Given the need to improve patient knowledge about HPV-related oral lesions, awareness of HPV infection prevention measures, and compliance with vaccination, as well as patient demand for free and easy access to well-tailored and time-saving health information, the present cross-sectional study examined the accuracy of relevant YouTube videos and their suitability for mass-reach health communication and HPV vaccination promotion. A video search was performed, using keywords obtained from the Google Trends website, until 9 January 2023. Video selection and data collection were performed by independent, pre-calibrated examiners. Descriptive statistics were performed on videos’ general characteristics, source reliability, popularity, information and quality, content topics, vaccination-encouraging/discouraging messages, and educational value. Pearson’s correlation was calculated between educational value and all parameters. Mann–Whitney U test compared very low/low vs. medium/good/excellent educational value and HPV vaccination-encouraging vs. -discouraging videos. Most of the 97 YouTube videos analyzed were moderately accurate and reliable, 53% had moderate/good/excellent educational value, and 80% encouraged HPV vaccination, making them suitable for mass-reach communication. The limited role of oral healthcare providers in uploading relevant content, with the poor dissemination of information about HPV-related benign and malignant oral lesions, may be expanded by purposefully using YouTube and other mass media to improve patient knowledge of HPV-related oral lesions and promote HPV vaccination, which also underscores its potential beneficial oral effects. Human papillomavirus (HPV) is the most common sexually transmitted pathogen in the world population ,2. HPV cApproximately 200 viral genotypes, over 40 associated with low-risk HPV and 15 with high-risk HPV , have beHPV-16 and HPV-18 genotypes are the most commonly associated with HPV-related Oral Squamous Cell Carcinoma (OSCC) . ApproxiMoreover, while the early detection of HPV-related cervical cancer can be aided by screening tests, such as the Pap smear and HPV test , there aThree types of HPV vaccines are currently administered: Gardisil  against HPV-6, -11, -16, and -18 genotypes; Gardisil9  against HPV-6, -11, -16, -18, -31, -33, -45, -52, and -58 genotypes; and Cervarix  against HPV-16 and -18 . Over 90Nevertheless, because HPV vaccination provides more effective protection against cancer when given at a younger age , pediatrPatient education regarding HPV transmission routes, virus-related mucocutaneous and oral lesions, and awareness of possible latent or persistent HPV infection, especially if sustained by the so-called high-risk viral genotypes, can help limit viral transmission ,27,28. SPatient education that increases literacy and leads to behavior changes is based on direct communication in clinical environments ,33, indiSocial media is considered the easiest and fastest means of mass-reach communication at present ,36,37. YThe disseminated information should be understandable to everyone, easy to remember , and accTherefore, given the need to improve patients’ knowledge about HPV-related oral lesions, awareness of HPV infection prevention measures, and compliance with vaccination, as well as patients’ demand for easy access to tailored and time-saving health information, the present cross-sectional study investigated the accuracy of YouTube videos about HPV infection, mucocutaneous and oral lesions, and vaccination, as well as their suitability for preventive interventions, including mass-reach health communication and the promotion of HPV vaccination.https://returnyoutubedislike.com/install, accessed on 9 January 2023) was downloaded and installed to record YouTube video dislikes.The study protocol was established before the search began. Computer history and cookies were cleared so as not to affect the results based on previous computer searches. The “Return YouTube Dislike” extension  was searched to determine the most frequently used search term worldwide in the past five years among “HPV/Human papillomavirus infection”, “HPV/Human papillomavirus lesions”, “HPV/Human papillomavirus vaccine”, and “HPV/Human papillomavirus vaccination”. The relevant term searched most frequently on both Google and YouTube was “HPV vaccine”.The Google Trends website  were saved and recorded on the same day to avoid losing search results, which may change in the following days.http://www.youtube.com, accessed on 9 January 2023) that were compliant with the eligibility criteria shown in Three independent investigators  eliminated duplicates, and videos retrieved from YouTube , number of views, number of likes, number of dislikes, number of comments, number of subscriptions, time elapsed since upload;▪Source: classified as dental care providers, other healthcare providers (any), hospital/university, pharmaceutical industries, commercial, other;▪Target audience: classified as laypersons, professionals, both;▪Score: Video Power Index (VPI) ,43, VideThree independent and pre-calibrated investigators M.P.D.P, D.C., N.C. extracted, calculated, and collected the following data in a standardized extraction form for each video included in this study:In case of disagreement, a fourth examiner was involved (F.D.A.)Video Power Index, assessing video popularity, was calculated as follows [The  follows ,40,43:LiThe Video Information and Quality Index (VIQI), with a score from 1 to 20 , evaluatA 5-point Likert-type scale  was used to assess each of the following parameters: “flow of information; accuracy of information; quality ; sensitivity (level of consistency between video title and content)”.Content on HPV infection: route of transmission; risk factors; screening; genotypes; oncogenic role.Content on HPV-related lesions: skin lesions (benign); mucosal lesions (benign); oral lesions (benign); female genital cancer; male genital cancer; oral cancer .Content on HPV vaccine; age; gender; type of vaccines; HPV vaccine safety; HPV vaccination advice ; face news.Content on HPV-related lesions and vaccination epidemiology: vaccination course; projections of female genital cancer; projection of male genital cancer; projections of oral cancer  ,48,49.The content of the videos was evaluated, providing a total content score of 1–23, according to the following topics:“Authorship Attribution Disclosure Currency (dates that content was posted and updated should be indicated)”.The four benchmark criteria of the Journal of American Medical Association (JAMA), suggested by Silberg et al. , were us“Score 1 = Poor quality; very unlikely to be of any use to patientsScore 2 = Poor quality but some information present; of very limited use to patientsScore 3 = Suboptimal flow, some information covered but important topics missing; somewhat useful to patientsScore 4 = Good quality and flow, most important topics covered; useful to patientsScore 5 = Excellent quality and flow; highly useful to patients.The videos’ educational value was evaluated based on the 5-point Global Quality Scale (GQS) criteria ,46, as fVideos rated 3< were classified as having very low/low educational value, and those rated ≥ 3 as having medium/good/excellent educational value”.The Shapiro–Wilk test was used to calculate the normality of the data distribution. Descriptive statistical analysis was performed for all the included YouTube videos.The correlation between educational value and video characteristics, popularity, Information and Quality Index (VIQI), content topics and total score, and video source reliability was calculated through Pearson’s correlation test.Very low/low and medium/good/excellent videos based on their educational value were compared using the Mann–Whitney U-test. A further comparison was similarly performed between HPV vaccination-encouraging and -discouraging YouTube videos.A total of 313 videos were retrieved, of which 23 were excluded using the duration filter, eliminating videos of less than 4 min and more than 20 min.Of the remaining 290 videos, sorted by order of appearance, the first 120 were included.Twenty-three videos were further excluded, specifically 4 that were not in English and 19 in which HPV-related lesions and vaccination were not the primary content(s).A total of 97 YouTube videos on HPV met the eligibility criteria and were included in the present study.The extracted, calculated, and collected data are summarized in The mean length of the videos was 7.88 (4.02–17.4). Videos were uploaded between 5 and 4885 days (mean time elapsed since upload 1527.82) before the search, and received a mean number of views of 27,026.6, with a mean number of likes of 375.77  and a mean number of dislikes of 47.66 (0–2796), providing a mean Video Power Index (VPI) of 48.03.The mean Video Information and Quality Index VIQI (0–20 score) was 12.The mean video educational value (0–5 score) was 2.59, meaning that, on average, the videos were classified as being of low to medium educational value.Descriptive statistics of video length, number of views, likes, dislikes, comments, and subscriptions, the time elapsed since upload, the Video Power Index (VPI), the Video Source Reliability, the Video Information and Quality Index (VIQI), the video content, and the video educational value (GQS) of the YouTube contents on HPV that were analyzed are detailed in The mean Video Source Reliability (0–4 score) was 2.78, and no videos were uploaded by dental care providers. Other healthcare providers, who uploaded about 9% of the videos, were obstetrician–gynecologists (33%), general practitioners (22%), pediatricians (22%), infectious disease specialists (11%), and sexual health physicians (11%).Most of the videos (58%) were directed to laypersons.The source and target audience of YouTube videos on HPV are shown in The mean video total content score (1–23 score) was 9.91, indicating that the videos included covered less than half of the investigated topics.The oncogenic role of HPV was the most frequently covered topic (92%), followed by the role of HPV in female genital cancer (90%), the recommended age for HPV vaccination (88%), and the safety of HPV vaccines (81%). HPV-related oral lesions were the least covered topic (3%) .The educational value of the videos, as assessed by the 5-point Global Quality Scale (GQS), was distributed as follows: 14% of the videos had a very low value, 32% had a low value, while 36%, 15%, and 2% of the analyzed videos were assigned a medium, good, and excellent value, respectively.p-value = 0.0498), loosely significant, and HPV vaccination content concerning “Gender” .No statistically significant correlation was found between video educational value and any other parameters, except for the video length  YouTube videos on HPV infection, mucocutaneous and oral lesions and vaccination were rated 3< and classified as having very low/low educational value, and the remaining 52 (53.60%) were rated ≥ 3 as having medium/good/excellent educational value, based on the 5-point Global Quality Scale (GQS).Variables of very low/low and medium/good/excellent regarding the educational value of videos are reported in p-value < 0.05) were found for time elapsed since upload , Video Information and Quality Index (VIQI)  and “Professionals” audience . A comparison of variables between videos with very low/low and medium/good/excellent educational value, calculated with the Mann–Whitney U test, is shown in When comparing YouTube videos on HPV with very low/low and medium/good/excellent educational value, significant differences , the time elapsed since upload , Video Power Index (VPI) , Video Content score  and Video Source Reliability . A comparison of variables between vaccination-encouraging and -discouraging videos computed with the Mann–Whitney U test is shown in When comparing YouTube videos encouraging and discouraging vaccination, a significant difference was found in the number of views  of 2.78. The mean video educational value (0–5 score) was 2.59, meaning that, on average, the videos were classified as being of from low to medium educational value. The mean Video Total Content score (1–23 score) was 9.91, indicating that the videos included covered less than half of the investigated topics, with the oncogenic role of HPV being the most frequently covered topic (92%), followed by the role of HPV in female genital cancer (90%), the recommended age for HPV vaccination (88%), and the safety of HPV vaccines (81%). HPV-related oral lesions were the least covered topic (3%).No statistically significant correlation was found between video educational value and any other parameters, except for the video length and HPV vaccination content concerning gender.p-value < 0.05) were found for time elapsed since upload , Video Information and Quality Index (VIQI)  and “Professionals” audience .About half (46.39%) of YouTube videos on HPV infection, mucocutaneous and oral lesions and vaccination were rated 3< and classified as having very low/low educational value, and the remaining 52 (53.60%) were rated ≥ 3 as having medium/good/excellent educational value, based on the 5-point Global Quality Scale (GQS). When comparing YouTube videos on HPV with very low/low and medium/good/excellent educational value, significant differences , time elapsed since upload , Video Power Index (VPI) , Video Content score  and Video Source Reliability .The majority (79%) of the videos encouraged HPV vaccination, while only 3% were discouraging, and 18% were neutral towards vaccination. When comparing YouTube videos encouraging and discouraging vaccination, a significant difference was found in the number of views  were uploaded by nonprofit or academic organizations and fell into the “Other” category . HospitaThe mean Video Source Reliability (0–4 score) was 2.78 . The criMore than half of the videos (58%) were directed to laypersons , indicatIn addition, the mean Video Information and Quality Index (VIQI) (0–20) was 12 , indicatThe mean Video Content (1–23) score was 9.91, suggesting that YouTube videos, on average, covered less than half of the examined information about HPV infection, oral and mucocutaneous lesions, and vaccination.In detail, HPV infection and risk factors, although crucial to primary prevention, were addressed in less than half of the videos.Distinguishing between HPV genotypes occurred in less than a quarter of the YouTube videos, likely because they were primarily aimed at laypeople whose cultural background may not be sufficient to understand this topic.Slightly more than 60% of YouTube videos about HPV discussed the route of viral transmission, but they generally described only sexual transmission. However, it should be noted that HPV is primarily transmitted through skin-to-skin or skin-to-mucosa contact .Furthermore, nearly half of the videos provided information on screening methods for HPV, and some emphasized the importance of HPV screening even in individuals who have received an HPV vaccine.HPV-related benign lesions were a less-discussed topic compared with malignancies. Specifically, benign HPV-related skin lesions and benign mucosal lesions  were addressed in two of the ten videos. It would be desirable for this last topic to be emphasized more, as previous studies have shown that the association between HPV infection and skin and genital warts is poorly understood in the general population .Moreover, only 3% of YouTube videos addressed benign HPV-related oral lesions  . This fiNotably, 92% of YouTube videos addressed the oncogenic role of HPV, the most frequently covered topic in YouTube videos about HPV . Indeed,Regarding information about HPV vaccination, it is worth highlighting that 81% of the YouTube videos guaranteed the safety of vaccine administration, as there is no evidence that the vaccine is associated with serious physical risks or side effects .p-value = 0.013).Age for vaccination was another frequently raised issue, further underpinning that individuals should be vaccinated before they potentially come into contact with the virus . HoweverThe included YouTube videos did not contain “Fake News”. This was a promising finding, as inaccurate content could potentially mislead public opinion and negatively impact vaccination programs and other prevention efforts .Finally, epidemiologic information on HPV, such as vaccination progression and projections regarding female and male genital cancers and OSCC, was unfortunately not emphasized, nor was the potentially positive role of HPV vaccination on OSCC prevention.Nearly half (46%) of YouTube video on HPV vaccine were of very low/low educational value (GQS < 3), and just over half (54%) were of medium/good/excellent educational value (GQS ≥ 3); specifically, 36% of the videos had a medium educational value, and 15% and 2% had a good and excellent educational value, respectively. However, the majority of YouTube videos about HPV were rated as poor for patient education.These findings are consistent with those of YouTube videos on other medical and dental content. For example, studies of the accuracy and quality of YouTube videos in orthopedics  and alleNo significant correlations were found between the video educational value and all other parameters .p-value < 0.05), indicating how closely the quality of the information provided is related to its usefulness in improving patient knowledge for educational purposes  , the number of views , and the Video Power Index (VPI) , suggesting that vaccination-discouraging videos were generally uploaded earlier and had greater distribution and popularity than those encouraging vaccination    suggestiThe main limitation of the present cross-sectional study of YouTube videos for mass-reach health communication and HPV vaccination promotion may be related to the dynamic nature of the YouTube platform, where new videos are uploaded daily, and the exclusion of non-English-language videos from the study that could have provided alternative perspectives on this topic.Nonetheless, the present study may be the first to comprehensively assess the dissemination of information (topic coverage), popularity, accuracy, and reliability of YouTube content on oral HPV-related lesions, along with information on viral infection, clinical manifestation, and control measures, including vaccination, as well as epidemiologic data on HPV vaccine administration and HPV-related cancer prediction.Further cross-sectional studies should be conducted without language restrictions, on other websites and social media platforms, and continuously updated.In addition, the impact of mass-reach communication on patient awareness of HPV infection control measures, knowledge of HPV-related mucocutaneous and oral lesions, and attitudes toward HPV vaccination should be investigated.A total of 97 videos were included in the present cross-sectional analysis of the accuracy of YouTube contents on HPV infection, oral and mucocutaneous lesions and vaccines, and their suitability for mass-reach health communication and the promotion of HPV vaccination strategies.Most videos were uploaded by nonprofit or academic organizations (69%), and the mean Video Source Reliability (0–4 score) was 2.78 , with thThe mean Video Information and Quality Index (VIQI) (0–20) was 12 , indicatMore than half of the videos (58%) were directed at laypersons , and thuThe oncogenic role of HPV was the most frequently discussed topic (92%) in the analyzed YouTube videos, followed by the role of HPV infection in female genital cancer (90%), the recommended age for HPV vaccination (88%), and the safety of HPV vaccines (81%). HPV-related cancers were generally a highly divulged topic, whereas HPV-related benign mucocutaneous lesions were a less covered topic, with oral lesions being the least covered topic (3%), revealing a poor dissemination of related information on YouTube. Similarly, the recognized risk factors for HPV infection and lesion development, as well as the related preventive strategies, although critical for primary prevention, were addressed in less than half of the videos. This last finding underscores the need to strengthen the potential role of dentists, who are often the first to recognize these lesions, in improving patient knowledge and awareness of the consequences of oral HPV infection and motivating patients to take infection control measures through both direct communication and population-based approaches, such as mass-reach communication.About half (46%) of YouTube videos on HPV infection, oral lesions, and vaccination had very low/low educational value (GQS < 0.05), and only 15% and 2% had a good and excellent educational value, respectively.Nearly 80% of videos advocated HPV vaccination, while 3% advised against it. However, vaccination-discouraging videos had a higher number of views and greater popularity compared to those that encouraged HPV vaccination. The need to improve gender-neutral HPV vaccination did not appear to be fully recognized, with only 39% of YouTube videos addressing this issue. Similarly, epidemiologic data on vaccination were barely reported, and projections of female and male genital cancers and oral carcinomas were not highlighted in the YouTube videos.Overall, these data suggest that currently available YouTube videos on HPV infection, mucocutaneous and oral lesions, and vaccination were moderately accurate and reliable as a mass-reach communication tool. The limited role of oral and dental healthcare providers in uploading relevant content, with the poor dissemination of information about HPV-related benign and malignant oral lesions, may be expanded by purposefully using YouTube and other mass media to further improve patient knowledge about HPV-related oral lesions and promote HPV vaccination, which also underscores the potentially positive role of HPV vaccination on OSCC prevention. YouTube and other mass media videos about HPV infection, mucocutaneous and oral lesions, and vaccination may be appropriately created by reliable sources as a mass-reach communication tool, especially content about HPV-related oral lesions and pangender HPV vaccination targeting laypersons with simple and easy-to-understand language. Information flow and quality , as well as consistency between video titles and content), should be accurate, and video length should be limited to about 10 min for videos that cover all or most of the topics currently being analyzed, or shorter for those that describe fewer topics to allow for the accurate and complete delivery of information.


We searched PubMed, EMBASE, CINAHL, Scopus, Google Scholar, and gray literature. Two independent reviewers screened article titles and abstracts for possible inclusion, reviewed the full text, and extracted data from eligible articles using a structured data charting table. We identified strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and reported their importance and feasibility. We retrieved 246 articles, included 28 of these, and identified 63 of the 73 ERIC implementation strategies with 667 individual uses, most of which were highly important and feasible. The most frequently used discrete strategies included the following: Build a coalition and change service sites 86% (24/28), distribute educational materials and conduct educational meetings 82% (23/28), develop educational materials, use mass media, involve patients/relatives and families, promote network weaving and stage implementation scale up 79% (22/28), as well as access new funding, promote adaptability, and tailor strategies 75% (21/28). This scoping review shows that implementation strategies of high feasibility and importance were frequently used, suggesting that some strategies may be cross-cutting, but should be contextualized when planned for use in any region.Barriers to successful implementation of the human papillomavirus vaccination exist. However, there is limited evidence on implementation strategies in sub-Saharan Africa (SSA). Therefore, this scoping review aimed to identify implementation strategies used in SSA to increase HPV vaccination uptake for adolescent girls. This scoping review was guided by Joanna Briggs Institute guidelines for scoping reviews and an a  The human papillomavirus (HPV) primarily affects human beings and is one of the most common sexually transmitted agents affecting approximately 3 out of 4 sexually active people early in their sexual life ,2. GenerCancers caused by HPV include anal, penile, oropharyngeal, vulval, and the commonest being cervical cancer, which has the highest incidence in SSA . ParadoxPrimary prevention of cervical cancer is possible with the HPV vaccination of prepubertal girls aged 9 to 14 years before sexual debut . CurrentThe benefits of HPV vaccination are evident in high-income countries which introduced national HPV vaccination programs earlier. A meta-analysis including fourteen high-income countries implementing the HPV vaccination program reported a reduction in the prevalence of HPV 16 and 18 among adolescent girls and young women . SimilarOn the contrary, many SSA countries are yet to implement national HPV vaccination programs and further challenged by low vaccine uptake in implementing countries ,24. SomeThere is an urgent need at the global level to increase HPV vaccine uptake, a priority of the WHO accelerated global strategy for cervical cancer elimination, with targets set for 2030 . The WHOConsidering the long-standing need to increase HPV vaccination coverage in SSA and now with the pronouncement of WHO cervical cancer elimination strategy to achieve success in different real-world settings, implementation strategies are necessary to overcome bottlenecks and reach the target groups. Implementation strategies are “a systematic intervention process to adopt and integrate evidence-based health innovations into usual care” . Some exA systematic review by Mavundza et al.  on effecResearch question: What implementation strategies have been used to increase human papillomavirus vaccination by adolescent girls in sub-Saharan Africa? a priori protocol [This scoping review followed the Joanna Briggs Institute (JBI) updated methodology for scoping reviews  and an aprotocol . We included studies aiming to increase HPV vaccine uptake by adolescent girls; however, these implementation strategies often target various stakeholders. Therefore, participants included adolescent girls, parents/guardians, healthcare providers, teachers, key community leaders, politicians, and policymakers. We included studies that used at least one of the 73 implementation strategies defined by the ERIC taxonomy  to increThe second step of the ERIC compilation validated the distinctness of the 73 strategies and organized them into nine clusters: 1. Use evaluative and iterative strategies, 2. provide interactive assistance, 3. adapt and tailor to context, 4. develop stakeholder interrelationship, 5. train and educate stakeholders, 6. support clinicians, 7. engage consumers, 8. utilize financial strategies, and 9. change infrastructure . The 73 This review considered only studies carried out in SSA aimed at increasing the uptake of the HPV vaccine by adolescent girls. We considered all study designs, peer-reviewed studies, gray literature, and reports. Narrative literature reviews and articles including multiple countries were included if they had country-specific data for any SSA country and met the inclusion criteria . We readWe initially searched PubMed, EMBASE, and Scopus to identify articles on adolescent HPV vaccination, guided by a medical librarian. The text words in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for PubMed . This seThe reference lists of included sources of evidence were screened for additional studies. Similar articles in PubMed were also searched. Studies published in other languages besides English were excluded due to the teams’ limited competence. We included studies published from January 2006, when WHO approved the use of the HPV vaccine among prepubertal girls through December 2021. Data from identified articles were collated and uploaded into Endnote X9 , removed duplicates, and imported the rest of the studies into the JBI System for the Unified Management, Assessment and Review of Information  . Two indSources of information for the implementation strategies included surveys within vaccination programs or Expanded Programs for Immunization managers, government documents, community surveys, registers for HPV vaccinations, HPV training manuals, micro plans, training reports, and support supervision reports. The search results are presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR) flow diagram  in FigurData from the included papers were extracted and summarized by two independent reviewers (MKL and MMW) and checked by MK using a data extraction chart developed by this team. The extracted data included the first author’s name, year of publication, country of study, the title of the article, article type, study design (where applicable), targeted stakeholders, and type of program .The draft extraction chart was trialed on five included papers by . The revisions included (i) clarifying the sample size to be that of the eligible girls other than study participants as this was dynamic and not consistently reported; (ii) not to report the framework for data collection as this was rarely reported.A meeting was held among MKL, MK, MWM, and MM to pilot the coding process of the ERIC strategies on three included studies. Three reviewers  independently coded and charted data for the specific ERIC implementation strategies and their allocated codes (1 to 73) along with the corresponding ERIC cluster (1 to 9). Co-authors MKL and MWM iteratively and inductively coded other strategies which emerged but could not neatly fit into the ERIC compilation ; these wThe extracted data are presented in table form to align with the study objectives and accompanied by a narrative summary. The identified strategies were mapped onto the ERIC compilation, grouped into the ERIC’s nine conceptually relevant clusters, and mapped to the four go-zones to understand their relative importance and feasibility rating according to Waltz et al. . This scn = 8 [n = 3 [n = 2 [n = 2 [n = 2 [Our search yielded 246 articles and finally included 28 studies as shown in the Prisma flow chart in n = 8 ,48,49,508 [n = 3 ,52, Mala3 [n = 2 ,54, Tanz2 [n = 2 ,56, Ugan2 [n = 2 ,58, and 2 [n = 2 , Cameroo2 [n = 2 , The Gam2 [n = 2 , Ghana [2 [n = 2 , Mozambi2 [n = 2 , Nigeria2 [n = 2 , Rwanda 2 [n = 2 , Senegal2 [n = 2 , Togo [62 [n = 2 , Zambia 2 [n = 2 , and Zim2 [n = 2 . n = 14 [n = 7 [n = 5 [n = 18 [n = 5 [n = 3 [n = 2 [n = 8 were published in 2021 [n = 2 in 2018 [n = 3 in 2017 [n = 2 in 2016 [n = 4 in 2015 [n = 3 in 2013 [n = 4 in 2012 [n = 2 in 2011 [A significant amount of data was from demonstration projects, n = 14 ,67,68,704 [n = 7 ,60,62,647 [n = 5 ,65,66,697 [n = 5 . Of the 8 [n = 5 ,59,61,685 [n = 3 ,63,67, a3 [n = 2 ,65. Publ in 2018 ,63, n =  in 2017 ,54,64, n in 2016 , n = 4 i in 2015 ,57,61,70 in 2013 ,51,68, n in 2012 ,55,60,65 in 2011 ,58. See The target adolescents’ age group varied from 9 to 18 years or grades four to seven. One study used the recommended multi-age cohort outside demonstration projects . Other sSome studies indicated reaching out-of-school girls through community sensitization and active tracing by community healthcare workers ,63,65,68n = 24 [n = 24 [n = 23 [n = 23 [n = 23 [n = 22 [n = 22 [n = 22 [n = 21 [n = 21) [We identified 63 of the 73 ERIC implementation strategies across the 28 studies, while 10 were not reported in any article . All incn = 24 ,68,69,70 [n = 24 ,68,69,70 [n = 23 ,68,69,70 [n = 23 ,67,69,70 [n = 23 ,67,69,70 [n = 22 ,67,69,70 [n = 21 ,67,68,69n = 23 [n = 3 [n = 2 [n = 1 [Stakeholders involved were varied within the included studies. Most articles included more than one stakeholder group, e.g., policymakers, politicians, healthcare workers, community volunteers, teachers, parents, and adolescent girls n = 23 ,67,68,693 [n = 3 ,60,62, h3 [n = 2 ,64, or a2 [n = 1 . This scoping review aimed to identify implementation strategies to increase HPV vaccination of adolescent girls in SSA and map them according to the ERIC compilation. Majority of the identified implementation strategies were of high importance and feasibility falling within ERIC clusters 1, 4, and 5. Furthermore, most studies reported multifaceted implementation strategies which combine discrete strategies, and none neatly fit into blended strategies, which have been described as “multiple strategies packaged as a protocolized or branded implementation intervention” .Strategies under the cluster of train and educate stakeholders were among the most frequently used. However, there is mixed evidence on the value of education strategies to increase the uptake of interventions generally and for HPV vaccination . A recenWe recently demonstrated that knowledge levels in a population of parents in Zambia affected their consent to vaccinate their adolescent daughters against HPV . AdditioWe found that multiple stakeholders worked together across the different studies, which was under the strategy “build a coalition,” cluster to develop stakeholder’s interactions. For example, healthcare workers played a pivotal role in administering the vaccine, and thus ought to be knowledgeable and have positive attitudes toward the vaccine , as theiAs expected, given the scope of our review, we did not find the strategies that SSA countries used to navigate the HPV vaccination roll-out during the COVID-19 pandemic. To date, the available evidence shows that some LMICs rolled out national HPV vaccination programs during the COVID-19 pandemic. In contrast some SSA countries, such as Cameroon, had their HPV vaccine introduction programs interrupted during the same period . TherefoGenerally, there were fewer articles reporting implementation strategies for national HPV vaccination rollout programs despite reports of 17 countries currently implementing these programs . There iThe change in service site which falls within the “change infrastructure” cluster was one of the most frequently used strategies. This was mostly seen as delivering HPV vaccines in schools outside the usual health facility settings. Most studies acknowledged that large numbers of adolescents targeted for the vaccine are found in schools, favouring this platform ,48,68. AHowever, school-based delivery poses a challenge for reaching out-of-school girls who may be more vulnerable to early sexual debut and exposed to HPV infection in early discordant marriages . Some stThe most frequently used strategies under the cluster “adapt and tailor strategies” were to promote adaptability and tailor strategies. A systematic review and meta-analysis on effective communication strategies to increase HPV vaccination uptake among adolescent girls in SSA reported that tailoring communication interventions to specific stakeholders yielded positive results . The revTherefore, promoting, and tailoring strategies in the use of the HPV vaccine in SSA implies developing tactics specific to the region’s circumstances and problems. Addressing issues, such as culturally appropriate communication, scarce resources, inadequate healthcare facilities, and low knowledge is part of this. To guarantee that HPV vaccination is successful and ongoing, adaptation needs to be encouraged.We identified monitoring of side effects as an implementation strategy outside the ERIC compilation. HPV vaccination can result in transient minor side effects, such as pain and redness on the injection site. This scoping review found that active management of side effects was used in some settings to increase HPV vaccination. Occurrences, such as mass hysteria among vaccine-eligible adolescents have been erroneously associated with the HPV vaccination . These uHowever, the HPV vaccine is not the only vaccine marred with misinformation about Adverse Events Following Immunization. Other vaccines, such as Diphtheria, Tetanus, and Pertussis, and Measles, have suffered a similar fate . Gains mEven though the cluster with strategies to “utilize financial strategies” was not frequently used and deemed to be of both low feasibility and importance by the initial expert consensus, access new funding and fund and contract for clinical innovation were deemed important though less feasible. Therefore, the non-feasibility of raising new funding in SSA may explain the presence of funders, such as Gavi, the vaccine alliance, Merck, Bill and Melinda Gates Foundation, GlaxoSmithKline, PATH, and others, that have made it possible to increase vaccination in many SSA countries by supporting the supply chain; therefore, partially, or completely removing the cost to the end users. However, concern remains whether the Gavi-supported countries will sustain the HPV vaccination program when they transition to self-financing due to the high cost of the vaccine and its implementation .Scoping reviews are ideal to determine the scope of literature on a given topic as we have established here; however, there are some inherent limitations. We did not synthesize the findings or assess the methodological quality and risk of bias for included studies, according to guidance by the JBI methodology for scoping reviews ; therefoThis scoping review has mapped and provided a broad overview of implementation strategies used to increase HPV vaccination uptake in SSA using the ERIC compilation and reported research gaps unique to SSA. Implementation and sustainability of the HPV vaccination remain challenging, as shown by low global levels of HPV vaccine uptake, which is lowest in SSA. We present clearly defined discrete implementation strategies to ease replication and understanding of findings. Most strategies used were of high importance and feasibility, which indicates that they could be adapted within the SSA to increase HPV vaccine uptake for adolescent girls.We found low availability or reporting of implementation strategies for national HPV vaccination rollout programs, even though 17 countries in SSA are currently implementing this program . Most st


To identify the bibliometric information of Human papillomavirus (HPV) genotype co-infection in certain literature database over the past two decades.Web of Science was used as the main database to identify all eligible articles focusing on HPV genotype co-infection at the date of October 16, 2022. From this journal database, we identified 463 articles on HPV genotype co-infection, conducted statistical analysis according to the author, journal, publication year and month, country or region, keyword and impact factor.The articles included in our analysis were published between 1994 and 2022. The index of citations per year ranged from 170.4 to 13.1. These articles were from 78 countries or regions, with most publications from the United States (n = 73), followed by China (n = 65) and Italy (n = 50). The journal that contributed the most publications on HPV heterotypic gene co-infection was PLOS ONE with a total of 29 articles, followed by JOURNAL OF MEDICAL VIROLOGY (n = 28), INFECTIOUS AGENTS AND CANCER (n = 14) and JOURNAL OF CLINICAL VIROLOGY (n = 12). Among existing research in the field of HPV co-infection, we found that epidemiological distribution and infection mechanism has been the two major topics for scholars, and studies on detection methods for HPV multiple genotypes were also included.Over decades, epidemiological studies and mechanism investigationhas been the central topics when it comes to HPV genotypes co-infection. Studies on HPV co-infection remained relatively insufficient, mainly stays in qualitative level while detailed infection data and high quality literature publications were still lack of valuable discussion. It is noteworthy that HPV can cause severe cervical cancer, and the World Health Organization (WHO) estimated a great prevalence of 604,000 new cases along with 342,000 deaths worldwide in 2020 (Human papillomavirus (HPV) is a common and highly invasive virus that causes diseases of the female population on the lower reproductive tract. in 2020 . As a glAs is known, HPV was a large family with more than 130 variants detected. In addition to single genotype infection, there are also a large number of patients showed more than one genotype joint infection  AND TS= AND TS=(genotype OR genotypes OR genogroup). Inclusion criteria were as follows: (I) studies with HPV as the main topic; (II) English or Chinese written articles. Exclusion criteria were: (I) HPV was not the core of the study. (II)The study is about HPV co-infection with other viruses. In this article, a total of 463 publications from the web of science core collection were selected for bibliometric statistical analysis, published between 1994 and 2022. The author, journal, year and month of publication, country or region, and five-year infection factors were recorded. Article types were categorized into articles, reviews, abstract, meeting, clinical trial, case report.All search results and data critical to our analysis including citations and metrics were extracted from Web of Science on October 16, 2022. The complete document list was exported in the form of TXT file and imported into VosViewer for further analysis of co-occurrence atlas. WPS Excel 2022 was used to construct the tables and Originlab was used for bar charts and line charts visualization.The 463 articles on HPV genotype co-infection from WOS core collection included in our study were published from 1994 to 2022. An average of 32 references were cited by each articles, and the number of references cited ranging from 9 to 104 per paper, with a total of 14993 references. To explore which articles are more frequently cited with higher citation value, we ranked the publications with different citation frequencies. There were ten articles that had over 100 citations at the time of our search. The most cited article with a citation number of 225 was carried out by Cuschieri et al, published in 2004 on JOURNAL OF CLINICAL PATHOLOGY  to 43(in year 2020). According to their abstracts, the first publication in our collection that explicitly addressed the co-infection phenomenon of different HPV genotypes of HPV was in 1994. The study showed the occurrence of HPV16 co-infection with HPV31/33/35 detected in 234 cervical specimens from 1126 Alaska Native women . In our The 463 publications were from 200 different journals with article on HPV multiple genotype co-infection published. Overall, 33.5% (67/200) journals published more than two documents.The most represented journals were PLOS ONE , JOURNAL OF MEDICAL VIROLOGY , and INFECTIOUS AGENTS AND CANCER , JOURNAL OF CLINICAL VIROLOGY, BMC INFECTIOUS DISEASES Figure 2The literatures studied were from 78 countries and regions. The United States(n=73) led the way in this category, followed by China (n=65) and Italy (n=50). In Europe, France and Spain also made significant contributions to this research field, with 28 and 29 articles respectively Figure 3In our literature collection, a total of 89 researchers contributed more tha 3 articles. Villa LL, the author with the most publications contributed, participated in 8 relevant literatures, among which the most cited publication focused on the persistent infection of HPV, believing that HPV co-infection was an important factor for the prolonged duration of infection . One autIn our collection, 46 institutions contributed more than 5 articles to the publication of literature, and the top 5 contributing institutions were UNIVERSIDADE DE SAO PAULO(n=14), WORLD HEALTH ORGANIZATION(n=13), INTERNATIONAL AGENCY FOR RESEARCH ON CANCER IARC(n=12), KAROLINSKA INSTITUTET(n=10), DDL DIAGNOSTIC LABORATORY(n=9), INSTITUTO MEXICANO DEL SEGURO SOCIAL(n=9), CHINESE ACADEMY OF MEDICAL SCIENCES PEKING UNION MEDICAL COLLEGE(n=8), UNIVERSITY OF CAPE TOWN(n=8), VRIJE UNIVERSITEIT AMSTERDAM(n=8), FUNDACAO OSWALDO CRUZ(n=7).The co-occurrence keywords network visualization map with extraction frequency more than five times or more was shown in The high incidence of HPV co-infection is still being updated by epidemiologists around the world. In the latest epidemiological statistics published in 2023, high rates of HPV polygenotype co-infection have been reported in Asia, Africa, and South America , the probability of CIN1 in a single infected person is 39.5%, which is significantly lower than the probability of CIN1 in multiple infected persons (60.4%). However, the opposite result is shown in patients with cervical cancer   . All theAccording to our investigation on highly cited article collections, studies on infection mechanism, clinical practice and Epidemiological characteristics have became the top three research direction in the number of citations. In the top 20 cited articles, a study published in 2011  indicatiChanges of the numbers of publications and citations over the years can also give us some insight and conjectures. The year in which the highest amount and quality studies of HPV co-infection were published can be observed in the number of citations over time. In this article, we found that there was a peak in the total number of citations around 2006, which we suspect might be related to the world’s first FDA approval of the HPV vaccine in 2006. However, with the HPV vaccine being put into clinical practice in most countries around the world, the number of publications related to HPV infection has decreased significantly in the past five years until 2010, indicated that since human beings have developed better coping strategies in face of HPV infection and are closer to the goal of eliminating HPV infection, the research motivation seems to be reduced. When it comes to 2009, German scientist Harald Hausen was awarded the Nobel Prize in Physiology and Medicine for his discovery of a causal relationship between HPV and cervical cancer, which was seen as the basis for further vaccine research. We suspect that the steady increase in the number of publications on HPV co-infection which began after 2009 possess certain relevance to this issue, as this Nobel Prize gave significant recognition to the clinical value of all HPV-related research. Significant scientific accomplishments and major events in the field have never failed to stimulate research enthusiasm, and HPV research has evolved to the point where the scope of research should be narrowed down and discover more unknown phenomena rather than known.Statistically, JOURNAL OF MEDICAL VIROLOGY ranked among the top five publications with the highest impact factor, which reached 12.203 in the past five years. In this journal, a total of 28 literatures related to HPV co-infection were published, most of which focused on the geographical distribution of HPV infection. Studies related to the epidemiology of HPV co-infection have been in-depth and detailed to a certain extent, but the number of higher quality literature published in mainstream journals is far from enough. Higher impact factors and more authoritative publications mostly equate to more informative and influential accomplishments and discoveries. At this stage, although HPV co-infection research has gained some results in simple analysis of large sample data collection, there are still few people who can explore the essence through the phenomenon and lack higher-level interpretation of the mechanism. As expected, HPV genotypes co-infection remains a niche topic that has received less attention and investment in this area.The analysis of the number of studies by country and region also allows us to draw some reliable conclusions. Among the data we obtained, the United States and China contributed the highest number of publications, and in addition to their scientific strength, the significant population base of these two countries is an important factor that cannot be ignored. Among the European countries which has relatively small populations, Italy, France, and Spain also ranked among the top, indicating that there is also a great interest and concern in the topic of HPV co-infection in western developed countries. The number of publications was lowest in less developed regions such as Central Asia, South America and Africa. Based on some epidemiological statistics, there is also a correlation between HPV infection rates and ethnicity, so it is crucial that countries around the world work together and share findings to further our understanding of this virus comprehensively.The results of the keyword co-occurrence analysis of our collected articles suggest some of the most frequently occurring keywords in the existing studies. In Mathematical models have recently been studied to understand the transmission dynamics of HPV infection (, the construction of the co-infection mathematical model of HPV and other virus benefits for the control and management of the disease (. In the future, the establishment of co-infection models exclusively involving multiple HPV genotypes may yield valuable insights. Although the amount of existing article is still insufficient, the current article can be used as the first step into this field, following the top journals, authors and publications, setting the stage for in-depth discussion.The concept of HPV co-infection was first mentioned in the 1990s, and at that time it only remains a simple description of this phenomenon without any statistical description. With the improvement of sophisticated HPV genetic testing technique, more HPV genotypes can be detected and the major genotype combinations of HPV infection are gradually recognized. When the time came to around 2010, the literature on HPV epidemiology studies no longer ignored co-infection and the exploration of co-infection pattern even infection mechanism went much further. fection , the condisease , 38. In Last but not least, since this bibliometrics research is conducted by using the web of science Core collection as the archive, relevant articles that are not included in the core collection or belong to other repositories may inevitably be omitted. Despite the fact, this article might still be the largest bibliometric study on the topic of HPV polygenotypic co-infection.This study also has its limitations. First of all, in terms of citations statistics, some articles published in recent years need more time to accumulate citations, so there may be some inevitable bias in the analysis of citations. The keyword search strategy of Web of Science is difficult to filter out publications containing “HPV” and “coinfectoin” but focused on HPV coinfecton with other viruses, resulting in the total number of calculated articles exceeding the actual number. Also, due to the search strategy limitations, HPV co-infection mentioned in this article has not distinguished between high-risk HPV, low-risk HPV and potentially high-risk HPV. Restrictions on the language of inclusion may result in some articles written in other languages not being included. The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.Conception and design: YL. Collection and assembly of publications: TB. Manuscript writing: TB/YG. Final approval of manuscript: All authors. All authors contributed to the article and approved the submitted version.


Human Papillomavirus (HPV) is widely prevalent across the globe. In Lebanon, the society is transitioning from traditional conservatism to a more open attitude. Although previous studies have examined the knowledge of adults in Lebanon with regard to HPV and its vaccine, there is a lack of research on secondary school students. Moreover, HPV is considered a worldwide public health matter that needs to be addressed. Therefore, the objective of our study is to assess factors associated with knowledge and conspiracy beliefs towards HPV vaccine among a sample of Lebanese adolescents.Between December 2022 and February 2023, we conducted a cross-sectional study on Lebanese adolescents aged 15 to 18 years old. Parental approval was needed in order to participate. We used a questionnaire to collect data, which included the HPV-knowledge questionnaire (HPV-KQ) and the Vaccine Conspiracy Belief Scale (VCBS).Of the 406 participants who filled the survey, 64.8% were female, with a mean age of 16.62 ± 1.01. Results showed that 31.0% of students had high knowledge about HPV, while 27.6% had high conspiracy beliefs, and 48% of participants relied on the internet to access information on HPV. Students who had previously heard of HPV, received sexual education at school or outside, and had received at least one dose of the HPV vaccine demonstrated significantly higher knowledge of HPV. Additionally, students with high knowledge had a lower mean House Crowding Index, and those whose fathers had a university education had lower conspiracy beliefs. Females had a higher vaccination rate than males, while no significant difference was found between those who had engaged in sexual activity and those who had not. The multivariate analysis indicated that previous awareness of HPV and receiving sexual education outside school were significantly associated with higher knowledge.Our study brings to light the urgent need for action to increase HPV awareness and vaccination among Lebanese secondary school students. The prevalence of vaccine misconceptions and conspiracy beliefs and the limited knowledge of HPV underscore the importance of more comprehensive sexual education in schools and the dissemination of accurate information about HPV and its vaccine. Furthermore, given the low vaccination rate among males, efforts should be made to promote HPV vaccination among this population. Addressing these issues can improve public health and help prevent the spread of HPV and its related diseases. Human papillomavirus (HPV) is very prevalent in the population worldwide . The CenApproximately 200 strands of HPV have been identified . StrandsThere are currently 3 vaccines available on the market; the bivalent vaccine “Cervarix”, which covers the 16–18 HPV strands, the quadrivalent vaccine “Gardasil”, which covers the 6-11-16-18 strands . The WorIt is estimated that 2.2% of women in Lebanon’s general population currently have cervical HPV infection . In a coTraditional perceptions of Lebanon place the community as a conservative society with a low incidence of STIs, however, today’s youth are less rigidly bound by their social norms than they were in the past . CervicaHigher conspiracy beliefs have also been demonstrated to be associated with higher refusal of getting the HPV vaccine in Canada  and in JA cross-sectional study was conducted from December 2022 till February 2023. Data was collected by sharing the questionnaire through social media applications using the snowball technique and spreading the questionnaire to different adolescents. Consequently, those who enrolled in the study were asked to share the questionnaire with their friends and family members they knew from the same age category. Inclusion criteria were Lebanese males and females secondary school student from grade 10, 11, or 12 between the ages of 15 to 18. A total of 412 students accepted to fill the questionnaire, after getting parental approval. Among those 412, 6 students were then excluded because they were under 15 years old. Hence, 406 students were included in the final database.2 = 0.02, alpha error of 0.05, power = 0.8, and 13 predictors to be used in the analysis.Minimal sample size calculation was done using the G-power software version 3.0.10, which came out to be 395, by using the linear multiple regression test, and using an effect size fThe questionnaire was done in the English language, and included socio-demographic data  , their vThe Human Papillomavirus Knowledge Questionnaire consists of 13 questions that inquire about general information on HPV transmission, symptoms, and vaccination. Students were required to respond to each question by selecting one of three options: “True”, “False”, or “I don’t know”. A score of 1 point was assigned for each correct answer, while incorrect and “I don’t know” answers were given a score of 0 . Higher The vaccination conspiracy beliefs scale (VCBS) is made of seven statements where students expressed their level of agreement or disagreement with a particular statement using a 7-point Likert scale that ranges from “strongly disagree” to “strongly agree” . Higher p < 0.25 in the bivariate analysis were entered as independent variables in the regressions. P < 0.05 was considered statistically significant.Statistical analysis was performed using SPSS software version 22. Reliability analysis was evaluated using Cronbach’s alpha values. The 75th percentile was used as a cutoff point to divide participants into low/high knowledge and conspiracy beliefs . To compThe Cronbach’s alpha values were good for the knowledge and conspiracy beliefs scales (α = 0.89 for both). The mean age was 16.62 ± 1.01 years , with 64.8% females. Moreover, 126 (31.0%) of the students had high knowledge (75th percentile cutoff = 7), and 112 (27.6%) showed high conspiracy beliefs (75th percentile cutoff = 29). All details of the participants are summarized in Table A higher percentage of students who have previously heard of HPV, those who have received sexual education at school or outside it, and those who have received at least one dose of the HPV vaccine had a significantly high level of knowledge of HPV. Moreover, a lower mean HCI was significantly found in students with high knowledge. Furthermore, a lower percentage of students whose fathers have a university level of education, had high conspiracy beliefs Table .A higher vaccination rate was significantly found in females compared to males . No significant difference in vaccination rate was found between those who have ever had a sexual activity compared to not .Having heard of the HPV (aOR = 6.06) and having received sexual education outside the school compared to not (aOR = 2.01) were significantly associated with high knowledge Table , Model 1To our knowledge, and despite the prevalence of HPV infections, there is no prior research that has focused on the information and attitudes toward HPV among minors in Lebanon. To address this knowledge gap, we conducted a study that directly examined HPV awareness and vaccination rates among Lebanese secondary school students.Our findings revealed that among the 406 participants, 126 31.0%) of the students had high knowledge, similar to the percentage found among female university students (36.5%) . Another.0% of thThe multivariable analysis found that having heard of HPV and having received sexual education outside of school compared to not, were significantly associated with high knowledge about HPV. These findings are good yet worrisome at the same time. Our results correlate with a study previously done in the United States, which also found that individuals who used the internet as a way to access information on HPV had higher knowledge scores , yet notFurthermore, our bivariate analysis showed that students who received prior sexual education either inside or outside the schools and those who had received at least one dose of the HPV vaccine exhibited a higher level of knowledge about HPV. A previous prospective study done in the United States of America found that students who were exposed to sexual education at school had higher knowledge on HPV compared to students who did not , and thiIn addition, our results revealed that only 46 (11.3%) students had gotten at least one dose of the HPV vaccine, with significantly higher vaccination rate found among females compared to males (87.0% vs. 13.0%). A study carried out on Lebanese mothers in 2018 showed that the vaccination rate of their daughters against HPV was only 2.5% . VaccinaOn the other hand, the discrepancy in the vaccination rates between men and women can be due to the lack of recommendations to vaccinate men in Lebanon. In fact, a previous study conducted on Lebanese physicians of different specialties found that they did not follow international guidelines in terms of recommending the HPV vaccine, with females being recommended the vaccine 6.8 times more than males . MoreoveAdditionally, we found that students with a lower mean household crowding index were significantly associated with higher HPV knowledge and that students whose fathers have a university level of education had low conspiracy beliefs. In contrast, a study done on adolescents in Brazil found no association between knowledge about HPV and sociodemographic characteristics . Yet, acOn the other hand, it is important to highlight that 70 (17.3%) students had prior or are currently sexually active, with no significant difference in vaccination rate between those who have ever had a sexual activity compared to those who had not (28.3% vs. 16.0%). A research study carried out on college students in the United States revealed that sexually active students had a higher probability of being vaccinated against HPV in comparison to students who had not engaged in sexual activity . Our resOur study has some limitations. First, the study design is cross-sectional, where data was collected using a questionnaire; hence, recall bias could not be avoided as well as over- or underestimation of questions. Second, selection bias is to consider because of the snowball sampling method used for the recruitment and since our questionnaire could only be filled if you had access to an internet connection and if you knew English. Henceforth, the results of our study cannot be generalized to the overall Lebanese population. In addition, the knowledge and conspiracy beliefs scales used in the questionnaire are not validated in the Lebanese population; however, the Cronbach’s alpha values were good for both scales (α = 0.89 for both), which make our results strong and decrease the importance of this limitation. Lastly, there is a possibility of residual confounding effect, since some variables were not included in our survey (such as the absence of information on prior STIs), which may have had an impact on our results.To our knowledge, this is the first study conducted in Lebanon that directly targets the minor population. Our study highlights the need for more comprehensive sexual education in Lebanese high schools, as well as the importance of spreading accurate information about HPV and its vaccine, since students are relying mainly on the internet to access information about HPV. The findings suggest that only a small percentage of Lebanese secondary school students have high knowledge about HPV, and that misconceptions and conspiracy beliefs about vaccines are prevalent. The study also sheds light on the need to promote HPV vaccination among males. Addressing these issues can improve public health and help prevent the spread of HPV and related diseases. Overall, this research can serve as a foundation for future studies aimed at improving HPV awareness and vaccination rates among Lebanese youth.


Organic light-emitting diodes (OLEDs) have outperformed conventional display technologies in smartphones, smartwatches, tablets, and televisions while gradually growing to cover a sizable fraction of the solid-state lighting industry. Blue emission is a crucial chromatic component for realizing high-quality red, green, blue, and yellow (RGBY) and RGB white display technologies and solid-state lighting sources. For consumer products with desirable lifetimes and efficiency, deep blue emissions with much higher power efficiency and operation time are necessary prerequisites. This article reviews over 700 papers covering various factors, namely, the crucial role of blue emission for full-color displays and solid-state lighting, the performance status of blue OLEDs, and the systematic development of fluorescent, phosphorescent, and thermally activated delayed fluorescence blue emitters. In addition, various challenges concerning deep blue efficiency, lifetime, and approaches to realizing deeper blue emission and higher efficacy for blue OLED devices are also described. Organic light-emitting diodes (OLEDs) have attracted great attention due to their applications in high-contrast, innately thin, easily adaptable, full-color, flat-panel displays and solid-state lighting ,5,6,7,8.A recent report from Statista depicted global annual revenue for LED lighting and estimated it to be 70 billion in 2019. An increment of 41% is expected until 2023, with a forecasted amount of 99 billion annually. However, on closer analysis, there was an approximate annual increase in value of less than 10 billion from 2019–2023  16]. Th. Th16]. On the other hand, ElectroniCast, a US-based company, says that the estimated global revenue for the OLED lightings is set to grow speedily from 0.14 billion in markets in 2015 to nearly 7 billion by 2023, representing a compound annual growth rate (CAGR) of 7% in the next ten years . AccordiTwenty-five years ago, the first OLED product, a monochromatic display in car stereos, was launched by Pioneer . Since tThere is a strong demand for energy-efficient and optimal next-generation lighting because approximately 20% of total global electricity is consumed for general lighting . Researc2  emitter imidazole , the res40 cd/m2 .It is well established that pyrene-based emitters, either molecular or polymeric, possess a planar or partial planar molecular structure, which tends to show excimer emissions and lower quantum efficiencies, resulting in an extensive bathochromic shift in emission spectra owing to the π–π stacking of pyrene chromophore units in the solid state.In 2012, Hu and Yamato et al. synthesized a series of pyrene-based Y-shaped blue emitters using the Suzuki cross-coupling reaction of 7-tert-butyl-1,3-dibromopyrene with p-substituted phenylboronic acids. These emitters realized a low degree of π-stacking due to the steric effect of the tert-butyl group in the pyrene ring at the 7-position ,169.In the search for new light-emitting compounds, Promarak et al. synthesized a series of solution-processable pyrene-functionalized carbazole derivatives, N-dodecyl-3,6-di(pyren-1-yl)carbazole (CP2), N-dodecyl-1,3,6-tri(pyren-1-yl)carbazole (CP3) and N-dodecyl-1,3,6,8-tetra(pyren-1-yl)carbazole (CP4) , by using = 170 °C and Td = 407 °C).These pyrene-carbazole hybrids showed a glass-transition temperature and decomposition temperature ranging from 70 to 170 °C and 375 to 407 °C, respectively. Among the four pyrene-moieties containing carbazole compounds, CP4, showed the highest thermal stability  behavior because the carbazole central unit acts as a donor and the pyrene functional group acts as an acceptor. It is known in the literature that the DA molecular systems tend to extend π-conjugation and generate an intramolecular charge transfer (ICT) state, inducing an unwanted bathochromic shift in the search for a deep-blue emission.2 with CIE coordinates of , and 2.5 cd/A and 9700 cd/m2 with CIE coordinates of  via spin-coating anthracene (TPVAn)  that con devices .g higher than 64 °C, while TAT has above 150 °C. The Tg for TAT is twice as high as the commonly used host material DPVBi (64 °C) and slightly higher than MADN (120 °C). The CIE coordinates were  with an EQE of 7.2% , 9--10-anthracene [MAT], and 9,10-bisanthracene [TAT]  were des of 7.2% .g ≥ 133 °C, due to the presence of sterically congested terminal groups. The TBDNPA-based device outperformed the others by showing a low turn-on voltage of 3.0 V with an initial brightness of 1 cd/m2. The device displayed an EQE of 5.2% at 8.4 mA/cm2 with CIEy < 0.1  anthracene (TBDNPA), and 2-tert-butyl-9,10-bis[4-phenyl] anthracene (TBMFPA) , using nEy < 0.1 .2. A negligible efficiency roll-off is observed over a broad range of current density imidazole (ACPI), 2-anthracen-9-yl)phenyl)-1-p-henyl-1H-phenanthroimidazole (1-NaCPI), and 2-anthracen-9-yl)phenyl)-1-phenyl-1H-phenanthroimidazole (2-NaCPI) . The matensities .g of 194 °C. The device showed a low turn-on of 3.1 V with an EQE of 8.4% and a maximum luminance of 7100 cd/m2 at CIE of  -9,9-dimethyl-fluorene-7-yl}-9,9-dimethyl—fluorene (MDP3FL) . When doped with a 10 wt% in CBP, a 5.1% EQE was observed for a deep-blue emission at CIE  naphthalene (DPASN), and di(triphenyl-amine)-1,4-divinylnaphthalene (DPVP)  . Among tIn 2010, Jeon et al. reported a series of spiro-based emitters, namely, N,N,N′,N′-tetraphenylspiro (SFBF)-5,9-diamine (BD-6DPA), N,N′-di-(2-naphthyl)-N,N′-diphenyl-SFBF-5,9-diamine (BD-6NPA), N,N′-diphenyl-N,N′-di-m-tolyl-SFBF-5,9-diamine (BD-6MDPA), and N,N′-diphenyl-N,N′-bis(4-(trimethylsilyl)phenyl)-SFBF-5,9-diamine (BD-6TMSA) , synthes3. Among the series, a 2,2′,7,7′-tetrakis(3-fluorophenyl)spiro-9,9′-bifluorene (Spiro-(3)-F) . The photophysical properties, energy levels, and thermal properties can be tuned using different substitutional groups of electron-withdrawing moieties, such as F and CFo-(3)-F)  blue emi23q3). The presence of two electron-donating methyl groups widened the HOMO/LUMO gap and blue-shifted the EL peaks to 470 nm. The resultant device showed a power efficacy of 0.6 lm/W at 300 cd/m2 -4-yl)-1, 3, 4-oxadiazole (Oxd-bCz) , by incoy ~ 0.07 .Developing phosphorescent emitters is essential as they have the potential to realize a high-efficiency OLED. In 1998, Forrest and Thompson et al. discovered a phosphorescent emitter to develop a nearly 100% internal quantum efficiency because of their ability to efficiently harvest both singlet and triplet excitons ,207,208.On the basis of previous investigations, it is well established that complexes of heavy metals such as iridium (III), platinum (II), and ruthenium (II) have been utilized to synthesize promising blue emitters ,210,211.In 2001, Adachi et al. reported a sky-blue phosphorescent emitter, FIrpic , with an3) and (m-Ir(pmb)3), respectively (3 was doped into a p-bis(triphenylsilyly)benzene (UGH2) host, the device showed an EQE of 5.8% for a deep-blue emission with CIE coordinates of    212] an an212] a3)  by employing its modified complex, (dfpypy)2Ir(μ-Cl)2) indole (CzDPEPI) and 9,90-)bis(9H-carbazole) (CzDPECz) . The pre9, 0.37) .max of 22% and PEmax of 24 lm/W at CIE coordinates of  , n = 1–5 based on tetradentate bis(pyridyl azolate) chelates. Among them, L5  showed a9, 0.34) .max of 18% and a lifetime of 709 h [LT70] at 1000 cd/m2 with CIExy  . However, no efficiencies or color coordinates were reported imidazol-2-yl)phenolate) , based ot 422 nm . In 2013000 nits .Suitable host materials were presented to aid the emission of phosphorescent-based blue emitters as reported by Chaskar et al  and YookHigh price and rare availability of heavy metals have limited the low-cost and long-term mass production of phosphorescent blue emitters. To resolve these problems, the search for a highly efficient deep-blue fluorescent emitter is still a subject of current interest, as they have a greatest possibility of a longer operational lifetime and a deep-blue emission at low cost with highly sustainable purely organic luminescent molecules .In 2009, Adachi et al. designed and synthesized the first heavy metal-free TADF emitter . Since tΔEST) ,244,245.Over the past few years, researchers have extensively designed and synthesized aromatic-based efficient TADF emitters by using abundant elements, such as carbon, hydrogen, oxygen, nitrogen, sulphur, etc. So far, a few molecular design strategies have been reported to achieve smaller 00% PLQY . MoreoveIn aromatic-based TADF emitters, the spatial overlap between the frontier molecular orbitals can be successfully controlled by choosing a suitable D–A pair. Moreover, it has been found that the donor–acceptor–donor (D–A–D) type emitters are more effective than those of the D–A type in achieving a higher PLQY and a strong spatial separation of HOMO LUMO levels ,247. SinOn the basis of D–A pairs, aromatic-based TADF blue emitters can be classified into seven sub-categories , which cST of 0.54 and 0.45 eV and a PLQY of 57 and 65%, respectively. In a doped device with a bis[2-(diphenylphosphino)phenyl]ether oxide (DPEPO) host, the DPA-DPS-based device exhibited an EQEmax of 2.9%, while the DTPA-DPS-based device showed an almost double EQEmax of 5.9%. The higher EQE of the DTPA-DPS emitter is attributed to a low ΔEST, which possessed an effective triplet to singlet-exciton upconversion.Diphenylamine moiety-containing aromatic compounds are well-established hole-transporting materials in OLED devices. In contrast, diphenylsulfone moiety-comprising materials are well studied as electron transporting materials. These moieties have also been used to design bipolar hosts ,252,253.ST of 0.08 eV with an 80% PLQY and a 1.7 to 3 μs TADF decay time. By doping into a DPEPO host, the DMAC-DPS-based device exhibited an EQEmax of 20% for a greenish-blue emission at . The resultant device performance was almost independent of the emitter doping concentration -10′-one (ACRSA), in a bis-(2-(diphenylphosphino)phenyl)ether oxide (DPEPO) host  sulfone (DTC-DPS)  , into a le units .ST value, in 2014, Wu et al. designed a blue emitter, bis [4-phenyl]sulfone (DMOC-DPS)  coordinates . In 2013, Adachi et al. reported two TADF blue emitters, 10-phenyl)-10H-phenoxazine (PXZ-TAZ) and 10,10′-bis)-2-bis(10H-phenoxazine) (2PXZ-TAZ) , by usinST of 0.05 eV and a delay lifetime of 3.6 μs with an 83% PLQY. Furthermore, the ΔEST and the delay lifetime were decreased to 0.046 eV and 1.9 μs, respectively, while the PLQY was increased to 90% as the DMAC-TRZ emitter was doped into a 9-(3-(9H-carbazol-9-yl)phenyl)-9H-carbazole-3-carbonitrile (mCPCN) host. At 100 nits, the resultant non-doped DMAC-TRZ-based device exhibited a maximum EQE of 20% with a bluish-green emission, while a doped emissive layer (at 8 wt% DMAC-TRZ and mCPCN)-based device showed a maximum EQE of 27% with a slightly blue shifted emission. These devices also exhibited relatively high power efficacy, at 46 and 66 lm/W, and current efficacy of 61 and 67 cd/A at 100 cd/m2, respectively, for non-doped and doped emissive layer-based devices imidazole (PI) chromophore. All the three emitters displayed HLCT characteristics. Among them, the device based on TPA-2PI displayed a CIE of 0.08 .max of 7.1% and a CIEy of 0.09 imidazole (PPI) unit. The composed device displayed an EQE of 0.09 .0) of the emitter while the other is excited to the higher-level singlet state, S2. After fast intermolecular relaxation (S2 − S1), the S1 state is re-populated, which is beneficial for the high efficiency of fluorescent emitters  of thmax of 12% and a CIEy of 0.06. The enhanced EQE is attributed to the occurrence of the TTA mechanism [Hu et al. reported three compounds, 1,4-bis(10-phenylanthracene-9-yl)benzene (BD1), 1-(10-phenylanthracen-9-yl)-4-(10-(4-cyanophenyl)anthracen-9-yl)-benzene (BD2), and 1-(10-(4-methoxyphenyl)anthracen-9-yl)-4-(10-(4-cyanophenyl)anthracen-9-yl)benzene (BD3). Among them, the doped device based on a BD3 emitter and CBP host displayed an EQEechanism .max and a CIEy of 0.09 [Chen et al. reported an approach to developing TTA materials for high-efficiency fluorescence via a styrylpyrene core and an electron-donating group. The device with a PCzSP emitter doped in CBP host displayed a 9.1% EQE of 0.09 .max of 5.9% and CIEy of 0.06. The doped device displayed an EQEmax of 6.6% corresponding to a CIEy of 0.05. As said by the authors, the TTA enabled the slow roll-off in the device [Zeng et al. reported two quaterphenyl derivatives with a PLQY of nearly 80%. The nondoped device based on a 4PS emitter displayed an EQEe device .max of 4.6 to 5.9% corresponding to a CIEy from 0.07 to 0.08. They have attributed the good device performance to TTA occurrence [Peng et al. reported dianthracenylphenylene-based emitters. The non-doped devices based on these emitters displayed an EQEcurrence .max of 7.3% and CIEy of 0.09. They also attributed the efficiency improvement to TTA occurrence [Recently, Wu et al. reported two anthracene-based molecules, 4-(10-(3-(9H-carbazol-9-yl)phenyl)-2,6-di-tert-butylanthracen-9-yl)benzonitrile (mCz-TAn-CN) and 4-phenyl)anthracen-9-yl)benzonitrile (m2Cz-TAn-CN). Among them, the doped device based on the m2Cz-TAn-CN emitter showed an EQEcurrence .Although high-efficiency and long-lifetime deep blue emitters have some advantages, such as reducing the pixel size/number of pixels in a display or fabricating a high-quality light for lighting, they might have some drawbacks if used inappropriately. Intense blue light tends to disrupt ecosystems, pollute night skies, suppress melatonin secretion, discolor artifacts, and cause numerous eye diseases as well as cancers.(i)Turn off or dim the light after dusk or at least 2 h before going to bed.(ii)Change indoor illumination to a blue light-free candlelight style lighting for nighttime.(iii)Avoid the use of 3C products before going to bed. Audio activities are preferred over video ones.(iv)Embrace darkness. The bedroom should be completely dark during sleep.(v)Consult physicians for melatonin supplements for sleep improvement, especially for older persons.Professor Jou, also the corresponding author of this review article, from National Tsing Hua University has recommended several precautions regarding how to avoid blue-light hazards and safeguard the health of eyes and physiologies in the popular science speeches he has delivered over 100 times in the past 10 years and the book entitled “Embracing Darkness” . He has Precautions are always better than cures. Now is the right time to develop a good habit of “staying in darkness at night”.In summary, this review depicts the global revenue and forecast for lighting and display technologies. Since 2018, OLED display revenues have surpassed those of LCD displays, proving which truly is a disruptive display technology. However, OLED lighting is not yet successful as compared against LED lighting, although its revenue is rising gradually. Until 2023, an increment of 41%, i.e., a forecasted amount of 99 billion, is expected annually.Overall, the number of papers published and patents filed for blue OLEDs have increased significantly over the past years, especially those based on Gen-3 materials, confirming the need for blue OLEDs. It is also surprising to see that publications based on Gen-1 materials rose significantly in 2021, indicating the importance of deep-blue emitters. Some progress was seen in the development of deep-blue OLEDs with high efficiency and/or long lifetime, increasing the possibility of mass production of displays with a higher resolution that are also more energy-saving and reliable.Having high efficiency along with a long lifetime still remains challenging, although there are several approaches available for realizing deep-blue emission.Furthermore, while the marked progress on deep-blue OLEDs is delightful, it is strongly suggested that we keep one eye on the plausible negative impacts that might result from the same, and embracing darkness is always essential after dusk to safeguard human health and ecosystems.


Increasing evidence has demonstrated that high TTN‐AS1 expression is highly related to poor prognosis in diverse human cancers. However, the findings concerning the prognostic value of TTN‐AS1 were inconsistent, as these conclusions were usually drawn with relatively small sample sizes. Hence, this meta‐analysis proposes to investigate the prognostic significance of TTN‐AS1 in multiple malignancies systematically.Web of Science, Springer, Embase, PubMed, Cochrane Library, and Scopus databases were comprehensively searched to retrieve studies related to the TTN‐AS1 expression with the prognosis of malignancies. The significance of the TTN‐AS1 in cancers was estimated by hazard ratios (HRs) or odds ratios (ORs). Additionally, the Gene Expression Profiling Interactive Analysis (GEPIA) analysis tool was used to strengthen our results further.p < .00001) when compared with low TTN‐AS1 expression in malignancies. Additionally, elevated TTN‐AS1 expression significantly contributed to lymph node metastasis , larger tumor size , worse tumor differentiation  and more advanced tumor stage  with low or no heterogeneity existing. Moreover, high TTN‐AS1 expression  was connected with worse disease‐free survival in five different cancers based on the GEPIA online database.Twenty studies involving 17 different cancers and 1330 patients were recruited into this meta‐analysis. The research revealed that high TTN‐AS1 expression was remarkably associated with unfavorable overall survival (OS) (HR = 2.07, 95%CI , The results of this meta‐analysis support that high TTN‐AS1 expression significantly correlates with worse prognosis in various cancers. Therefore, TTN‐AS1 may be considered as a novel biomarker for malignancies. Lin et al.p < .05) but not to the tumor stage (p > .05). Owing to the limitation of sample sizes from a single study, the significance of these associations may be inaccurately and insufficiently estimated. Therefore, this meta‐analysis was performed to further assess the prognostic importance of TTN‐AS1 expression in various malignancies.However, several clinical studies exploring the association of TTN‐AS1 expression with variables in malignancy have generated controversial conclusions. For example, Xiao et al.22.1This study was conducted following the preferred reporting program of the systematic review and meta‐analysis (PRISMA).2.2A relevant study satisfying the following inclusion criteria would be included in the analysis: (1) Original research articles; (2) study focused on the associations between various human malignancies and TTN‐AS1 expression; (3) study reported OS, disease‐free survival (DFS), or clinic parameters at least; (4) study's sample was derived from tissue; (5) study involved sufficient data; (6) there were no ethnic and geographical restrictions.The exclusion criteria were as listed: (1) Duplicate publications, cellular‐based experiments, reviews, letters, and animal experiments; (2) study data acquired from public databases; (3) articles with insufficient data.2.3The full text of the relevant studies that met the inclusion criteria were selected for the data collection process. The major characteristics of the included studies were summarized according to a predesigned standardized template: the author's last name, publication time, cancer types, sample capacity, the number of patients based on TTN‐AS1 expression level, detection methods, outcomes , hazard ratio (HR) and corresponding 95% confidence interval (CI) of OS, OS data extraction methods and follow‐up time. If the study failed to offer the HR and 95% CI in the article, Engauge Digitizer 4.1 software was adopted to extrapolate the HR and 95% CI indirectly, based on the available Kaplan–Meier curves.2.4http://gepia.cancer-pku.cn/), was applied to evaluate the correlation of TTN‐AS1 expression level with DFS. We input the gene name “TTN‐AS1” to match 33 types of cancers in GEPIA. A median was adopted for the cut‐off value. p < .05 was considered significantly statistical.Gene Expression Profiling Interactive Analysis (GEPIA), a public database from TCGA and GTEx data  value with 95% CI. The interstudy heterogeneity was assessed with 33.1A total of 302 articles were initially retrieved. After removing 236 studies owned to duplication, 66 studies remained for further evaluation. Subsequently, 42 studies were removed based on eligibility criteria through reading titles, abstracts, or full text. As for the remaining 24 studies, 4 with insufficient data were also excluded. Ultimately, 20 studies published between 2018 and 2021 were included in this analysis  was performed to detect TTN‐AS1 expression in tissues. The sample sizes varied from 36 to 145. There were 718 cases in the high TTN‐AS1 expression group and 612 cases in the low TTN‐AS1 expression group. Moreover, all included studies provided clinicopathologic parameters, including lymph node metastasis, age, tumor size, gender, tumor differentiation, and tumor stage. Twelve studies reported OS, and one study reported DFS. There were 17 different types of malignant tumors in this meta‐analysis. Regarding the study quality, all included publications scored ≥6, attesting to the high quality of the 20 studies (Table 3.3p < .0001), larger tumor size (p < .0001), worse tumor differentiation (p < .0001), and more advanced tumor stage (p < .0001). Nevertheless, TTN‐AS1 expression was not evidently associated with age (p = .68) and gender (p = .69). As for the publication biases, we performed funnel plot analysis for these metrics containing more than 10 studies, and no apparent asymmetry was observed , the fixed‐effect model was applied and the result revealed that high TTN‐AS1 expression was prominently correlated with shorter OS while compared with low TTN‐AS1 expression  .Twelve studies involving 793 patients were extracted in this meta‐analysis for OS. As there was no heterogeneity existing among these studies  Figure . The poo3.5p < .05), as listed in Figure Although DFS is an essential prognostic index for patients with malignancy, only one study reported DFS.4The aberrant expression of numerous lncRNAs, demonstrated recently, might interrupt various cancer progression and metastasis by affecting  the coding genes' expression and splicing.This study demonstrated that increased TTN‐AS1 expression was explicitly associated with shorter OS and worse DFS. The close correlation between TTN‐AS1 expression and OS and DFS was validated by subgroup analysis and the GEPIA database, respectively. Furthermore, we also found that high TTN‐AS1 expression rendered more advanced clinical stage, lymph node metastases, larger tumor size, and worse tumor differentiation when compared with low TTN‐AS1 expression. Taken together, our findings suggested that increased TTN‐AS1 expression implied a worse prognosis, indicating that TTN‐AS1 expression might be served as a promising biomarker for prognosis in various cancers.In addition, the mechanisms underlying the TTN‐AS1 expression in malignancies are rather complex. Chen et al. found that TTN‐AS1 could expedite the proliferative, migratory, and invasive capabilities of nasopharyngeal carcinoma by targeting miR‐876‐5p/UPF1/NETO2 signaling.p > .05),To the best of our knowledge, this is the first meta‐analysis to evaluate the prognosis significance of TTN‐AS1 in diverse malignancies. Although the potential role of TTN‐AS1 in various cancers has been proved recently, firm conclusions need to be drawn due to the limited sample sizes. Hence, this meta‐analysis, which included 20 studies involving 17 types of cancer and 1330 patients, aimed to provide more convincing evidence. Interestingly, our findings indicated that high TTN‐AS1 expression was significantly associated with worse OS, and Begg's tests, Egger's tests, along with sensitivity analysis results demonstrated that our conclusion was reliable and robust. Second, two studies failed to provide the correlation of tumor differentiation with TTN‐AS1 expression ; formal analysis ; methodology ; validation ; writing – original draft ; writing – review and editing . Xiyu Liu: Methodology ; resources ; software . Chao Cong: Data curation ; investigation ; validation ; visualization . Lianwei Xu: Conceptualization ; supervision ; writing – review and editing .The authors have stated explicitly that there are no conflicts of interest in connection with this article.This article does not contain any studies with human participants or animals performed by any of the authors.