starbucks and our partners, and all other US companies and employees whose healthcare benefits are threatened. (2007)16. Through our efforts, we hope to alleviate healthcare With regards to the collocate ‘injury,’ although the negative-meaning-loaded word is used, its mentioning in the sentence is to address stakeholders’ relevant concern explicitly and to showcase Starbucks’ attitude and commitment toward mitigating risks of injury. In this way, Starbucks discursively constructs an identity of a responsible and conscientious company who goes all out to ensure the safety of its stakeholders, as is in (17). And in terms of collocates detonating natural disasters, such as in (18), Starbucks discursively constructs an identity that actively shoulders the responsibility of a global citizen who compassionately provides aides to people in need.injury as possible. (2006)17. We consider partner and customer safety first and foremost as we develop and select Starbucks products and equipment – and strive to “engineer out” as many causes of earthquake and tsunami in Japan, the Starbucks Foundation and Starbucks Coffee Japan gave $1.2 million to the Red Cross for relief and recovery efforts and established a Caring Unites Partners (CUP) fund to help eligible impacted partners in Japan. (2011)18. In response to the 2011 To conclude, the semantic prosody of ‘Starbucks’ is overwhelmingly positive. In the cases of collocates with negative connotations, they are used to construct Starbucks as a responsible, proactive, caring, and conscientious global citizen. And this finding is in congruence with the findings of Another linguistic resource for nominating Starbucks are the first-person pronouns. As companies are inanimate, it can only speak through its representatives in a collective voice. Therefore, only the plural forms of first-person pronouns  are used as self-referring linguistic devices for the construction of corporate identity. A search of the three devices in Starbucks’ CSR reports shows that there are 3,630 occurrences of ‘we,’ 2,810 of ‘us,’ and 4,908 of ‘our.’For identity construction, the use of the subject form of first-person plural pronoun ‘we’ is considered to be of primary importance, as it helps construct the company as an active agent in the social world. Moreover, the intensification/mitigation discursive strategy can contribute to the construction of identity by reinforcing or weakening the degree of certainty invested in the statements being made. Therefore, by investigating the collocates of ‘we,’ we can gain some insights on how this discursive strategy is utilized in Starbucks’ CSR reports for identity construction. Among all the resulting collocates, those which serve to intensify or mitigate the voice are identified, with the top six collocates presented in On the whole, it is quite revealing that all of the top six collocates serve to intensify rather than mitigate the voice. In order to better understand how are these voice-intensifying devices used in Starbucks’ CSR reports for identity construction, and more importantly, what actions are being intensified, we will explore the collocates for these devices further.To begin with, verb collocates of ‘will’ are identified. By a careful reading of all concordance lines, it is found that this voice-intensifying device is mainly used to reassure the audience of Starbuck’s strong volition and firm determination to fulfill its CSR agenda. Here, we come across an interesting finding: the most frequent verb following ‘we will’ is ‘continue,’ appearing 40 times in the corpus. The strong commitment made to continuing what Starbucks has been doing is, by itself, an acknowledgment and reinforcement of the righteousness and achievement of Starbucks’ CSR activities, see (19).19. We will continue to work cooperatively with organizations throughout the world to identify, test and implement the most effective and sustainable energy efficiency initiatives. (2011)The manual examination of its use in context reveals that the second most frequent collocate ‘can’ also serve to intensify the voice of the self, expressing a relatively strong degree of certainty and emphasizing Starbucks’ capability of helping, improving, and making impacts on the environment and the stakeholders, as in (20). Another prominent voice intensifier on the list is ‘must,’ whose use in Starbucks’ reports is accentuating the strong obligation perceived by Starbucks to take certain actions to fulfill its CSR, see (21).20. We can use our scale for good, and catalyze change across entire industries so that Starbucks and everyone we touch can endure and thrive. (2012)21. As we grow, we must focus on engaging with local groups, listening to our neighbors about what’s important to them and determining how Starbucks can best contribute to their neighborhoods. (2004)Among the top eight collocates, there are three cognitive verbs , all of which carry a relatively strong degree of certainty. As such, they intensify the corporate voice and construct an identity that is assertive and confident. All of their concordance lines are carefully examined to identify to what end they are used in Starbucks’ CSR reports.To begin with, of the 110 occurrences of ‘believe,’ three topics are identified. That is, in Starbucks’ CSR reports, ‘believe’ is mainly used to: justify an action (22), emphasize positive impacts (23), and acknowledge the importance of CSR (24). From the examples, we can see that Starbucks uses this voice-intensifying device to constructs an identity that is highly committed and confident in the positive impacts its CSR activities can bring to the stakeholders.22. We believe the process leads to better results. (2005)23. We believe the growth of Starbucks has created employment and business opportunities within the specialty coffee industry. (2001)24. We believe it’s our environmental responsibility to find ways to reduce these emissions. (2004)The other two voice-intensifying verbs are ‘recognize’ and ‘know,’ whose concordance lines are examined, resulting in the following findings about their usages in Starbucks’ CSR reports. To begin with, over half of the occurrences of ‘know’ convey Starbucks’ explicit acknowledgment of existing challenges and room for improvement, as in (25). Its other usages involve the recognition of the importance of customers’ trust (26) and of farmers’ contribution (27). The use of another voice intensifier ‘recognize’ shows similar patterns, with Starbucks emphasizing its acknowledgment of the imperfections and the need for continuous CSR efforts.25. Although we are proud of how far we have come since our first report, we know there is still a long way to go. (2010)26. We know that our customers’ loyalty and trust must be earned. (2007)27. We know our success as a company is linked to the success of the thousands of farmers who grow our coffee. (2013)In general, the six most frequent voice adjusting collocates of ‘we’ all serve to intensify instead of mitigate the voice. In other words, they are conducive to the construction of a strongly assertive, confident, and committed corporate identity.Main stakeholders are identified in the wordlist of the corpus. Altogether, four groups of stakeholders are identified, whose frequencies are presented in From the frequency of total occurrences, we can infer the relative weight each stakeholder group bears on Starbucks’ CSR performance. Clearly, the most frequently nominated and thus the most heavily weighted are partners, followed by farmers and customers, and suppliers are least nominated.According to the frequency of the nomination of partner(s), this stakeholder group is of utmost salience in Starbucks’ CSR reports. Indeed, the fact that Starbucks refers to its employees as partners is a proof that Starbucks recognizes the importance and value of its employees. A collocation analysis is conducted to find out how ‘partner(s)’ is predicated in Starbucks’ CSR reports, with the top six most frequent collocates being presented in As is shown in the table, the most frequent collocate is ‘program,’ and the examination of the concordance lines shows that in Starbucks’ CSR reports, frequent mention is made about the various programs it carries out for partners. The next frequent collocate is ‘store,’ and the examination of its concordance lines show that ‘store partners’ are frequently nominated in Starbucks’ CSR reports. In most of the occurrences, Starbucks explicitly conveys its recognition of the contribution of store partners (28), and acknowledges their significance to Starbucks (29).28. Our store partners are very innovative when it comes to reducing waste. (2004)29. Our baristas and their fellow store partners are the face of Starbucks, engaging with our valued customers every day. (2003)There other three collocates are ‘support,’ ‘benefits,’ and ‘help.’ A close examination of their concordance lines shows that in most cases, partners are the receivers of the support, benefits, and help from Starbucks, as is shown in (30–32). And through voicing the partners in this way, Starbucks constructs for itself an identity of a supportive, helpful, and caring employer.30. The Thrive Wellness Initiative combines education, communication and participation to help our partners live healthy lives. (2015)support partners to make a difference in their communities. (2007)31. We have many programs that encourage and benefits for U.S. partners, including paid time off to get vaccinated… (2020)32. Recently, we extended COVID-19 Due to the specific industry to which Starbucks belongs, farmers who grow coffee beans are arguably the most important stakeholder group in its value chain. Therefore, it comes as no surprise that farmers are frequently voiced in Starbucks CSR reports. The examination of the collocates of ‘farmer(s)’ results in collocates that are identified as serving the predication strategy for the discursive construction of identity, with the top four presented in An examination of the concordance lines shows that these four collocates are all linked together in voicing and evaluating the farmers. To start with, ‘support’ and ‘help’ both position farmers as the recipients. That is, the farmers are constructed as beneficiaries who receive support and help from Starbucks, as is shown in (33). The help given to the farmers who grow coffee beans for Starbucks is meant both for increasing the coffee bean quality (which is to the advantage of Starbucks) and for providing economic returns for the farmers, as is in (34). By such positioning, the farmers are discursively constructed as relying on Starbucks for their livelihoods.support helped nearly 56,000 farmers who grow our coffee in ten countries. (2010)33. In 2010 alone this help farmers increase both coffee quality and yields to help them become more economically stable and more resilient, long-term producers supporting the specialty coffee market. (2013)34. Ultimately, we hope to The collocate ‘small’ specifically nominates farmers who work on a small coffee farm as important stakeholders for Starbucks. In the CSR reports, these farmers are constructed as being vulnerable and disadvantaged, to whom Starbucks shows much care. By discursively constructing the problems faced by these farmers, Starbucks expresses its steadfast commitment and determination to help solve these problems, as in (35). By voicing the farmers in this way, Starbucks discursively constructs an identity that is the provider of financial help and support for small-scale farmers.helping small-scale farmers thrive now and in the future. (2009)35. We’re steadfastly committed to Customers constitutes the third most frequently nominated stakeholder group in Starbucks’ CSR reports. However, a close examination only results in the identification of two collocates that reveal how customers are voiced in the reports, as are shown in As is shown in the table, the most frequent collocate is ‘partners,’ which means that the nomination of customers often goes in tandem with the nomination of partners. As such, customers are discursively constructed as sharing common ground and having a close relationship with partners. An investigation of the concordance lines of their co-occurrences shows that they are recognized by Starbucks as a means for the CSR end. To be more specific, Starbucks views customers and partners as the subjects toward whom it has the responsibility to raise their environmental awareness as part of its own CSR calling, as is exemplified in (36).Why are customers voiced as sharing the same ground as partners in Starbucks’ CSR reports? The answer may be found in (37). That is, in the CSR reports, partners and customers are constructed as constituting the communities that Starbucks serves. In other words, partners are the interface and medium through which Starbucks interacts and builds relationships with the customers.building awareness among our partners and customers about the responsibility we all share for the environment. (2004)36. But it also serves as a platform for 37. When the holiday season arrives, it heightens the community spirit in our partners and customers. (2007)38. Earning and maintaining the trust and respect of our more than 145,000 employees – whom we call partners – means improving our customers’ experience and our success as well. (2006)The collocate ‘experience’ also helps constructs the relationship between customers and partners. In (38), Starbucks equates earning the trust and respect of its partners with improving customers’ experience. In this way, customers are voiced as the service/products receiver of Starbucks, while Starbucks is constructed as a reliable provider of good customer experience.The last stakeholder group voiced in Starbucks’ CSR reports consists of the suppliers. In fact, the total frequency of the nomination of suppliers is significantly lower than that of the other four stakeholder groups, indicating the relatively low importance attached to them. The most frequent collocates predicating the suppliers are presented in As is shown in the table, ‘diversity’ and its adjective form ‘diverse’ are the top two most frequent collocates that predicate the suppliers. A close examination of their concordance lines shows that in the CSR reports, Starbucks accentuates its commitment to supplier diversity frequently. For instance, in (39), Starbucks discursively constructs its responsibility toward the suppliers as ensuring their diversity, and frames supplier diversity as creating business opportunities and economic impacts.Another collocate of ‘suppliers’ is ‘preferred.’ In (40) and (41), it is shown that Starbucks evaluates suppliers as being preferable or not based on whether they share Starbucks’ values and meet its requirements, and that the favored ones can receive better contract terms from Starbucks. In this way, Starbucks constructs suppliers as candidates vying for its preferences, and itself as a strict evaluator and selector of the suppliers in its efforts to ensure the coffee beans conform to the CSR values.39. The commitment we have made to supplier diversity is intended to provide not only opportunities for diverse businesses, but also to create a positive and sustained economic impact on the local communities where these businesses are based. (2006)40. When doing business with suppliers in the U.S., Starbucks has made a strong commitment to diversity. We select companies that share our core values and meet our key requirements of quality, service, value, stability and sound business practices. (2004)41. We buy from our preferred suppliers first, paying them higher prices and offering better contract terms. (2003)Up to Starbucks’ latest CSR report (of the year 2020), the biggest scandals or problems it has faced include its tax avoidance in United Kingdom reported in 2012, the arrest of two African black men in its store in Philadelphia in 2018, and the ongoing problems of employee unionization throughout the years.To begin with, Reuters published a report entitled “Special Report: How Starbucks avoids UK taxes” on October 15, 2012, explaining how Starbucks’ UK stores legally reported no taxable income while generating profits in the United Kingdom since it started operations there. This story has received wide media attention, and Starbucks’ attempts to address the criticism only fuel the criticism from the media, its customers, politicians, and UK tax-paying businesses . A searcAmong the 20 lines, there are several repetitions of the same wording, revealing very formulaic corporate expressions around the topic of tax. A close-reading of the concordance lines show that 12 occurrences come from the same paragraph in the reports of 2005–2007, as is in (42). In its tax policy, transparency and responsibility is not mentioned. Instead, tax policy is only viewed from the light of providing ‘competitiveness’ and ‘incentives for increased productivity.’ Clearly, here tax is not regarded as part of the company’s social and legal responsibility, but serves the profit-seeking end. In this sense, Starbucks’ tax avoidance in UK seems not so much a surprise.42. Tax Policy – Sound tax policy will continue to play a key role in the competitiveness of U.S.-based companies. Starbucks closely monitors tax policy developments and has advocated for a tax structure that maintains incentives for increased productivity. Another scandal of Starbucks involves the arrest of two African black men in its Philadelphian store on April 12, 2018. An employee called the police after the two black men declined to either leave or place an order before the arrival of the colleague they were waiting for. In the wake of the public outrage on this incident, Starbucks responded by calling the arrests “reprehensible” and starting to implement racial bias training for its employees . A searcrace, national origin, age, sex, religion and disability. (2017)43. We are an equal opportunity employer. In addition, we consider all qualified applicants for employment without regard to the federally protected categories of It is interesting that Starbucks makes no mention about its non-discriminating policy regarding the race of customers in the CSR reports, although it frequently emphasizes its commitment to creating a Third Place for people in its communication to the public. Whether this lack of specific mentioning in the CSR reports can be said to reveal something about the implicit corporate culture is a question open for interpretation.Another problem related to the stakeholder group of employees is unionization. It is an ongoing problem of Starbucks. Howard Schultz, who founded Starbucks and took the role of CEO several times, have fought against unionization all the along . A searc44. The election was to take place, the union voluntarily withdrew its petition, and the election did not take place. We believe that the union realized that the majority of partners who were eligible to vote were not in support of union representation. In addition, the 13 partners in one of our U.S. roasting plants who are currently represented by a union have indicated to that union, and to us, that they no longer want to be represented by the union. (2004)45. We recognize our partners’ right to organize, and do not take action or retaliate against partners who express their views about unions or who take part in union activity. (2007)The fact that statements like (45) only appear in the reports between 2003 and 2007 is, in itself, quite revealing about Starbucks’ stance toward employee unionization. Regarding the latest development of this issue, with Starbucks being reported to fire employees who have been involved in unionization efforts, the few mentioning of its acknowledgment of employee unions seems like a glimpse into its long-held attitude.Following a CDS perspective, this study does not content itself with the analysis of discursive and linguistic elements only. Since discursive practices may have important ideological effects, producing and reproducing unequal power relations between the majority and minority groups through how they use language to represent the world and position people , p: 258.Based on how partners are voiced in Starbucks’ CSR reports, we can see that a two-fold relationship is constructed between Starbucks and its partners. On the one hand, Starbucks relies on its partners’ work, talents, and contributions. On the other hand, as part of its CSR calling, Starbucks has the responsibility to care for both their safety and their wellbeing, providing programs and benefits to support them. Indeed, in such discursive construction, Starbucks constructs an identity that is caring and supportive to the partners, which makes a responsible and reliable employer. The fact that Starbucks calls its employees by the term ‘partners’ is a deliberate effort in constructing a positive corporate identity that hides the power relation inherent in corporate capitalism.In such discursive construction, Starbucks skillfully obscures the capitalistic ideology that employees’ value as labor force is to be maximumly exploited. And the responsibility to the employees, for instance, providing safe work environment and healthcare, is premised on employees’ value creation for Starbucks. Besides, as have been shown, in the CSR reports, Starbucks makes little recognition of the partners’ right to unionize. This somehow goes against an identity of employer who respect the rights of the employees. And the power relation between them is anything but equal, with Starbucks dominating the employees.In Starbucks’ CSR reports, farmers are voiced and evaluated as being vulnerable and thus highly dependent on Starbucks for their livelihoods. The ideologies behind such discursive construction are also capitalistic in nature, as farmers are positioned as being inferior and thus having little power. Starbucks discursively constructs the problem faced by the farmers as something beyond their own means. In this way, it constructs itself as the solution to the problem. In essence, this is an unequal relationship, with Starbucks having power dominance over the farmers. And to mask such unequal power relations, Starbucks discursively and rhetorically constructs a mutually dependent relationship between the farmers and the company.On the other hand, in the discursive construction of its identity as the provider of help to farmers, Starbucks obscures the fact that such help also benefits itself. In this sense, Starbucks positions itself in a somewhat altruistic way. That is, it is helping the poor and vulnerable farmers because it is a responsible citizen who cares for the farmers in need.However, the goal of Starbucks’ transaction with the farmers is to get the coffee beans to make its products so as to earn profits. And in fact, Starbucks cannot survive without buying the beans from the farmers. It just happens that the coffee bean farmers are in the under-developed areas suffering from poverty, so Starbucks can constructs its action of buying from them as heling them, shielding the fact that this transaction serves its own profit-making end.In the context of the business world, customers can be said to be one of the most important stakeholder groups (the other being investors) for any company. And the relationship between a company and its customers is based on exchange, i.e., providing goods/services in exchange for profits. However, in Starbucks’ CSR reports, customers are not voiced as the provider of economic returns for Starbucks, but as the stakeholder group to which it has the responsibility to serve by providing consistent and satisfactory customer experience. As such, Starbucks obscures the exchanging nature of its relationship with the customers. In this sense, customers are positioned as the taker while Starbucks is positioned as the giver, constituting a corporate identity that is responsible and sensitive to customers’ needs.However, Starbucks’ erasure of the issues of employees’ racial bias toward the customers may cast some doubt on its commitments to create a third place that is inviting.Suppliers are an important link in the value chain for a company. However, the demand for suppliers is relatively stable and fixed, whereas the supply of suppliers obviously exceeds the demand. As such, the nature of the relationship between Starbucks and the suppliers is also unequal, with Starbucks the selector and evaluator having power dominance over the suppliers who are being evaluated without much agency.On the other hand, the discursive construction of a corporate identity that is strongly committed to supplier diversity, to some extent, masks the fact that in essence, Starbucks will only choose and include diverse suppliers to its own advantage. Besides, Starbucks does not mention in the CSR reports that the diversity of suppliers actually contributes to the diversity of Starbucks’ products , adding to its strengths and competitiveness.This study conducts a corpus-assisted critical discourse analysis on Starbucks’ CSR reports to shed light on how Starbucks utilizes the discursive strategies and linguistic resources to construct its corporate identity in the CSR dimension. Through its positioning of the various stakeholders, Starbucks constructs itself as a supportive care-taker of the partners, committed provider of good customer experience, powerful helper of the poor farmers, and CSR-conscious selector of suppliers. Moreover, these identities are further reinforced by Starbucks’ use of intensification strategy to emphasize its CSR commitments, contributing to a proactive CSR stance.However, viewing Starbucks’ identity construction from a critical perspective, we can be aware of the hidden corporate capitalism behind its discourse. Starbucks’ relationships with the main stakeholder groups are all based on its corporate capitalistic nature, serving the profit-seeking end. In other words, its very own survival relies on the transactions with these stakeholder groups. Despite its discursive efforts to construct a positive identity, this study finds that it ‘erased’ the corporate scandals or problems about tax avoidance, employees’ racial bias, and its own attitude toward unionizations. Besides, on a more general level, corporate capitalism entails the maximization of business growth and economic development, which necessarily creates the tension between companies and the environment as well as society at large .Therefore, we need to take a more neutral and objective stance toward companies’ discursive construction of a socially responsible identity. If the whole society can be more aware of the companies’ roles and stances in CSR, as well as the hidden values behind in the CSR communication, companies may be prompted and pressured to take CSR more seriously and engage in more CSR activities that will truly benefit the environment and the society.The limitations of this study lie in the relatively small size of corpus and the lack of a diachronic perspective on the features of identity construction in different time periods. Also, due to the space limit, the discussion of the hidden values behind the discourse unfortunately may not go as deep as would be expected from a critical perspective. Future studies may consider investigating other corporate discourse . Second, comparative studies can be conducted to see whether there are industry-specific and/or country-specific features in companies’ discursive construction of the corporate identity. Also, studies can take a diachronic view to find out to what degree does companies’ identity construction vary in different time periods.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.XL contributed to the conception and design of the study, the collection and preparation of the corpus data, the analysis of the data, and the writing of the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Biomarkers are crucial in oncology, from detection and monitoring to guiding management and predicting treatment outcomes. Histological assessment of tissue biopsies is currently the gold standard for oropharyngeal cancers, but is technically demanding, invasive, and expensive. This systematic review aims to review current markers that are detectable in biofluids, which offer promising non-invasive alternatives in oropharyngeal carcinomas (OPCs). A total of 174 clinical trials from the PubMed search engine in the last 5 years were identified and screened by 4 independent reviewers. From these, 38 eligible clinical trials were found and subsequently reviewed. The biomarkers involved, categorized by human papillomavirus (HPV)-status, were further divided according to molecular and cellular levels. Recent trials investigating biomarkers for both HPV-positive and HPV-negative OPCs have approaches from various levels and different biofluids including plasma, oropharyngeal swabs, and oral rinse. Promising candidates have been found to aid in detection, staging, and predicting prognosis, in addition to well-established factors including HPV-status, drinking and smoking status. These studies also emphasize the possibility of enhancing prediction results and increasing statistical significance by multivariate analyses. Liquid biopsies offer promising assistance in enhancing personalized medicine for cancer treatment, from lowering barriers towards early screening, to facilitating de-escalation of treatment. However, further research is needed, and the combination of liquid biopsies with pre-existing methods, including in vivo imaging and invasive techniques such as neck dissections, could also be explored in future trials. Biomarkers are crucial in oncology, from the detection and monitoring of cancer to guiding management and predicting treatment outcomes. However, histological assessment of tissue biopsies, which is currently the gold standard for oral cancers, is technically demanding, invasive, and expensive. Liquid biopsies, through the analysis of cancer biomarkers in bodily fluids, offer promising non-invasive alternatives to patient care in oral cancers. The aim of this comprehensive literature review was to explore and discuss current markers that are detectable in various biofluids, including plasma, oropharyngeal swabs, and oral rinse.Specifically, this review will cover recent advancements in the application of fluid biomarkers to cancers of the oropharynx and the tongue base. These two sites are in close proximity, and the terms are often used interchangeably but give rise to notably different pathologies. Unfortunately, this leads to challenges when aggregating and comparing results in the field. The oropharynx includes the soft palate, lateral and posterior walls of the throat, tonsils, and the back third of the tongue, also known as the tongue base . There iWe performed a scoping review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 checklist. A systematic search was performed in PubMed, with 174 articles identified. Search results were limited to the recent 5 years. They were screened by 4 independent reviewers, with 7 being excluded due to duplication. No filters were used, and clinical trials were manually selected. Inclusion criteria included: (1) the tumor is of oropharyngeal origin; (2) fluid biomarkers were investigated; (3) data derived from clinical studies; (4) were conducted in the recent 5 years from 1 Jan 2017 to 1 May 2022. The selection process is summarised in Search terms included: (oropharyn*) and (carcinoma or cancer or tumo *) and (squamous) and ((circulating tumo * dna) or (circulating tumo * cell) or (cell free dna) or (plasma biomarker) or  or (liquid biopsy) or (extracellular vesicle) or (exosome *) or  or (biofluid)) and .n = 45). Finally, 38 were included in this review. The biomarkers being considered in this review were further divided into categories including HPV-associated, extracellular vesicles (EV), and methylated genes. A significant number of studies on tissue markers were observed. However, since the focus of this research is on biofluid markers, these were not reviewed in detail and will only be referred to when appropriate. After the initial search and deduplication, 122 records were later excluded due to irrelevance, and only clinical trials on fluid biomarkers were kept. Titles/abstracts deemed potentially eligible for inclusion were advanced to full-text screening , the use of HPV circulating tumor DNA (ctDNA) has been a promising biomarker in various aspects of clinical management, especially in early detection, prognosis prediction, and treatment outcome monitoring. The articles and biomarkers identified have been summarised in Early detection has been associated with lower incidence and better survival. The use of ctDNA or cell free DNA (cfDNA) as biomarkers for early detection has already been established in various types of cancers, such as Epstein–Barr virus (EBV)-associated nasopharyngeal cancers . HoweverThe potential use of HPV DNA in oral rinse as an early detection tool for OPC has been showcased in two studies. Twelve participants from a cohort of 660 cancer-free individuals were discovered to have positive oral HPV16-DNA and were followed-up for 24 months in a prospective study from Australia .Apart from oral rinse, HPV cfDNA in plasma could also serve the function of detecting OPC. HPV cfDNA could be detected in OPSCC patients with 100% specificity and 72% sensitivity, respectively .A meta-analysis reviewing 10 studies involving a total of 457 HPV-positive HNSCC patients ascertained the above conclusions. It was reported that HPV cfDNA in blood has diagnostic ability with a pooled sensitivity and specificity of 0.65 and 0.99, respectively . Given tApart from detection, liquid biopsy of HPV ctDNA in plasma could be applied to predict prognosis in HPV-positive OPC patients, particularly in the selection of patients who may benefit from de-intensified treatment.HPV cfDNA E6 and E7 concentrations were found to increase with size of tumor in HPV-positive OPSCC, with the median copy number of E6 and E7 cfDNA per mL plasma being significantly higher in large tumors . SimilarThe above findings are partially consistent with those from another study which ascertained the positive correlation of baseline HPV16 ctDNA levels with tumor burden among HPV-positive OPC patients . HoweverThere is yet to be a broad consensus on the role of baseline HPV ctDNA for risk stratification. Easily obtainable biofluid including saliva and blood shows the potential value of providing supplementary information for treatment choice, though its clinical application as a prognostic marker awaits large-scale multicentric study to further investigate.Apart from initial staging, it has been reported that HPV ctDNA concentrations could be used to predict and monitor treatment response by reflecting the dynamic tumor burden.From a small-scale study, among six patients with post-treatment serum, a patient with negative baseline HPV ctDNA detection and another four that had significantly decreased HPV ctDNA loads post-treatment showed a complete clinical response to treatment, whereas the patient having fivefold increase in HPV ctDNA load after treatment died within days .A similar conclusion could be drawn from research conducted by Haring et al. in which changes in plasma HPV16 ctDNA concentrations were shown to correlate with radiographically determined treatment responses for OPC patients on immunotherapy . ResultsWith more accurate predictions on treatment response, patients could be selected for de-escalation of treatment and avoid unnecessary biopsies and surgical treatment.Recurrences of OPSCC mostly occur within the first two years following treatment completion. HPV-positive OPSCC can recur up to five years or more after therapy ,16. It iIn a prospective clinical trial, HPV ctDNA in plasma demonstrated the ability to identify disease recurrence in non-metastatic HPV-positive OPSCC patients receiving CRT. With a median follow-up time of 23 months post-treatment, all 87 patients that had undetectable HPV ctDNA throughout did not develop recurrence . Among tThis is also illustrated by Lee et al. where a patient in the study showed elevated HPV DNA level despite lack of active disease at the primary site or cervical lymph nodes . PositroTwo articles have been identified regarding RNA biomarkers for HPV-positive OPC, and their biomarkers are summarised in The use of genetic markers for the detection of HPV-positive OPC extends to RNA apart from DNA. Presence of HPV E6/E7 mRNA indicates transcriptionally active HPV, which is involved in the carcinogenesis of OPSCC. HPV E6/E7 mRNA from fine needle aspiration (FNA) of neck lymph nodes of metastatic OPSCC patients showed an overall agreement of 88%, which is comparable to conventional immunohistochemical p16 staining of tumor tissue, allowing it to serve as a tool for diagnosis [Instead of focusing on HPV, a prospective study observed the role of oral and gut microbiomes on HPV-positive OPSCC patients after CRT through measuring rRNA of bacteria . Pre-theComposition of microbiome in oropharyngeal swabs was revealed to correlate with the treatment status, with the number of species in oropharyngeal swabs decreasing significantly after therapy. A shift in taxonomic composition could also be observed with an increase in relative abundance of gut-associated obligate anaerobes, such as Bacteroides species. However, the underlying reason behind such a change is yet to be discovered.With emerging interests on the action on microbiome, the possible implications of how novel development in the field could aid in the diagnosis and monitoring of OPC is worth further exploration.Findings of the two studies looking into the use of epigenetic biomarkers are summarised in Studies have investigated a range of novel methylation markers aiming to identify suitable ones for diagnostic or monitoring purposes. Various genes were found to associate with OPC, warranting studies to assess the relationship between epigenetic modifications and clinical progression of the cancer.Calmodulin-like 5 (CALML5) is a skin-specific calcium binding protein which is involved in regulation of epidermal differentiation . TransloDNAJ heat shock protein family member C5 gamma (DNAJC5G) belongs to the DNAJ family, in which various members were revealed to have different interactions with viruses including adenovirus, vaccinia virus, HIV-1 , and HPVPost-translational modification of genes in the salivary rinse has also been investigated to identify markers for post-treatment surveillance of HPV-positive OPSCC. It has been shown that a combined panel of HPV DNA (HR E5L2-4) and hypermethylation of endothelin receptor type B gene (EDNRB) gave the best sensitivity (0.90) and specificity (0.81) in detecting recurrence . The panWith promising results, these liquid biopsy markers may be utilized complementary to conventional radiographic examination in long-term patient surveillance.Extracellular vesicles are actively released by cells to facilitate cell-to-cell communication. They contain molecular cargo such as nucleic acids and proteins, and are present in all biological fluids, making EVs valuable and worthy of investigation. It has been established that in HPV-related cervical cancer, their contents, in particular microRNAs, are altered. Two articles have been identified and their corresponding biomarkers are summarised in In an in vitro study on oropharyngeal tumor cells, it was revealed that HPV-positive OPSCC cells produced less EVs than HPV-negative cells. Their cargo was analyzed and revealed an abundant number of miRNAs independent of HPV status, with 9 common miRNAs found to be present in all samples. Pathway analysis showed that PI3K-Akt, Fox0, HIF-1, mTOR, and p53 signaling pathways were targeted by these miRNAs. However, 14 and 19 miRNAs were identified to be only enriched in HPV-positive and HPV-negative groups, respectively. miR-99a-5p, miR-27a-3p, and miR-27b-3p, which were previously reported as cargo of EVs from HPV18 + HeLa cervical carcinoma cells, were also found to be enriched in HPV positive OPSCC-produced EVs. Expression of miR-20b-5p, which is also enriched in HPV-positive OPSCC-derived EVs and promotes cancer cell invasion, has been proven to be dependent on the viral E6 oncoprotein. Therefore, although EVs of different origins may have overlapping miRNA profiles, certain miRNAs are dysregulated in specific subtypes, providing potential for detection of OPSCC .One major challenge to developing clinically significant miRNA biomarker panels is the biological variability and differences in detection methodology, including collection, storage, RNA isolation, and processing, thus leading to unreproducible findings. In a study of 40 OPSCC patients, a cross-validated StaVarSel (stable variation selection) method was utilized and produced a 11-miRNA-ratio model that accurately identified HPV-positive OPSCC (90% sensitivity and 79% specificity), showing good potential for diagnosis and predicting recurrence. However, the subjects were in advanced stages of OPSCC and thus the ability of EV signatures in early detection was not tested .Three articles investigating the use of oncoprotein biomarkers in OPC have been identified and summarised in Patients with HPV + OPSCC have better overall and disease-free survival. Determination of HPV status is therefore important for risk stratification. However, the surrogate immunohistochemical marker, p16(INK-4a), which is used clinically with high sensitivity, only has a specificity of 83%, leading to potential misclassification of a specific subgroup of patients who are p16(INK-4a) positive but HPV DNA-negative. These patients have been reported to have distinct clinical features, worse prognosis, and increased metastasis potential compared to both p16(INK-4a) and HPV DNA-positive patients.Thirty-six patients with newly diagnosed OPSCC were analyzed with three serum markers, which were increased in the sera of HPV-associated OPSCCs, and were identified to differentiate HPV-associated and HPV-independent OPSCCs, including ApoF, Galactin-3-Binding protein, and complement component C7 . ApoF isOral testing is another focus of non-invasive biomarker development, due to the close proximity to oropharyngeal tumors in addition to the easy collection of saliva and swabs. A study compared HPV E6 oncoproteins and E6/E7 mRNA in fine-needle aspiration samples and oropharyngeal samples  and found that HPV E6 oncoprotein tested in such samples agreed with results of p16 or HPV tested tumors, but at a lower concentration and rate than mRNA and DNA [Although HPV-positive OPSCC has a more favourable prognosis, 10–25% still recur. A small single-institution study evaluated the possibility of using a liquid biopsy as a prognostic marker, measuring HPV E6E7 expression in circulating tumor cells (CTCs). Pre-treatment baseline expression of HPV E6/E7 oncogene in CTCs were associated with both progression-free survival and overall survival, with patients having significantly higher risk of relapse and death. However, the presence of E6E7 + CTCs at the end of treatment was not significant in PFS and overall OS . ResearcA range of immune response-related markers have been identified to have prognostic and surveillance functions, which are summarised in Immunological responses to HPV may provide insights for treatment response as well. A correlation is likely between the HPV-positive status of the tumor and T cell response to HPV antigens, as demonstrated by a study which found that 80% of patients who had detectable HPV16 DNA in tumors also had CD4+ or CD8 + T cell response to HPV16 E6/E7. This study provided survival data in OPSCC stratified by cell-mediated immune response to HPV16 peptides, and demonstrated that enhanced immunoreactivity to antigen E7 was correlated with longer disease-free survival. The average disease-free survival (DFS) for all patients was 43.7 months, and was increased to 47.3 months for the HPV+ cohort. Higher average DFS (49.6 months) was observed in patients with an increased CD8 + T cell response to E7. Cox regression analysis revealed that a retained or enhanced CD8 + T cell response to E7 has significant influences on DFS . Rising Apart from T cell response, antibodies directed against HPV antigens have also been investigated as prognostic biomarkers pre- and post-treatment. With removal of the tumor and thus the source of antigens, B cell responses should in theory become limited. A study on 77 patients revealed better survival outcomes for patients with higher levels of anti-E2 IgG. Interestingly however, the presence of IgA antibodies does not appear to be linked to survival outcomes. It was also found that levels of anti-E6 and E7 IgG antibodies differ pre- and post-treatment. However, their application on predicting recurrence is still unknown due to limitations of the cohort.Although some oropharyngeal cancers are HPV-negative, there are still alternative biomarkers that could assist in detection and management. Eighteen clinical studies were found in the systematic search and are categorized into genetics, protein, and immune response-related biomarkers below.Three articles and biomarkers for HPV-negative OPC have been summarised in DNA methylation patterns of genes used as biomarkers may serve the early diagnosis of OPSCC. A previous study conducted in Thailand identified that methylation at cg01009664 of the thyrotropin-releasing hormone (TRH) gene may be a potential marker for OPSCC screening by a bioinformatics approach . Within Another candidate biomarker is the DEK oncogene, which was shown to play an important part in tumorigenesis as a chromatin structural and remodeling protein. Downregulation of plasma DEK oncogene was found to be associated with poor prognostic factors including HPV-negative status and advanced tumor stage in HNSCC patients . Plasma p = 0.01), this still showcases the possibility of incorporating poly ADP-ribose polymerase (PARP) inhibitor therapy in the treatment of certain patients, since cells without functional DDR genes for homologous recombination repair (HRR) pathway are sensitive to PARP inhibition. Thus, testing for DDR gene mutations in ctDNA may help to identify patients that are susceptible to target PARP inhibitor therapy, allowing another option aside from the conventional ways of treatment.Previous studies have explored the possibility of identifying gene mutations by next-generation sequencing for target therapy. DNA damage repair (DDR) gene mutations in ctDNA within an 18-gene panel were detected in 37.0% of the HNSCC patients, which included 68 (40.0%) OPC patients . SpecifiA range of protein biomarkers were found to have diagnostic or prognostic function for HPV-negative OPC, which is summarised above in Matrix metalloproteinases (MMPs) play a role in the regulation of extracellular matrix (ECM) remodelling, in which MMP-1, also known as collagenase-1, was the first to be discovered in the family in 1962. Being responsible for initiating the degradation of native fibrillar collagens by cleavage of peptide bonds , MMP-1 hDiagnostic value was also found in another secretory enzyme lysyl oxidase like 2 (LOXL2), which was speculated to be involved in ECM remodeling and epithelial-mesenchymal transition, thus contributing towards tumor progression . Strong Neurotrophin-3 (NT-3) is known to be involved in various cancers including breast cancer , lung caNumerous studies have investigatated the possibility of utilizing enzymes in the MMP-1 cascade to predict prognosis in OPC. ProMMP-1, the inactive precursor of MMP-1, gains function via a proteolytic process involving proteases and MMP-3. The activity of MMP-1 is further regulated by the enzyme tissue inhibitor of metalloproteinase-1 (TIMP-1) . TIMP-1 The prognostic value of MMPs has been demonstrated, with levels correlating with factors involved in cancer staging, including tumor size, nodular metastasis, and degree of cancer cell differentiation. Salivary MMP-1 levels were found to increase significantly between stage I and stage IV patients, thus reflecting cancer progression . MoreoveAnother novel study suggested the use of MMPs in surgical drain fluid instead of conventional saliva and blood samples, since it is obtained routinely and eliminates effects due to proximity from tumor sites, an issue in salivary samples. Measurements of MMP-1 and MMP-3 from fluid samples were collected postoperatively every 8 h . Within Apart from MMP itself, overexpression of TIMP-1 in serum was also associated with poor prognosis specifically in HPV-negative OPC. Carpén et al. demonstrated the concordance of TIMP-1 with OPC among 90 patients, showing that high TIMP-1 serum levels were strongly associated with poorer overall survival (adjusted HR 14.7) and disease-free survival (adjusted HR 8.7) among HPV-negative patients . This seTen clinical studies were identified that investigated the potential of utilizing peripheral changes in immune response as markers for HPV-negative OPC. Blood, saliva, and post-surgical drain biofluids were investigated. The applications of these biomarkers included early detection, tumor staging, as well as assessing prognosis and predicting survival.The changes in immune response can be categorized into genetic, cellular, and tissue levels, and are summarized in Salivary lactate dehydrogenase (LDH) and plasma interleukin-1 receptor antagonist (IL-1Ra) levels were hypothesized to be upregulated in patients with cancers of oropharyngeal origin.Tumor cells increase metabolic processes, including glycolysis, to meet the heavy energy demands. LDH is increased in cancer cells to catalyze pyruvates into lactates. It is also expressed during cellular necrosis and in HNSCC patients has higher levels than that of the healthy control group, as found in a study on 44 HNSCC patients . It is nPlasma IL-1Ra was also investigated as another potential marker for early detection in a study on 87 patients . Being aCytokines, immunosuppressive cells, and membrane-bound enzymes have been found to have potential in assisting tumor staging in recent studies including IL-1Ra and CD73.Although IL-1Ra was found to not have a diagnostic value, its level correlates with tumor size and body mass index (BMI). Larger tumors  had higher IL-1Ra levels than those with T1 and T2 smaller tumors, and this was seen in all sub-locations of HNSCC. However, nodal involvement and metastasis did not correlate with IL-1ra levels. The increase could be a response to the increased inflammation in the tumor micro-environment. This would inhibit anti-tumor immune responses, leading to continuation of carcinogenesis and tumor growth. The explanation by increased inflammation is supported by the correlation with BMI, as obese patients, who were found with higher IL-1Ra levels, had more adipose tissue and thus increased inflammation.Apart from circulating cytokines, myeloid-derived suppressor cells (MDSCs) in peripheral blood have been found to directly correlate with clinical stages of HNSCC. MDSCs are a heterogenous group of immature myeloid cells, including macrophages, granulocyte progenitors, and dendritic cells. They can be divided into monocytic (M-MDSC) and polymorphonuclear (PMN-MDSC) forms. PMN-MDSC levels rise in cancer patients, leading to T-cell immunosuppression through the adenosine pathway. A small study on 53 patients revealed that these cells can be indirectly identified and measured through the enzyme CD73 (ecto-5′-nucleotidase), which is expressed on cell surfaces and contributes towards MDSC-mediated immunosuppression .Extracellular adenosine suppresses effector T-cells and stimulates angiogenesis through activation of the adenosine receptors A2A and A2B. Precursors are dephosphorylated into adenosine by CD73, which is found, membrane-bound, on multiple cell types, including tumor cells and tumor infiltrating lymphocytes . Both PMIt is important to note the small study size which led to large variation in the samples. Tumor differentiation was also not explored in the study. Considering how CD39 plays an important step in hydrolyzation before CD73-mediated dephosphorylation in the adenosine pathway, it also has potential for further investigation. Given the significant impact of immunosuppression by MDSCs through the adenosine pathway, ectonucleotidase inhibitors are promising pharmacological treatments in immunotherapy against HNSCC.Immune checkpoints have been a hot topic in the recent decade, with CTLA-4 and PD-1 being major targets in immunotherapy. PD-1 is a transmembrane co-inhibitory receptor of the IgG family, expressed upon activation of T and B cells on many immune cells, including monocytes, natural-killer cells, dendritic cells, T-cells, B-cells, and tumor-infiltrating lymphocytes. A total of 26 HNSCC patients were investigated with flow-cytometric analysis, and results showed that although inhibitory T-lymphocytes preferentially concentrate at the tumor sites, elevation of peripheral CTLA-4+ and PD-1+ cytotoxic T-lymphocytes was still found in patients with stage IV tumors . It is nAnother study investigated tissue-resident memory T cells (TRM) in the tumor microenvironment and peripheral TRM-like cells in circulation, which also highly express PD-1 and TIM-3. The specific roles of TRM cells have not been established, but they have direct cytotoxic and antitumor effects through producing effector cytokines. It has been found that TRM-enriched tumors correlate with HPV status, proportion of oropharyngeal lesions in HNSCC patients, and favorable prognosis. CD69+ PD-1+ TIM-3+ TRM-like cells, which circulate peripherally in blood, were also found in the tumor micro-environment. As it is often difficult to collect tumor samples from metastatic sites of HNSCC, the possibility of measuring peripheral PD-1+ TIM-3+ TRM-like cells were investigated. However, blood from 60 HNSCC patients, 50% positive with HPV, were analyzed and no significant correlation was found between peripheral TRM-like cells and clinical features of HNSCC patients . Given tPD-1 interacts with two ligands, PD-L1 and PD-L2, which are expressed widely in non-lymphoid tissues, including cancer cells. Although circulating PD-1 positive cells have potential applications in tumor staging and management, a study measuring free serum PD-L1 protein levels in 30 patients with an electrochemiluminescence assay found no correlation with PD-L1 levels in tumor and surrounding immune cells of 101 patients with oral tongue squamous cell carcinoma (OTSCC) . There wSmoking and alcohol consumption are major risk factors for OPC aside from HPV status. However, genetic variations have been proven to play a role in altering the risk of these lifestyle factors in individuals, as well as contributing independently to the risk of carcinogenesis.A study on 90 patients with HNSCC  with varying TNM stages conducted HLA typing on leukocytic DNA samples extracted from peripheral blood . Patient+ cytotoxic T lymphocytes, leading to destruction of cancerous cells. It is suggested that altered frequencies affect HLA ability in binding and presenting tumor associated antigen peptides, thus impairing immunosurveillance.Well-established risk factors of sex, age, location, HPV-status, and TNM stages were analyzed beforehand and had no significant impact on PFS on their own apart from T4 stage HNSCC. However, when HLA traits were added as a covariate to the model, the aforementioned factors were significantly associated with PFS. HLA-A, B, and Cw play a vital role in presenting aberrant peptides from mutated proteins to CD8Saliva and blood are not the only biomarkers that can be used in OPCs. Post-surgical drain fluid can also provide markers that potentially represent both the tumor condition and also the stages of wound healing. The normal phases of post-operational wound healing, including haemostatic, inflammatory, and angiogenic stages, are tightly regulated by cascades of cytokines, chemokines, and proteases. These levels are expected to change with time over the course of healing and could be monitored by fluid collection at regular intervals after surgery.It is known that pro-angiogenic factors and anti-angiogenic factors are associated with tumor prognosis. Vascular endothelial growth factors (VEGF) and soluble fms-like tyrosine kinase 1 (sFlt-1), which is an antagonist of VEGF-1, were studied in a small study of 20 patients. Low levels of sFlt-1 in post-surgical fluid were found to have significant correlation with tumor recurrence, while VEGF-A levels were associated with nodal metastasis .Post-surgical drain fluid is not just limited to measurements of cytokines; proteins and enzymes such as metalloproteases have also been found to correlate with tumor prognosis and recurrence. It is therefore a promising method of non-invasively monitoring progress following tumor resection.Cells which inhibit tumor growth have been investigated in multiple studies. Mononuclear cells (MNCs), which also reduce cancer proliferation, were investigated using in vivo and in vitro zebrafish models involving OTSCC cells. However, peripheral circulating MNCs were found to have no significant effect on OTSCC cell migration .Pre-treatment leukocytic count was also investigated, but in p16-positive OPSCC patients. Neutrophil lymphocyte ratio (NLR), a marker of inflammation, was measured prior to chemoradiation therapy in 167 patients . Tumor sThe same study on p16-positive OPSCC patients found hemoglobin concentration, another hematological parameter, to correlate with OS and PFS. Recurrence states however, although higher in patients with pre-treatment anemia (23.1% vs 9.1%), did not have a statistically significant increase. Anemia reflects tumor oxygenation, an important factor affecting the tumor micro-environment. Worse prognosis in anemic patients has been well-established in previous studies involving head and neck tumors. A possible explanation is that pre-existing hypoxic conditions in the tumor micro-environment are exacerbated due to the decreased oxygen-carrying capacity of red cells. Resulting effects include a dampened response of cancer cells to cytotoxic therapy. Further investigation is needed to determine if anemia can be a marker to predict treatment response.There were several limitations in this systematic review. Firstly, no statistical nor sensitivity analysis was done to assess the robustness of the synthesized results. Furthermore, reporting bias and certainty assessments were lacking. During the review of eligible papers, it was also observed that many trials studied HNSCCs as a whole, with OPCs being only a proportion of the test. Some of the data regarding the distribution of cancer types were also missing and could lead to decreased reliability of data when focusing on OPC alone.Recent clinical trials investigating biomarkers for both HPV-positive and HPV-negative cancers have approaches from various levels and different biofluids. Promising candidates have been found that could aid in detection, staging, and predicting prognosis of OPCs, in addition to well-established factors including HPV, alcohol consumption, and smoking status. These studies also emphasize the possibility of enhancing prediction results and increasing statistical significance by multi-variate analyses.Liquid biopsies, being non-invasive methods, offer promising assistance in enhancing personalized medicine in treating cancer patients. The majority of fluid biomarker research is still in plasma, with HPV ctDNA remaining the most-studied fluid biomarker, which has already been applied clinically to other HPV-related cancers. On the other hand, non-HPV related OPCs often present at younger ages, and oral rinses may lower perceived barriers and encourage screening due to its non-invasiveness and simplicity. Markers such as HLA traits may also serve a role in enhancing prognosis prediction when added as covariates for well-known factors including smoking and alcohol consumption status. Furthermore, de-escalation of treatment is potentially improved with the introduction of reliable fluid biomarkers, as they can reduce the need for unnecessary invasive biopsies and monitoring, and even being able to detect recurrence before routine radiographic imaging.However, further research is still needed, with larger sample sizes and more specific categorization of marker subtypes. In addition, a combination of these markers with pre-existing methods, including in vivo imaging techniques such as PET scans, and invasive techniques such as neck dissections, could also be explored in future trials. With better stratification of patients for HPV-positive cancers, there are also potential implications for treatment deintensification to reduce treatment complications yet sustain survival for these patients.


GLOBOCAN 2020, it has an age-standardised rate (ASR) world incidence of 13.3 per 100 000 worldwide, and 14.9 per 100 000 in Latin America and the Caribbean (LAC) region. In the LAC region, cervical cancer is the third most common cancer type among women, with the highest ASR mortality after breast and colorectum cancers. Human papillomavirus (HPV) infection is one of the main causes of cervical cancer. More than 170 HPV serotypes have been described, and HPV16 and HPV18 are the most frequently cited aetiological agents of cervical cancer. HPV infection is sexually transmitted and, despite being preventable, it still leads to cervical cancer, causing over 300 000 female deaths worldwide.Cervical cancer is the fourth most common gynaecological cancer in the world. According to Shin et al., 2022 conducted a micro-costing analysis on HPV self-sampling in Peru. These tests are distributed by women recruited by the HOPE Project, who help disseminate the self-sampling kits and link women to follow-up care. The HOPE Ladies raised awareness of testing in the community and were able to increase testing, with a participation of 94.2% compared with 53.3% in the control group with practitioner-sampled tests. According to the micro-costing analysis, the programme had competitive prices and could be successfully implemented in Peru, and probably other countries in the Americas. Loss to follow-up after Pap smear should also be of concern, and a combination of self-testing and text messages to increase triage has been proven effective. For example, in Jujuy, Argentina, a study implemented text (SMS) messages to increase follow-up, resulting in a 15.5% increase in adherence among women after receiving the HPV result. SMS messages are low-cost and could be useful in increasing triage and preventing cancer.Early detection of HPV lesions, such as by Pap smear and HPV screening, is a cost-effective way to prevent cervical cancer. WHO recommends screening every 3–5 years after age 30 years in the general population of women. However, in many low-income and middle-income countries, there are barriers to accessing these tests such as fear of gynaecological exams, cultural beliefs, insurance status, or sociodemographic inequities, among others. Thus, many HPV infections remain undiagnosed. As an approach to boosting test accessibility, Shapiro and colleagues evaluated the direct impact of public-funded, school-based HPV vaccination programmes for boys in Canada. Each jurisdiction implemented the vaccination programme for boys at different time points; however, some provinces did not implement the publicly funded HPV vaccination for boys, only for girls. The authors found a correlation between public-funded, school-based vaccination and greater uptake in boys, but there was no indirect uptake effect in girls. A survey was also applied to the parents to evaluate psychosocial factors and self-report vaccination, and a higher uptake was associated with child´s older age, health-care provider recommendation, and knowledge regarding vaccine effectiveness.Another highly successful approach to prevent cervical cancer is HPV vaccination, which targets mainly teenage girls and boys. Vaccination uptake varies depending on the area and time period. For example, in Canada, vaccination coverage ranges from 46.3% to 93.9% across the territories (2013-2015). In Brazil, vaccination rates decreased from 92% in 2014 to 69.5% (in girls aged 9–11 years) in 2015. In Colombia, the decline was even more pronounced: in 2013 the coverage was 97.5% and dropped to 20.4% in 2014, due to miscommunication about vaccination safety. The cost of the vaccine, misinformation, and cultural barriers are just some of the obstacles to a successful immunisation programme. In Canada, there are still issues regarding HPV vaccination rollout among children, as each province and territory is responsible for their health care, including vaccination programmes. global call for action to eliminate cervical cancer, and in 2020 the World Health Assembly adopted the Global Strategy to Accelerate the Elimination of Cervical Cancer, focusing on three main goals: one, vaccination; two, screening; and three, treatment. Latin America should build on its reputation as a region with a successful history of vaccination programme implementation, being one of the first to introduce new vaccines such as rotavirus and pneumococcal conjugate vaccines and successfully reaching coverage higher than 95% for Bacillus Calmette–Guérin (BCG) vaccine in countries such as Brazil, Argentina, Chile, and Bolivia. This historical success should be extended to HPV vaccination programmes across the region. In fact, HPV vaccine is already recommended and included as part of national immunisation programmes in many LAC countries, such as Panama and Mexico, some of the first countries that introduced HPV vaccines. Alongside the inclusion of HPV vaccines in national immunisation programmes, raising disease awareness in the population is an important task that can lead to an increase in testing and treatment seeking for HPV infection and cervical cancer. Incorporating the three goals of this Global Strategy—vaccination, screening, and treatment—into governments’ action plans will help eradicate cervical cancer sooner in LAC countries.In 2018, WHO announced a


HPV 감염은 대부분 별다른 증상 없이 자연적으로 소실되지만, 고위험군 HPV에 반복적으로 노출되는 경우 여성의 자궁경부암, 외음부암, 질암뿐만 아니라 남성의 생식기 사마귀, 직장암, 음경암 및 두경부암 등을 일으키는 주요 원인으로 보고되고 있다. 그러나 이 질HPV 백신은 HPV 감염 예방을 위한 가장 효과적이고 안전한 방법으로 알려져 있다,4,5. 특히 HPV 감염은 성관계 시작과 더불어 증가하므로 이를 예방하기 위해 HPV 백신 접종 시기는 첫 성경험이 이루어지기 이전이 가장 이상적이다. 또한 HPV 백신은 성인에서 3회 접종하는 반면 12세 이하에서는 2회 접종만으로도 높은 면역효과를 나타내기 때문에 보건학적, 경제적 측면에서 12세 이하에 HPV 백신 접종을 시행하는 것이 비용 효과적이다. 최근 우리나라한편, 계획된 행위 이론에 의하면 특정 행동에 대한 행동의도는 행위의 직접적 결정인자로 행위에 선행하며, 행동의도는 3가지 핵심요인인 행위에 대한 태도(attitude), 주관적 규범(subjective norm) 및 지각된 행위 통제(perceived behavior control)에 의해 결정된다. 즉, 특정 건강행동이 가치 있는 결과를 낳는다고 생각할수록, 그 행동을 수행할 능력과 기회가 있다고 생각할수록 그 행동을 실제로 할 가능성이 높아짐을 의미한다. 국내외 선행연어머니 혹은 부모의 HPV 백신 접종의도와 관련된 국외 선행연구들을 살펴보면, 남아 부모의 자녀 HPV 백신 접종의도 및 영향요인을 확인하는 연구가 최근 활발하게 진행되고 있다,12,18,20이에 본 연구는 HPV 백신 접종 최적 연령인 대전 소재 3개 초등학교에 재학 중인 4–6학년 남학생 어머니의 자녀(아들) HPV 백신 접종의도 및 관련 요인을 규명함으로써 초등학교 고학년 남학생 어머니의 자녀(아들) HPV 백신 접종의도를 높이고, 궁극적으로 남학생의 HPV 백신 접종률을 높이기 위한 중재 프로그램 개발 시 기초자료로 활용하고자 한다.본 연구의 목적은 초등학교 고학년 남학생 어머니의 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감 및 HPV 백신 접종의도를 파악하고, HPV 백신 접종의도에 미치는 영향요인을 확인하기 위함이며 구체적인 연구목적은 다음과 같다.1) 대상자의 일반적 특성 및 HPV 관련 특성을 파악한다.2) 초등학교 고학년 남학생 어머니의 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감 및 자녀 HPV 백신 접종의도를 파악한다.3) 초등학교 고학년 남학생 어머니의 자녀(아들) HPV 백신 접종의도와 HPV 지식, 자녀 HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감과의 상관관계를 파악한다.4) 초등학교 고학년 남학생 어머니의 자녀(아들) HPV 백신 접종의도에 영향을 미치는 요인을 파악한다.Ethics statement: This study was approved by the Institutional Review Board of Daejeon University (1040647-201812-HR-008). Informed consent was obtained from the subjects.본 연구는 초등학교 고학년 남학생 어머니의 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감이 자녀(아들) HPV 백신 접종의도에 미치는 영향을 확인하기 위한 서술적 조사연구이다.본 연구의 대상자는 대전 소재 초등학교 3개교를 임의 선정하여 4–6학년에 재학 중인 남학생(363명)의 어머니 전수를 대상으로 하였다. 본 연구에 필요한 대상자 수는 G*Power 3.2.1 프로그램을 사용하여 효과 크기 0.15 (중간 크기), 유의수준 .05, 검정력 90%, 일반적 특성 및 HPV 백신 관련 변수를 포함하여 회귀분석에 필요한 독립변수 10개를 투입한 결과 최소 표본 수는 147명으로 산출되었다. 배포된 363부 중 175부가 회수되었으며(회수율 48.2%), 이들 중 응답이 불충분한 24부를 제외한 151부를 최종 분석에 사용하였다.HPV 지식은 Kim과 Ahn 이 대학생을 대상HPV 백신 접종에 대한 태도는 Gerend와 Shepherd 가 개발한 TPBHPV 백신 접종에 대한 주관적 규범은 Gerend와 Shepherd 가 개발한 TPBHPV 백신 접종에 대한 자기 효능감은 Gerend와 Shepherd 가 개발한 TPBHPV 백신 접종의도는 Gerend와 Shepherd 가 개발한 TPB자료수집은 연구자가 사전에 해당 초등학교를 방문하여 학교장과 보건교사에게 연구목적과 방법 등을 설명하고 연구수행에 대한 동의를 구하였다. 그 후 보건교사는 학생들에게 연구목적과 내용이 담긴 설명문, 연구 참여 동의서, 설문지 및 회신용 밀봉지(양면 테이프가 부착된 대봉투)를 봉투에 넣어 밀봉된 상태로 배부하여 어머니들에게 전달하였다. 연구 참여 동의서에 자발적으로 서명한 어머니들이 동봉한 설문지를 작성하고 연구 참여 동의서와 함께 밀봉 처리하여 보건교사에게 제출하는 방식으로 자료를 회수하였으며, 연구에 참여한 모든 어머니들에게는 감사의 표시로 소정의 선물을 제공하였다. 자료수집 기간은 2019년 3월 1일부터 2019년 4월 10일까지였다.수집된 자료는 IBM SPSS Statistics for Windows ver. 25.0  프로그램을 이용하여 대상자와 자녀의 일반적 특성, HPV 감염 및 HPV 백신 관련 특성을 기술 통계를 이용하여 분석하였다. 대상자의 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감 및 접종의도도 기술 통계를 이용하여 분석하였으며, 대상자의 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감 및 접종의도 간의 상관관계는 Pearson’s correlation coefficients으로, HPV 백신 관련 특성에 따른 자녀(아들) HPV 백신 예방접종 의도의 차이는 독립표본 t-test와 one way ANOVA, Mann–Whitney U test를 이용하여 분석하였다. 대상자의 자녀(아들) HPV 백신 접종의도에 영향을 미치는 요인을 확인하기 위해 다중회귀분석을 실시하였다.대상자의 평균 연령은 42.74±3.19세였으며, 41–45세가 90명(59.6%)으로 가장 많은 분포를 나타내었고, 학력은 대졸 이상이 139명(92.1%)이었으며, 직업이 있는 대상자가 104명(68.9%)이었다. 종교가 있는 대상자는 72명(47.7%)이었고, 평균 월 수입은 500만 원 이상이 88명(58.3%)으로 가장 많았다. 자녀는 5학년이 88명(58.3%)으로 가장 많았고, 어머니가 생각하는 자녀의 HPV 백신 접종 최적 연령은 평균 14.85±2.45세였으며, 백신 접종 최적 연령인 13세 이하라고 응답한 수는 49명(32.5%)이었다.대상자의 자궁경부암 가족력은 ‘없다’가 145명(96.0%)이며, 부인과 질환 경험은 ‘없다’가 121명(80.1%)이었다. Papanicolaou (Pap) test 검사 경험은 ‘있다’가 123명(81.5%)이었고, 이 중 100명(81.3%)은 규칙적으로 Pap test 검사를 하고 있는 것으로 나타났다. 조사 대상 어머니 중 HPV 감염에 대해 들어본 경험이 있는 어머니는 111명(73.5%)이었고, HPV 백신에 대해 들어본 경험이 있는 어머니는 89명(58.9%)이었다. 자녀(아들) HPV 백신 접종 여부는 비접종이 151명(100%)이었다. 어머니의 HPV 백신 접종 여부는 접종이 15명(9.9%)이었고, 자녀(아들) HPV 백신 접종계획은 103명(68.2%)에서 자녀에게 HPV 백신을 접종할 계획을 가지고 있었다. 이 중 6개월 이내에 백신 접종계획을 갖고 있는 대상자는 19명(18.4%)이었다. 자녀(아들) HPV 백신 접종계획이 없다고 응답한 48명의 대상자 중 HPV 백신 접종을 하지 않으려는 이유는 ‘잘 몰라서’가 23명(47.8%)으로 가장 많았고, 다음으로 ‘백신의 부작용에 대한 우려’ 12명(25.0%), ‘백신의 효과에 대한 불신’ 9명(18.8%)의 순으로 나타났다. 의료보험 적용 시 HPV 백신 접종계획은 ‘예’가 115명(76.2%)이었다.대상자의 HPV 지식은 총 20점 만점에 평균 11.13±2.19점이었다. 대상자의 자녀 HPV 백신 접종에 대한 태도는 7점 만점에 평균 평점 5.25±1.15점, 주관적 규범은 7점 만점에 평균 평점 4.47±1.56점, 자기 효능감은 7점 만점에 평균 평점 4.94±1.44점, HPV 백신 접종의도는 7점 만점에 평균 평점 5.04±1.26점이었다.p=.001), 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감과 통계적으로 유의한 양의 상관관계가 있는 것으로 나타났다(대상자의 자녀(아들) HPV 백신 접종의도는 HPV 지식 HPV 백신 접종의도의 차이를 검정한 결과, 통계적으로 유의한 차이를 나타낸 변수는 없는 것으로 나타났다.p<.001), 주관적 규범이었고, 이들 요인들로 대상자의 자녀(아들) HPV 백신 접종의도를 81.0% 설명하는 것으로 나타났으며, 회귀방정식의 모형도 유의한 것으로 확인되었다 (대상자의 자녀(아들) HPV 백신 접종의도에 영향을 미치는 요인을 확인하기 위하여 HPV 백신 접종의도와의 상관관계 검정에서 연구 대상 어머니의 자녀(아들) HPV 백신 접종의도와 유의한 상관관계를 나타낸 HPV 지식, 자녀 HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감을 독립변수로 투입시켜 다중회귀분석을 실시하였다. 다중회귀분석을 실시하기 전 본 연구 회귀모형의 가정을 검정한 결과 회귀분석을 위한 모든 가정이 충족되었다. 즉, 잔차의 산포도를 분석한 결과 잔차의 분포는 ‘0’을 중심으로 균등하게 흩어져 있어 회귀식의 선형성과 등분산성의 가정을 충족하였다. 히스토그램과 회귀 표준화 잔차의 정규 P-P 도표를 검정한 결과도 잔차가 45도 직선에 근접함으로써 오차의 정규분포와 등분산성의 가정을 만족하였다. 오차의 자기상관을 나타내는 Durbin–Watson 통계량은 1.83으로 비교적 2에 가까워 오차항의 독립성 및 자기상관에 문제가 없었다. 독립변수 간의 상관관계는 .41에서 .88로 나타났고, 공차한계(tolerance)는 모든 독립변인에 대해 .29에서 .95로 모두 .1 이상이었으며, 분산팽창인자(variance inflation factor)도 1.06–3.51로 모두 10을 넘지 않아 독립변수 간 다중공선성 문제는 없는 것을 확인하였다. 분석 결과 어머니의 자녀 HPV 백신 접종의도에 영향을 미치는 변인은 자녀(아들) HPV 백신 접종에 대한 자기 효능감 .본 연구는 TPB를 적용하여 초등학교 고학년 남학생 어머니의 자녀(아들) HPV 백신 접종의도 및 이에 대한 영향요인을 파악하고자 시도되었다.연구 결과 초등학교 고학년 남학생 어머니의 자녀 HPV 백신 접종의도는 HPV 지식, HPV 백신 접종에 대한 태도, 자기 효능감, 주관적 규범과 유의한 양적 상관관계가 있었으며, 이들 중 자기 효능감, 주관적 규범은 초등학교 고학년 남학생 어머니의 자녀 HPV 백신 접종의도에 유의한 영향을 미치는 변수로 확인되었다. 본 연구에서 나타난 주요 결과를 중심으로 논의하고자 한다.본 연구에서 초등학교 고학년 남학생의 HPV 백신 접종률은 0%였다. 국내 선행연구에서 HPV 백신 접종률은 12–14세 남아에서 3.1% , 13–17세 본 연구 대상 어머니들이 생각하는 자녀의 HPV 백신 접종 최적연령은 평균 14.9세였고, 자녀 HPV 백신 접종계획이 있는 어머니 중 ‘6개월 이내에 백신을 접종하겠다’에 응답한 어머니는 18.4%에 불과하였다. 선행연구에서 어머니들이 생각하는 자녀 HPV 백신 접종 최적 시기로 초등학교 여학생 어머니는 13세 이상이 60.0% , 여중생 어머니HPV 백신 접종의도는 백신 접종행위를 유도하는 강력한 예측요인으로 알려져 있다,12-14. 본본 연구 결과 연구 대상 어머니의 자녀(아들) HPV 백신 접종의도는 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감과 통계적으로 유의한 양의 상관관계가 있는 것으로 나타났다. 그러나 이들 변수를 투입하여 대상자의 자녀(아들) HPV 백신 접종의도에 영향을 미치는 요인을 확인한 결과, 자녀(아들) HPV 백신 접종에 대한 자기 효능감과 주관적 규범이 어머니의 자녀(아들) HPV 백신 접종의도에 영향을 미치는 요인으로 확인되었고, 이들 변수로 대상자의 자녀(아들) HPV 백신 접종의도를 81.0% 설명하는 것으로 나타났다. 이와 같은 결과는 비록 TPB를 설명하는 모든 변수가 유의한 영향을 미치지는 않았으나, 자기 효능감과 주관적 규범이 행동의도를 예측하는 변인임을 검증함으로써 확장된 TPB의 기본 가정에 대한 경험적 근거를 축적한 점에서 의의가 있다.HPV 백신 접종에 대한 자기 효능감은 HPV 백신 접종 시 장애를 극복할 수 있는 개인의 능력에 대한 판단을 의미한다. 자기 효능감은 TPB에서 지각된 행위 통제와 높은 상관관계를 나타내어 이를 반영하는 지표로 널리 활용되고 있으며, 예방접종과 같은 예방적 건강행위를 선택하고 이를 지속하는 데 영향을 미치는 예측인자로 보고되고 있다,28. 본 연구본 연구 결과 대상자의 자녀(아들) HPV 백신 접종에 대한 주관적 규범은 7점 만점에 4.47점(100점 만점에 63.9점)으로 Kang 의 연구에서 보고한편, 연구 대상 어머니의 HPV 지식과 HPV 백신 접종에 대한 태도는 자녀(아들) HPV 백신 접종의도와 유의한 상관관계가 있었으나 HPV 백신 접종의도 예측요인에는 포함되지 않았다. 비록 측정도구가 동일하지 않아 직접 비교는 어렵지만, TPB 기반으로 TPB 변인에 HPV 지식을 포함하여 어머니의 자녀 HPV 백신 접종의도 예측요인을 확인한 국내 연구,21에서 어머니본 연구는 대전 소재 3개 초등학교 남학생 부모를 대상으로 편의 표집하였고, 설문지 회수율이 낮아 자료수집 대상 집단의 대표성을 충분히 확보하지 못했으므로 본 연구 결과를 확대 해석하는 데 신중을 기해야 한다. 연구의 목적이 어머니의 자녀(아들) HPV 백신 접종의도 및 관련 요인을 파악하는 것이기 때문에 실제 자녀(아들) HPV 백신 접종행위를 예측하는 데 한계가 있다. 또한 자료수집 시 자기보고식 설문지로 이루어져, 자기보고식 설문지가 갖는 대상자의 응답 편향을 배제할 수 없다는 제한점이 있다.그러나 본 연구는 국내 경험적 근거가 충분치 않은 초등학교 고학년 남학생 부모를 대상으로 HPV 지식, 자녀(아들) HPV 백신 접종에 대한 태도, 주관적 규범, 자기 효능감 및 HPV 백신 접종의도 간의 관계를 파악하고, HPV 백신 접종의도에 영향을 미치는 요인을 규명함으로써 HPV 백신 접종의도를 증진시키기 위한 효율적인 중재 전략을 수립하는 데 필요한 기초자료를 제공한 점에서 간호 실무에 기여하였다. 또한 자녀(아들) HPV 백신 접종에 대한 자기 효능감과 주관적 규범이 자녀(아들) HPV 백신 접종의도에 영향을 미치는 요인임을 규명함으로써 확장된 TPB의 기본가정에 대한 경험적 근거를 축적한 점에서 간호이론과 연구에 기여하였다.본 연구는 TPB에 근거하여 초등학교 고학년 남학생 어머니의 HPV 백신 접종의도, HPV 지식, HPV 백신 접종에 대한 태도, 자기 효능감, 주관적 규범 간의 관계를 파악하고, HPV 백신 접종의도에 미치는 영향요인을 확인하기 위해 시도하였다. 본 연구에서 대상자의 HPV 예방접종 의도에 유의한 영향을 미치는 요인은 자녀 HPV 백신 접종에 대한 자기 효능감과 주관적 규범으로 확인되었다. 따라서 HPV 백신 접종의 적기인 초등학교 고학년 남학생 어머니의 자녀 HPV 백신 접종의도를 효과적으로 증진시키고 나아가 남아의 HPV 백신 접종률을 높이기 위해서는 HPV 백신 접종에 대한 자기 효능감, 주관적 규범을 강화할 수 있는 중재 전략을 마련할 필요가 있다. 즉, 자녀(남아) HPV 백신 접종에 대한 어머니들의 자기 효능감을 증진하기 위해 HPV 백신 접종에 대한 정확한 정보를 제공하고 적극적인 홍보를 통해 백신 접종의 장애요인을 줄이며, 주관적 규범 증진을 위해 의료인과 보건교사에 의한 교육과 권고를 실시해야 할 것이다. 또한 국가적 차원에서 초등학교 고학년 남아에게도 HPV 백신 접종비용을 보조하거나, 같은 연령대의 여학생의 경우처럼 무료로 접종하는 등 국가 차원의 정책적 제도 마련이 필요하다.본 연구 결과를 토대로 다양한 지역의 초등학교에 재학 중인 남학생의 어머니를 대상으로 반복 연구를 실시하여 어머니들의 HPV 백신 접종의도 영향요인에 대한 경험적 근거를 축적할 것을 제언한다. 또한 본 연구에서 영향요인으로 확인된 HPV 백신 접종에 대한 자기 효능감과 주관적 규범을 강화하는 중재 프로그램을 개발하고 그 효과를 검증하는 후속 연구를 제언하는 바이다.