Background: Many countries had initial success with HPV vaccination campaigns worldwide. The HPV vaccine coverage during the COVID-19 pandemic dropped consistently. The aim of our research is to assess the barriers and facilitators of the current Romanian HPV vaccination campaign. Methods: An analytical cross-sectional observational survey was conducted in the Romanian general population; a self-administered questionnaire was used. Results: 1122 responders were interviewed; 666 (59.36%) were parents, and 67 (5.97%) HPV vaccinated themselves. A multinominal logistic regression carried out in the parents’ category showed that women with university studies and informed from medical sources have greater chances to HPV vaccinate. Reticence regarding vaccination comes from the high cost of the vaccine and a lack of information. Only 118 (10.51%) vaccinated against HPV. From the logistic regression analysis, gender ), geographic area of residence ), and the inclusion of the HPV vaccine in the National Vaccination Program ) were the factors found most associated with HPV vaccination. Conclusions: In the general population, the inclusion of HPV vaccination in the National Vaccination Program would be the most important facilitator of HPV vaccination in Romania. In parents that did not vaccinate their children, one important barrier to HPV vaccination was the high cost of the HPV vaccine and the lack of proper information. The acceptability of HPV vaccination in Romania is low; therefore, public health educational programs are needed. Human papillomavirus (HPV) infection is well-known as being the number one sexually transmitted viral infection in the world. Almost every sexually active person comes into contact with at least one of the strains of the HPV virus in the course of their life . HPV cauThe Romanian HPV vaccination experience started in 2008, and until 2020, it was never a success story due mainly to the low level of information ,12. The An analytical cross-sectional observational survey was conducted in Romania in the general population. For an accurate design, we used “The Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) recommendations in our observational study. The STROBE checklist is included in the The study was conducted with the aid of volunteers, mainly medical students or former graduates of the “Carol Davila” University of Medicine and Pharmacy from Bucharest in Romania in all 41 counties and in the capital, Bucharest. The volunteers explained the questionnaire to the general population to achieve accurate answers.This study was addressed to the general Romanian population, all people living in the Romanian counties and the capital. The goal of attendance was at least 1000 participants and at least 25 answers from each county. The inclusion criteria for the participants were to be at least 18 years of age and to have Romanian citizenship. The participants were contacted by volunteers, and everybody was welcomed. The domain of activity of the participants was defined as employed, unemployed, student, or employed in the medical domain. The activity in the medical domain included medical doctors, nurses, pharmacists, paramedics, and midwives. We considered that people working in the medical domain may impact the general population’s vaccination acceptability. The level of education was reflected by the level of completed studies, including high school, post-secondary school, and university/post-university studies.The data were collected with the use of a self-administered questionnaire, and informed consent was required and obtained from each willing participant. The questionnaire was administered online using the Google Forms cloud-based survey software and was available online for four months: March, April, May, and June in 2022. It included 14 multiple-choice questions spread into a general data section and an HPV vaccine information section . After iThe questionnaire was peer-validated and approved by the Ethics Committee of the Obstetrics and Gynecology Hospital, Ploiesti, Romania (41482/09.08.2022); all the procedures in the study respected the ethical standards of the Helsinki Declaration. Informed consent was compulsory.® SPSS® Statistics Version 23.0 software. For data processing, the COUNTIFS function in Excel was used to filter and sort the initial database. The decision regarding vaccinating children  in people having children was considered the most important variable and was, hence, considered as the main dependent variable for consecutive analysis. Applied tests were descriptive ones. Since all data, except for age, were discrete variables, we applied also the non-parametric Kruskal–Wallis test. Age was tested in a correlation test . The variables considered significant in relation to our main dependent variable were included in a logistic regression to identify the most important predictors for deciding to vaccinate children. For all tests, the threshold for statistical significance was considered to be 0.05.The data from the questionnaire were analyzed by means of the Microsoft Office package Excel and IBMIn total, 1122 responders were interviewed. The answers to the questions are summarized in the In the whole studied group, there were 666 (59.36%) parents; i.e., participants that had children of various ages. There were 39 (3.48%) parents that had children aged less than 9 years old. The characteristics of the parents according to HPV vaccination and intention to vaccinate their children are described in In the category of people with children, we carried out a multinominal logistic regression, having as a dependent variable the decision to vaccinate children, Men have greater chances to be in the non-vaccinating category than women. Additionally, receiving information mainly from non-medical sources implies greater chances of not vaccinating than receiving information from medical sources. Having finished just high school compared to a university degree put respondents more in the non-vaccinating category than in the vaccinating. Lastly, reticence regarding vaccination because of the high cost of the vaccine and because there is a lack of info about eventual adverse effects is also a very important predictor for not vaccinating children, compared with reticence for other reasons. Interpretation for the second category (intention versus vaccination) is similar to the previous case, but with a new factor, infection of the parent, which appears to be significant. HPV-infected patients have greater chances to vaccinate their children than just having the intention to do so.Altogether, the predictive factors for HPV vaccination of the children in the parents’ group were studies, occupation, and even the HPV infectious status of the parent. The HPV vaccine price was of great importance as well as the lack of information and the level of education of the parent.In one group of parents, there were 67 (5.97%) parents that vaccinated their children, p < 0.001, so it is more likely that a vaccinated parent will vaccinate his/her child. Additionally, we noticed that there was a statistically significant association between the recommendation to HPV vaccinate and HPV vaccination; all the individuals that were vaccinated also recommended vaccination, p < 0.001.We tried to make a profile of the HPV-vaccinated parent that agreed to vaccinate his child: a woman from an urban area, over 42, working in the medical domain with a university degree. We found a statistical association between the fact that one individual is a parent and is HPV vaccinated, Another category of responders that should have been more likely to vaccinate against HPV within the 1122 studied group was given by age. There were 282 responders that were of the eligible HPV vaccination age themselves, under 27 years of age. Out of them, only 2 were HPV vaccinated, and 43 intended to vaccinate against HPV. No one had children, and their main occupation was student, in the non-medical domain. Their characteristics are in p < 0.001, 756 (75.68%) of the women vs. 84 (68.29%) of the men considered that the HPV vaccine should be mandatory. The same association was encountered regarding the recommendation of HPV vaccination, 843 (84.38%) women vs. 96 (78.05%) men. We noticed that being a woman was in favor of HPV vaccination, p < 0.001. In fact, more individuals of the feminine gender were vaccinated compared with the masculine individual gender, p < 0.001.Another aim of our study tried to expose the level of information and the factors that were conducted to this low level of HPV vaccination which are the barriers and facilitators of the current HPV vaccination Romanian campaign. As previously said, of the 1122 total responders, only 118 were vaccinated against HPV, Some of the study variables, after stepwise selection, were significantly associated with HPV vaccination in the 118 of the group of responders that were HPV vaccinated. From the logistic regression analysis, HPV vaccination is important and was a controversial subject at one time both worldwide and in Romania. The HPV vaccine is not currently mandatory or included in the National Romanian Vaccination Program .Initially, the 2008 Romanian HPV vaccination campaign, when a free HPV vaccine was offered, failed, with a coverage of 2.57%, followed by the 2009 Romanian HPV vaccination campaign suspended in 2011 due to low coverage. In 2013, there was another HPV vaccination attempt in Romania, again with low vaccination coverage. All previous HPV vaccination campaigns implemented in Romania failed. It is important to ask why the coverage failed at that time. Everybody suspected that the poor acceptability was generated by poor vaccination strategies for HPV prevention [In trying to lower cervical cancer incidence in Romanian women, in 2016, the Romanian Ministry of Health launched The National Cancer Control Plan, and a media HPV vaccination campaign appeared for the first time in 2017 .The World Health Organization has adopted a global strategy that aims to accelerate the elimination of cervical cancer for the period 2020–2030. The global strategy aims for 90% of girls to be fully vaccinated with the HPV vaccine by age 15, 70% of women to undergo a high-performance test by age 35 and again by age 45, and 90% of women identified with cervical disease to receive treatment [In Romania, parents’ agreement to HPV vaccination is crucial until 18 years of age in order to reach this goal. For this reason, parents’ beliefs and HPV vaccination acceptance are critical to a successful HPV vaccination program. The present study investigates the barriers and facilitators of the present HPV vaccination campaign in Romania, where, despite HPV vaccination recommendations, HPV vaccination uptake remains low. Understanding the Romanian parents’ profile is essential for optimizing vaccination programs in Romania and improving vaccination rates.p < 0.001), likely as they were offered and/or had received the HPV vaccination [In the present study, we noticed that the Romanian population is very confused when it comes to the importance of the HPV vaccine. Although the majority of interviewed Romanians are aware of HPV and related cancers (1023 (91.18%)) and believe that the HPV vaccine poses no risk (823 (73.35%)), only 324 (28.88%) received their HPV information from the medical doctors, and only 118 (10.51%) are HPV vaccinated. People that receive information from medical sources are the ones more likely to be HPV vaccinated or to recommend HPV vaccination as well as the younger people similar to a recent study developed at the same time as ours in Germany, where younger individuals (age group 25–34) were significantly more aware of HPV  are HPV vaccinated, and the trend is the same in international studies; for example, in a similar study of 1035 responders in China, a total of 55.9% of males and 80.4% of females indicated that they would be willing to receive the HPV vaccine, a significant difference (p < 0.001) [In Romania, women are most likely willing to be HPV vaccinated; as revealed in our study, 126 (11.22%) women vs. 6 men (0.53%), (< 0.001) , but theThe HPV vaccine is available in our country from family doctors and Public Health Directorates as the last Ministry of Health communication announced on 31 August 2022, . Followip < 0.001.HPV vaccination is the best method of preventing cervical cancer, and the Ministry of Health encourages parents to request information from family doctors and specialists regarding the benefits of this type of vaccination. So, since for HPV vaccination until 18 years of age parental consent is needed in Romania, an important factor that may raise the HPV vaccination rate in our country may be the parent. In Austria, for example, consent to receiving vaccines is regulated at the federal-state level, and, for example, in Tyrol, children aged 14 years are allowed to consent to receive vaccination . In our Older studies showed that parents tended to postpone HPV vaccination as they associate HPV vaccination with sexual life or the hesitancy of medical recommendations for an early HPV vaccination . One stuHowever, the percentages of HPV vaccination are very small compared with the WHO desiderate for 2020–2030 . For exaThe fact that most parents who said they heard about the vaccine learned about it from their doctors suggests that they acquired their medical knowledge from different healthcare experiences, underlying the lack of medical HPV vaccination publicity and media campaigns and a critical need for better public education.Additionally, consistent with previous reviews, medical doctors’ recommendations for HPV vaccination appear to be an important clue for HPV vaccination acceptance and vaccination in general . BecausePerceived barriers to vaccination, including doubts about vaccine efficacy, cost, and fear of safety and side effects are usually the most cited reasons for vaccine unacceptability in the literature ,33. HereWithout government-funded immunization programs, cost and financial barriers were common reasons for refusing HPV vaccination and vaccination in general in the past in Romania as well as in other countries in the world ,38,39,40Health literacy is related to an individual’s ability to obtain, process, and understand basic health information and service needs and make appropriate health decisions . ParentsConsidering the problems most frequently described in recent international studies as the cause of non-vaccination ,46,47, wHowever, also, the lack of a free HPV vaccine may be important, as HPV vaccination requires at least two doses and is quite expensive.We believe that education is not enough if vaccination is not supported by the state, at least for the age groups most suitable for HPV vaccination.Some practical implications of this study. Perhaps from the information found in our study, one example—HPV vaccination was positively influenced by gender—may be considered and be used and processed at the national level in the health policies developed by the Ministry of Health for the development of new strategies for the implementation of HPV vaccination strategies that are compliant with what the WHO specifies; i.e., a gender-neutral HPV vaccine implementation strategy. Practically, this study shows the authorities in Romania responsible for developing vaccination strategies how exactly the situation is presented in terms of gender reporting in our country and something useful in recalibrating and rethinking future vaccination strategies. The results of the study can be used in meta-analyses at the European level. The positive and negative factors that influence vaccination can be different from one country to another. Therefore, the study can be a small but representative part of the global or European situation, and based on them, along with other studies of this type, the factors that positively or negatively affect HPV vaccination can be identified, and some vaccination implementation strategies can be refined, maybe at a higher level.This study was subject to several potential limitations. The study was limited by its cross-sectional design. The representativeness of the study sample is limited due to the default selection of respondents who have digital skills, as the studied sample mainly analyzed people who could use the internet and electronic documents. Another limitation of this study is that it analyzed only a short period of time of 4 months and included a limited number of participants with children . It is possible that people’s acceptability of child vaccination may change over time as further HPV vaccination campaigns may be instituted; therefore, longitudinal monitoring is indicated. Third, there are some limitations regarding the place of residence, as 930 (82.89%) of our studied group lived in an urban area, and 459 (40.91%) of the responders worked in the medical domain. Nevertheless, this may not, in fact, be a limitation because these people are opinion formers and may support children’s vaccination.The findings of this study reveal the barriers and facilitators of Romanian HPV vaccinations. In the general population, the inclusion of HPV vaccination in the National Vaccination Program would be the most important facilitator of HPV vaccination in Romania. In general, HPV vaccination in Romania was positively influenced by gender and area of residence. In the case of parents who have not vaccinated their children against HPV, one important barrier to HPV vaccination was the high cost of the HPV vaccine and the lack of proper information. The overall acceptability of HPV vaccination in the Romanian population is low. Therefore, public health educational programs are needed along with the inclusion of HPV vaccination in the National Vaccination Program, thus making the HPV vaccine free of charge and available for boys as well as for girls of HPV vaccination-eligible age.


For Tuscan speakers (predominantly from Florence), the BLUE area is argued to linguistically differentiate between azzurro “medium blue” and celeste “light blue.” We scrutinized “basicness” of the three terms. Participants  named each chip of eight Munsell charts encompassing the BLUE area  using an unconstrained color-naming method. They then indicated the “best exemplar”  of blu, azzurro and celeste. We found that frequencies of the three terms and of term derivatives were comparable. Referential meaning of blu, azzurro, and celeste was estimated in CIELAB space as L*a*b*-coordinates of the mean of focal colors and as “modal” categories, that is, dispersion around the mean. The three “blue” terms were distinct on both measures and separated along all three CIELAB dimensions but predominantly along the L*-dimension. Our results provide evidence that Tuscan speakers require all three terms for naming the BLUE area, categorically refined along the lightness dimension. Furthermore, celeste appears to be a third BCT for “blue,” along with commonly considered BCTs azzurro and blu. The “triple blues” as BCTs for Tuscan speakers are in contrast with outcomes of two “blue” basic terms estimated by using the same methodology in two other locations in Italy—azzurro and blu  or celeste and blu .Psycholinguistic studies provide evidence that Italian has more than one basic color term (BCT) for “blue”: consensually,  According to Berlin and Kay 1969/, p. 6, aNovel basic color categories (BCCs) were demonstrated to emerge due to needs for communication efficiency , 2022. Osinij “dark blue” and goluboj “light blue,” with the latter named by Berlin and Kay  shades of blue. The classic example is Russian Kay 1969/ as a potnjecture , 2007. Fnjecture . The addnjecture .azzurro , when school education became affordable to general population.analysis , listinganalysis , idiomatanalysis , and deranalysis . Azzurros lazuli . AccordiCeleste originates from Latin caeruleus, derived from caelu(m) “sky,” and at the time had no color meaning. With a symbolic religious meaning, but also with a color sense denoting light shades of blue, it is attested in the thirteenth century; in addition, it became associated with fabrics dyed in light blue . Since then celeste has become common in Italian dialects  blue conceivably as a result of its use in the cloth trade  shades of blue, while azzurro, with the meaning of “dark medium blue,” apparently is not a basic . Also, these authors used a much smaller number of chips (N = 55), unlike the large number of chips (N = 237) from the Munsell Color set employed in the Alghero and Verona studies (For speakers from Florence (Tuscany), BLUE area seems to be “clothed in triple blues,” with ht blue” . It is n studies , 2018.The aim of the present study was to further investigate the basic “blue” term inventory for Tuscan speakers, predominantly from Florence, and possible effects of the stimulus set on estimates of the term basicness. In the context of the present study, we heeded two of Berlin and Kay’s criteria of a BCT. Specifically, we explored whether the meaning of each term is not included in the meaning of one or the other “blue” term (criterion (b)). Also, we assessed psychological salience of each “blue” term (criterion (d))—stability of reference across informants; and occurrence in ideolects of all informants.The objective was to explore whether the discrepancies found in the number of Italian basic “blue” terms—two in the Alghero and Verona studies , 2018 anN = 31; 17 females) aged 19–26 y.o.; mean age 22.9 ± 2.1. All participants resided and were born in Tuscany. Further information about participants can be found in Table S1 of the Supplementary Materials. All participants had normal color vision assessed by the Ishihara Pseudoisochromatic Plates  were employed. The charts embraced the BLUE area, with Hue 7.5BG, 10BG, 2.5B, 5B, 7.5B, 10B, 2.5PB, and 5PB, as illustrated in N = 237) were re-notated in the CIELAB space.Eight charts from 2 , corresponding to illuminance of 1387 lux.Participants were adapted to mesopic lighting in an otherwise dark room for at least 10 min, the temporal window ensuring dark adaptation of cones . Followiceleste, azzurro, blu, indaco, tiffany), compound terms , terms with modifiers  or with suffixes .For naming the Munsell chips, an unconstrained color-naming method was used: participants were requested to name each chip freely. A certain color term could be used by a participant for naming more than one chip. The response sheets consisted of a replica of the structure of the eight Munsell charts. Participants were asked to write color names within blank cells corresponding to the chart chips . Particiblu, azzurro and celeste. The focal colors were noted by the experimenter on the response sheet and coded by their Munsell Hue, Value and Chroma.Each chart was presented one-by-one in a fixed order, to avoid “the danger that participants tested in one order … will adopt strategies or criteria different from those … adopted by participants tested in a different order” , p. 12. celeste, azzurro, and blu; also, other frequent non-BCTs terms were considered .Initially, linguistic frequency analysis of all terms offered by all participants was undertaken. Next, raw naming data of all elicited “blue” terms were transformed into their modal correspondents with the focus on celeste, azzurro, and blu included the basic forms, as well as their derivatives , compound terms either with an adjective  or a noun , and terms with brightness or saturation modifiers  , basic in Italian  cf., . Note th Italian , not exccelest*, azzurr*, and blu* were transformed to CIELAB coordinates (http://www.cis.rit.edu/research/mcsl2/online/munsell.php). For each modal category, the central tendency of the distribution of denotata was computed as the mean of L*, a*, and b* coordinates and standard error of mean along each coordinate. Also, Munsell coordinates of focal colors of celeste, azzurro, and blu were transformed to CIELAB coordinates, and mean and standard error of their distributions were computed.For psycholinguistic analysis, Munsell coordinates of the stimuli named by the modal terms H and Mann–Whitney U tests were used to assess differences between distributions along each coordinate, across the three categories and pairwise, respectively.Normality of distribution of denotata of each of the three modal categories and the focal colors along each CIELAB coordinate was assessed by the Shapiro–Wilk test. Since most datasets were not normally distributed, median and semi-interquartile range (sIQR) values were also computed. Kruskal–Wallis celest*, azzurr*, and blu* was calculated as the percentage of participants (out of 31), who named the same chip with the identical modal term.Finally, consensus of naming the BLUE area by modal Table S2 that lists the elicited color names according to their rank (up to rank 30). In the variety of color descriptors, 42 different combinations were recorded. Each individual participant  used all three “blue” terms, celeste, azzurro, and blu. Notably, among the three terms, celeste has the highest frequency, as is the case for Alghero speakers (azzurro (rank 5) and blu (rank 6). For the participant, who offered only nine color names in total, celeste, azzurro, and blu had ranks 2, 3, and 4, respectively (see Table S2).The tested Tuscan speakers used a large variety of color terms to describe the BLUE area. The total number of different terms is 1,344, while for individual participants, the total number of terms varied between 9 and 153. The list of terms most frequently offered by participants (having occurred in at least 14% cases) is presented in speakers , 2018; iblu* , 272 descriptors with azzurr* , and 262 terms with celest* .Relative occurrences of the three modal terms are different, though: participants offered 326 different combinations containing indaco (rank 48) and turchese (rank 56), which, too, were frequently named in previous list and/or naming tasks (carta da zucchero (rank 59) and frequent modern Italian terms like cobalto (rank 93), petrolio (rank 96), ciano (rank 106), and tiffany (rank 112), also attested in previous linguistic and psycholinguistic studies  Means and standard errors of the distributions of denotata, in CIELAB space, of the three modal terms, across all participants, are shown in celest*, azzurr*, and blu* separately along each of the L*, a*, and b* coordinates. Since none of the L*, a*, or b* distributions met the requirement of normality , the corresponding medians and sIQRs were calculated and are reported in  L* coordinate (2χ(2) = 2,423.77, p < .001), as illustrated by celest* category is lighter than both azzurr*  and blu* , and azzurr* is lighter than blu* .The three “blue” categories differ predominantly in their lightness, along the a* coordinate (2χ(2) = 85.77 p < .001), as illustrated by celest* differs from both azzurr*  and blu* ; also azzurr* differs from blu* , with azzurr* being more “greenish” than the other two terms.The three categories also differ along the b*-coordinate (2χ(2) = 156.54 p < .001): celest* is different from both azzurr*  and blu* ; as are azzurr* and blu* different . Among the three terms, blu* appears to be of greatest “bluishness.”A similar pattern of differences is observed for the blu foci is smaller than that of the other two terms' foci, the finding addressed below in relation to the naming consensus.Distribution of denotata of focal colors of the three categories, across all participants, is shown in L*, a*, and b* projections of focal colors are presented in H test indicated significant differences of the foci of the three categories along the L*-coordinate (2χ(2) = 2,423.77 p < .001), as illustrated by celeste is lighter than both azzurro  and blu , and azzurro is lighter than blu . Thus, as expected, the focal color of celeste is the lightest, whereas the focal color of blu is the darkest.Medians and sIQRs of a*-coordinate (2χ(2) = 85.77, p < .001), as shown in celeste and blu , as well as between focal colors of azzurro and blu , while there is no difference in “greenishness” between focal colors of celeste and azzurro .Differences between focal colors, across the three categories, are also significant for the b*-coordinate, too (2χ(2) = 156.54, p <.001), as illustrated by celeste differs both from azzurro  and blu ; in comparison, focal colors of azzurro and blu are not significantly different  and both are more “bluish” than that of celeste.Finally, there are differences between focal colors of the three categories along the blu* is higher than for both celest* and azzurr*, reaching 100% for chip 2.5PB 3/10; azzurr* consensus drops faster than that for celest*. Moreover, participants were rather unanimous (consensus >40%) in naming 8 chips  using either celest* or azzurr* modal names.The employed unconstrained color-naming method implied that the elicited CTs were of considerable diversity; nevertheless, for each modal “blue” term, we found consensus higher than 50%. Percentage of the naming consensus for each chip (in Munsell coordinates) is presented in Tables S3–S5 of the Supplementary Materials. Among participants, consensus for each of the three “blue” terms is rather high for most of the chips. Consensus for celest*, 40% (range: 29%–55%) for azzurr*, and 71% (range: 19%–100%) for blu*.Noteworthy, the chips with high(est) modal name consensus correspond to those frequently chosen as focal colors. Conversely, all (but one) chips chosen as focal colors reveal quite high modal name consensus rates: on average 44% (range: 16%–65%) for celest*, azzurr*, and blu* with consensus higher than 40%. It is apparent that for celest*, high consensus is observed for light blue shades of BLUE area, azzurr* for medium blue, and blu* for dark blue shades.celeste, azzurro, and blu, appear to be deeply entrenched and indispensable for communicative efficiency for Tuscan speakers. To support our conclusion that celeste, azzurro and blu meet the criteria to be considered BCTs, we discuss our outcomes in relation to the two Berlin and Kay’s . Celeste ranks higher than azzurro, which, in turn, ranks higher than blu. Frequencies of use their modal terms are comparable, confirming the finding of celeste and azzurro—derivatives, compounded and suffixed words , and in relation to criterion (b), that the term should not be subsumed under the meaning of another term. We found that the three color categories are distinctly segregated along each dimension of CIELAB space see –8 suggesceleste focal  is similar to that for Alghero  In comparison, the Florence azzurro focal  is similar to that for Verona sample . The coordinates of blu focal are comparable for the three speaker samples, namely, Florence: L* = 30.80, a* = 5.71, b* =  − 45.25; Alghero: L* = 28.45, a* = 4.07, b* =  − 41.53; Verona: L* = 32.90, a * = 4.74, b* =  − 45.33. In addition, azzurro appears to be the “greenest” among the three terms, while both azzurro and blu are more “bluish” than celeste.Compared with centroids of focal colors of the three “blue” terms reported for Alghero and Verona samples , Table 3blu being the highest, which also is reflected in low variability among observers in their choices of focal blu.The consensus outcomes provide, too, an additional argument that Florence speakers require three BCTs to denote BLUE area. In particular, there is high consensus in using all three terms, with consensus for celeste, azzurro, and blu—perform as BCTs. Our findings are in accord with “persuasive rather than conclusive” results of the color-naming experiment carried out in Florence by Bimler and celeste, denoting light blue, and azzurro, denoting medium blue, whereas blu denotes dark/navy blue, like in other regions in Italy. This is different from two BCTs, azzurro and blu, of Italian spoken in Veneto region and confirms the contention that Tuscan dialects have developed along their own lines; hence, their vocabulary does not always coincide with that of other regions , we conclude that the “triple Florence blues” probably resulted from the pressure for efficiency of communication , 2022 viIn general, linguistic labels are argued to implicate the fine-grained memory of the percept corresponding to the category and as such, serve as the source of top-down information increasing efficacy of perceptual evidence integration—in color choice accuracy and in discrimination of cross-category members, compared to within-category members .Divina Commedia), Boccaccio (Decameron) and Petrarca (Il Canzoniere)  . Florenc century .celeste can be found with a slightly different spelling, cilestro, which is formed by analogy with terrestre “terrestrial”  retained a marked conservatism and was still close to Latin . In the estrial” . Azzurro’s texts .Risorgimento, 1815–1870) only 2% of the Italian population could speak proper Italian , which meticulously regulated qualities of dyed cloth , cilestrini al modo nostro (“in the Florence fashion”).The above brief overview on the history of Italian language is presented here for a better comprehension of why the number of BCTs to denote the BLUE area appeared to vary in different regions of Italy. For Florence specifically, it is conceivable that the need for linguistic elaboration of the BLUE area arose due to the development of complex woad dyeing technology in the woollen cloth industry, as attested by the Florentine treatise ed cloth . The dyeIn addition, lexical refinement of the BLUE area probably was encouraged by the fact that no later than from Middle Ages, different blue shades of artefacts were functioning as cultural signifiers cf., . In relaIn Italy, iconography played a significant role from the fifteenth century, when at least two different blue pigments, extracted from blue minerals, were used: ultramarine, obtained from by grinding high-quality lapis lazuli, was more brilliant, saturated and, hence, much more expensive than a pigment, “less pleasant … of azure earth-like colour,” obtained from azurite , p. 43. In conclusion, we would like to reiterate Click here for additional data file.Supplemental material, sj-docx-1-ipe-10.1177_20416695221124964 for Florence “blues” are clothed in triple basic terms by Maria Michela Del Viva, Ilaria Mariani, Carmen De Caro and Galina V. Paramei in i-PerceptionClick here for additional data file.Supplemental material, sj-docx-2-ipe-10.1177_20416695221124964 for Florence “blues” are clothed in triple basic terms by Maria Michela Del Viva, Ilaria Mariani, Carmen De Caro and Galina V. Paramei in i-PerceptionClick here for additional data file.Supplemental material, sj-docx-3-ipe-10.1177_20416695221124964 for Florence “blues” are clothed in triple basic terms by Maria Michela Del Viva, Ilaria Mariani, Carmen De Caro and Galina V. Paramei in i-PerceptionClick here for additional data file.Supplemental material, sj-docx-4-ipe-10.1177_20416695221124964 for Florence “blues” are clothed in triple basic terms by Maria Michela Del Viva, Ilaria Mariani, Carmen De Caro and Galina V. Paramei in i-PerceptionClick here for additional data file.Supplemental material, sj-docx-5-ipe-10.1177_20416695221124964 for Florence “blues” are clothed in triple basic terms by Maria Michela Del Viva, Ilaria Mariani, Carmen De Caro and Galina V. Paramei in i-Perception


Callinectes sapidus, digs a shallow‐water pit. It appears that the crab has missed the outgoing tide and is waiting for the next one. But it is not the tide the crab is waiting for. A female fiddler crab, Minuca pugnax, picks at the mud near the pit with its claws. It is eating. The blue crab waits. The fiddler crab moves closer to the pit. Suddenly, the water explodes as the blue crab seizes the fiddler crab and pulls it into the pit. Now it is the blue crab's turn to eat.It is low tide in a salt marsh. A blue crab, Sesarma reticulatum, one of its prey, in its claw . One blue crab emerged from a pit, crawled slowly across the mud with its body low to the ground, stalked a fiddler crab, snatched it, and ran back to its pit to eat. The large claws of male fiddler crabs littered the outside of several blue‐crab pits  crabs in the literature or among my colleagues except for one who said they would seen similar attacks in Georgia and Mississippi salt marshes . Perhaps blue crabs use this hunting style throughout their range  (Appendix n = 31): 19 cm, range 3–36 cm; mean depth (n = 31): 3.4 cm, range: 0.5–8.0 cm). This result suggests that blue crabs are digging the pits themselves. Video evidence supports this suggestion, as it captured blue crabs burying in pits or scooping mud out with their claws  were successful. Most attacks happened when a fiddler crab was in front of the blue crab, but occasionally when a fiddler crab was behind or beside the blue crab. Blue crabs did not always attack, however, even when fiddler crabs fed at the edge of the pits. It is unclear what motivated the blue crabs to attack. Based on videos, I estimated that blue crabs chased fiddler crabs up to 5 cm if they missed on the first strike. Blue crabs sometimes tried to steal fiddler crabs from each other Video .Leucophaeus atricilla, a blue‐crab predator, walked within centimeters of a blue crab in a pit, but did not appear to notice it (Video Blue crabs feeding at low tide offer exciting opportunities to study predator–prey interactions regarding predation risk and foraging trade‐offs. For instance, low‐tide feeding by blue crabs escalates the risk of attacks by bird that also feed at low tide. However, a laughing gull, it Video . When init Video . I hypotSpartina alterniflora. I hypothesize that purple marsh crabs help blue crabs feed in the marsh at low tide, directly as prey and indirectly by removing plants. For instance, there were almost twice as many blue crabs in areas where plants had been removed by purple marsh crab grazing compared with in the areas with plants (Appendix My colleagues and I observed blue crabs ambushing low‐tide prey while conducting research on purple marsh crabs, which created denuded areas in the salt marsh through their overgrazing of Appendix . It may Appendix . If purpSalt marshes are rich with prey that fuel marine predators; however, the marsh surface is only available to them part of the time, when it is flooded. The blue crab seems to have solved this problem with a feeding strategy that allows for 24‐h feeding. This suggests that salt marshes are more important to their production than previously thought (Hyman et al., Predators can link different ecosystems. Blue crabs feeding in salt marshes at low tide offer the fascinating opportunity to study how predator behavior can affect trophic subsidies (the movement of energy from one ecosystem to another; Lesser et al., The author declares no conflict of interest.Appendix S1Click here for additional data file.Video S1Click here for additional data file.Video S1 LegendClick here for additional data file.


Women living with HIV (WLHIV) have a high risk of anal cancer. Identifying risk factors for anal HPV 16 infection, the most significant risk factor for anal cancer, is essential for prevention and screening strategies.In the EVVA Cohort study, 151 WLHIV had cervical and anal HPV testing with genotyping every 6 months for 2 years, while demographic and clinical data were collected via questionnaires and chart reviews. Here, we present results of baseline data analyzed using multivariable logistic regression.Among 150 women with adequate HPV test results at baseline, HPV 16 DNA was detected anally in 23  and cervically in 5 . In multivariable analysis, current smoking , nadir CD4 count ≤ 200 cells/μL , prevalent cervical HPV 16  and anogenital herpes in previous 6 months  were associated with prevalent anal HPV 16.Knowledge of risk factors can help identify WLHIV at greatest risk of anal HPV 16 infection and, potentially, developing subsequent anal cancer. Identification of the subgroup of these women in whom HPV 16 persists could be an early step in the algorithm of anal cancer screening. Among women living with HIV (WLHIV), the incidence of anal cancer is estimated at 22 cases per 100,000 person-years, in contrast to 1–2 cases per 100,000 person-years in the general population [Like cervical cancer, anal cancer occurs when infections with high-risk types of human papillomavirus (HR-HPV) persist, causing squamous intraepithelial lesions (SILs) , 3. AkinCompared to other HR-HPV types, the cancer risk associated with HPV type 16 is approximately 10 times higher . This hiThe EVVA study  is a prospective observational cohort study, which followed 151 WLHIV attending study visits every 6 months for 2 years , 18. BetSpecimens for anal HPV testing were collected every 6 months by a registered nurse who used a saline-moistened Dacron swab inserted 3–5 cm into the anal canal and rotated upon removal to collect epithelial cells. The anal epithelial cell samples from swabs were agitated in 1.5 mL of PreservCyt (Hologic), a methanol-based transport medium, and stored at 4°C. Cell suspensions were centrifuged at 13,000 xg for 15 minutes at 22°C. Pellets were suspended in 300 μL of 20 mml/L Tris buffer at a pH of 8.3. The Linear Array® HPV genotyping test by Roche Molecular Diagnostics was used to detect 36 genital HPV types and the presence of β-globin , 20. SamData regarding putative risk factors for anal HPV 16 infection were collected from participant questionnaires and chart review forms. Questionnaires were administered in clinic by the study coordinator, or self-administered if preferred, and included questions about sexual practices, socio-demographic characteristics, and medical history pertaining to HIV, hepatitis, HPV-related disease, HPV vaccination, anal health, sexually transmitted infections, injection drug use, and cigarette smoking. For sexually transmitted infections, participants were first asked, “Has a doctor ever told you that you had one of the following conditions? Select all that apply” The response choices included “chlamydia”, “gonorrhea”, “herpes ulcers or genital sore”, and other conditions not considered for this analysis. They were then asked, “In the last 6 months only, has a doctor told you that you had one of the following conditions? Select all that apply.”, and the same response options were provided. Chart review forms were completed based on electronic and paper patient charts by the study coordinator, documenting clinical factors including HPV vaccination, nadir CD4 count, current CD4 count, and current HIV viral load.Descriptive and inferential statistics were used to describe demographic and clinical characteristics. Select clinical markers, including CD4 count and HIV viral load, were dichotomized or categorized according to clinically relevant cutoffs. We focused our analyses on HPV 16 due to the higher prevalence and oncogenic potential of this HPV type for anal cancer compared to other types. Age was analyzed as a continuous linear variable, as there was no evidence of nonlinearity of its association with prevalent HPV 16. Univariable (binary) logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for putative correlates of prevalent anal HPV 16 infection at baseline. Risk factors to be included in the multivariable logistic regression model were selected a priori based on their potential to increase the risk of prevalent anal HPV infection. Of note, place of birth, substance use and hepatitis C infection are presented in Of 151 participants, the analysis included 150 women for whom adequate anal HPV testing samples had been obtained. The mean age was 45.2 years. Approximately one quarter (23%) were born in Canada, 44% in an African country, and 28% in the Caribbean. Only 2 women (1%) born in Canada self-identified as Indigenous. The vast majority (96%) responded that their preference for sexual partners was “men only”. Most women (78%) had an undetectable HIV viral load (<40 copies/mL). HPV 16 DNA was detected anally in 23  and cervically in 5  women. Among the 40 women who reported a history of anal sex, the number of lifetime anal sex partners ranged from 1 to 20. None of the 23 women with only 1 lifetime anal sex partner had prevalent anal HPV 16 , compared to 7 of the 17 women who had 2 or more anal sex partners . Selected baseline characteristics of the 150 participants are presented in Findings from logistic regression analyses are presented in These analyses based on EVVA cohort data contribute to the scant literature on risk factors for anal HPV infection in WLHIV. As for all prevalence studies, this study examined the combination of two possible outcomes represented in prevalence; the risk of acquiring HPV 16 and the risk of this infection persisting. In our cohort of WLHIV, current smoking, nadir CD4 count ≤200 cells/μL, concurrent cervical HPV 16 infection, and anogenital herpes in the last 6 months were associated with prevalent HPV 16 infection (baseline).The anal HPV 16 prevalence of 15.3% in our study sample is relatively similar to what is observed in women living with HIV  and higher than what is usually measured in HIV-negative women  . In men,The strong effect of cervical HPV 16 infection in the regression model was expected, based on shared mode of acquisition, proximity of the two anatomical sites, and potential for autoinoculation. This association was previously demonstrated by Heard et al. in France , and a sThe identification of low nadir CD4 count as a potential risk factor for anal HPV 16 is important, given the well-documented effect of nadir CD4 count on long-term health in PLHIV. Nadir CD4 count (<100 cells/μL) has been found to be associated with cervical HPV infection in WLHIV  and withThis study has some limitations. We cannot distinguish persistent from new HPV 16 infections based on baseline data, recognizing that the former situation represents a higher risk of anal cancer than the latter. Some important risk factor effects might not have reached statistical significance due to type 2 error, and bias may have been introduced into the sample due to differential participation. For example, the low prevalence of certain variables (such as injection drug use) in our sample may have been due to reticence to participate among women who have experienced marginalization, and, due to the low prevalence of these variables, we were underpowered to assess them as risk factors. It is also possible that the prevalence of HPV in our sample was overestimated, particularly if women with histories of HPV-related issues were more inclined to participate. An additional limitation concerns the cross-sectional nature of the analyses: Causality cannot be inferred directly from the correlational associations we observed, despite biological plausibility that the variables identified are true risk factors. Although our sample is representative of the population of WLHIV in Québec, its generalizability to other populations may be limited, in particular due to the low number of Indigenous women and women who have a history of injection drugs.In summary, our cross-sectional analyses confirmed the high prevalence of anal HPV 16 in WLHIV. We identified risk factors for prevalent anal HPV 16 including current smoking, nadir CD4 count ≤200, concurrent cervical HPV 16 infection, and anogenital herpes in last 6 months. Given the scarcity of studies of risk factors for prevalent anal HPV infection in WLHIV and, to our knowledge, the absence of literature specific to anal HPV 16 in this population, our findings are notable for anal cancer prevention efforts. Knowledge of risk factors for prevalent anal HPV 16 infection can help identify women at greatest risk of infection, and at increased future risk of anal precancerous and cancerous diseases. These women are most likely to benefit from screening, through either anal HPV testing, cytology, or high-resolution anoscopy.


The incidence of uterine carcinosarcoma steadily increased over time, from 2.2 in 2000 to 5.5 in 2016 , while cervical or ovarian carcinosarcoma showed no significant difference in incidence. The five-year CSS rates based on the site of origin  were 39.9%, 33.1%, and 25.8%, respectively. The incidence rates of gynecologic carcinosarcoma, especially uterine carcinosarcoma, are gradually increasing. Although uterine carcinosarcoma is associated with a higher incidence than the others, it has a better prognosis compared with ovarian and cervical carcinosarcoma. The survival rates were worst in ovarian carcinosarcoma.Carcinosarcomas  of a female genital organ are rare tumors associated with a poor survival. The purpose of this study was to identify site-specific differences in the incidence and prognosis in carcinosarcomas originating in the uterus, cervix, or ovary. The data of patients with gynecologic carcinosarcomas were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2016. The characteristics of gynecologic carcinosarcomas were compared using Pearson X2 and Fisher’s exact tests. Kaplan–Meier models were used for cause-specific survival (CSS) analysis. The cohort included 7086 females, including 5731 cases of uterine carcinosarcoma, 161 cervical carcinosarcomas, and 1193 ovarian carcinosarcomas. The age-adjusted incidence rates of uterine, cervical, and ovarian carcinosarcoma were 3.9, 0.1, and 0.6 per 1,000,000, respectively. In the distribution of carcinosarcoma incidence by race, compared with the uterus or cervix, those originating from the ovary were unequally distributed in Caucasians (84.4% versus 69.6%, 67.7%;  Carcinosarcomas, also known as malignant mixed Müllerian tumors, are rare but highly aggressive epithelial malignancies that contain both malignant sarcomatous and carcinomatous elements . GynecolUterine carcinosarcomas are uncommon and comprise less than 5% of uterine tumors, with more than 35% of cases presenting with extrauterine disease at diagnosis ,7. UteriThe recognition of trends and changes in the characteristics of carcinosarcomas, as well as the prevalence, recurrence, and poor overall survival, is useful in understanding the epidemiology of gynecologic carcinosarcomas. Nevertheless, published data regarding the trends in incidence and prognosis are not enough. The objective of this study is to investigate the site-specific differences in the incidence and prognosis by comparing carcinosarcomas originating in the uterus, cervix, and ovary.Data involving patients with gynecologic carcinosarcomas were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 to 2016; this database collects patients’ clinicopathological features and survival data. The SEER*Stat 8.3.6  was used to extract the SEER18 dataset, which contains reliable information on cancer incidence and survival derived from 18 population-based cancer registries, covering approximately 34.6% of the US population . PatientThe following information was obtained to investigate the clinicopathological features of gynecologic carcinosarcoma: age, race , tumor histology, grade , and the type of treatment received . The tumor stage was assessed according to the SEER historic staging system  for consistent cancer staging over all the research periods. The incidence rates were calculated per 1,000,000 person-years and age-adjusted to the 2000 US standard population. The age-adjusted incidence rates with 95% confidence intervals were analyzed by primary site, race, historic stage, age group , and the lymph nodes assessed. The cause-specific survival (CSS) rate was calculated at 5 years.t-test and analysis of variance (ANOVA). Comparisons of the characteristics between gynecologic carcinosarcomas were performed using Pearson X2 and Fisher’s exact tests. CSS was defined as the time from the date of diagnosis to the date of death from carcinosarcoma. Overall survival (OS) was defined as the time from the date of diagnosis to the date of death due to any cause or to the last follow-up. The incidence rates were calculated and exported to IBM Statistical Product and Service Solutions (SPSS©), version 20.2 . Kaplan–Meier models were used for CSS analysis. Statistical significance was accepted at p < 0.05.All continuous variables were analyzed using Student’s All procedures involving human participants followed the 1964 Declaration of Helsinki and subsequent amendments or the equivalent ethical standards. We signed the ‘Surveillance, Epidemiology, and End Results Program Data Use Agreement’ according to the database’s use requirements. Approval was waived by the local institutional review board because SEER data are public and anonymized.From 2000 to 2016, the total cohort included 7086 cases of gynecologic carcinosarcoma, including 5731 cases of uterine carcinosarcoma, 161 cervical carcinosarcomas, and 1193 ovarian carcinosarcomas. The clinical and demographic characteristics of the cohort are presented in p < 0.001). The distribution of stage at diagnosis varied depending on the primary site of the carcinosarcoma. In uterine carcinosarcoma, the localized stage was the most prevalent (37.6%), and the distant stage was found in only 23.4% of cases. Conversely, in ovarian carcinosarcoma, the distant stage was the most prevalent (72.3%), while the localized stage was observed in only 5.2% of patients (p < 0.001). In the carcinosarcoma of the cervix, the regional stage was the most common (43.5%), followed by distant and localized stages accounting for 29.2% and 22.4%, respectively (p < 0.001). Most patients (96.5%) diagnosed with ovarian carcinosarcoma did not undergo radiotherapy, whereas patients with other gynecologic carcinosarcomas more frequently underwent adjuvant radiotherapy . In terms of sequence of radiotherapy, adjuvant radiotherapy was most frequent . External beam radiotherapy (EBRT) was the most common treatment method . Vaginal brachytherapy (VBT) was performed more frequently for carcinosarcoma, other than ovarian carcinosarcoma . While 73.1% of ovarian carcinosarcomas were treated with chemotherapy, only 39.8% of cervical carcinosarcomas were managed with chemotherapy (p < 0.001). Lymph nodes were examined in 65.5% of uterine carcinosarcomas, and positive lymph nodes were found in 18.9%. By contrast, only 37.3% of cervical cancers had invaded lymph nodes (p < 0.001).Patients with uterine carcinosarcoma were older compared to those with cervical or ovarian cancer. The mean age at diagnosis was 67.7 ± 11.3 years. Gynecologic carcinosarcomas were most prevalent in patients in their 60s . They were prevalent in White women, and gynecologic carcinosarcoma predominance in that racial group is shown by case incidence: ovary, 84.4%; uterus, 69.6%; and cervix, 67.7%  involving the uterus, cervix, or ovary were 3.9, 0.1, and 0.8, respectively, from 2000 through 2016 . The incp < 0.001).The five-year CSS rates according to sites of origin, including the uterus, cervix, and ovary, were 39.9%, 33.1%, and 25.8%, respectively . The 1-yThis study presented the trends in incidence and CSS rates of gynecologic carcinosarcoma in the U.S. from 2000 through 2016. The incidence of uterine carcinosarcoma has increased over the specified timeframe in the U.S., a trend not observed in other gynecologic carcinosarcomas. Patients with carcinosarcoma of the uterus showed better 5-year disease-specific survival rates, whereas ovarian carcinomas were associated with a poor prognosis.Gynecologic carcinosarcoma was most prevalent in women in their 60s, consistent with a population-based study in Israel . During In our study, the distribution of carcinosarcoma according to primary organ varied slightly by race. Compared with cervical carcinosarcoma, ovarian carcinosarcoma involved a higher percentage of White women, whereas the percentage of Black women was lower . These incidental differences in race could be attributed to genetic factors, cultural differences, and socioeconomic status. A previous study showed racial disparities in disease characteristics and survival in gynecologic carcinosarcoma . In a U.Gynecologic carcinosarcomas are rapid growing tumors with prevalence and recurrence rates comparable to common gynecologic malignancies. The 5-year disease-specific survival rate associated with ovarian carcinosarcoma was inversely correlated with the disease stage ,16. SimiCervical carcinosarcoma was reported to occur in 0.2 per 100,000 people in Europe . It has The types of adjuvant treatment according to the primary site of carcinosarcoma also differed slightly in our study. The optimal treatment for gynecologic carcinosarcoma is controversial. Adjuvant therapies for uterine carcinosarcoma have advanced over time. Compared with locally advanced or metastatic disease, uterine carcinosarcoma can be treated via total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without pelvic and para-aortic lymphadenectomy. The decision to administer adjuvant treatments, including pelvic external beam radiotherapy, chemotherapy, and hormonal therapy, depends on the presence of certain risk factors. The benefits of adjuvant chemotherapy and radiation therapy for patients with uterine cancer carcinosarcoma were reported by the Gynecologic Oncology Group 150 . HoweverPrevious studies ,26 reporThe study has several strengths, including the large number of patients with gynecologic carcinosarcoma derived from the SEER database, which accurately reflects the incidence and survival rates of rare carcinosarcoma. Nevertheless, this study has limitations. Since many cases involved missing TNM stages, an accurate summary stage analysis could not be performed. Second, survival analysis was not performed specifically by race, age, or stage, nor was there a trend analysis of survival. Although survival analysis involved the primary sites of the carcinosarcoma, no survival analysis by stage was performed.In conclusion, the incidence rates of gynecologic carcinosarcoma, especially uterine carcinosarcoma, have gradually increased. Although the incidence of uterine carcinosarcoma is higher than that of the others, it is associated with a better prognosis compared with cervical and ovarian carcinosarcomas. The high recurrence rate and poor overall survival of gynecologic carcinosarcoma suggest the need for improved management strategies. Given the rarity of carcinosarcoma, however, large international prospective trials are warranted to establish treatment regimens.


Background: This study assessed awareness, attitudes, and uptake of human papillomavirus (HPV) vaccination and cervical cancer screening in detained women. Methods: The cross-sectional study was conducted from April to June 2022 in four women prisons in Italy. Results: 41.1% of participants recognized HPV infection as an sexually transmitted diseases (STD), 36.4% identified cervical, and 16.8% oral cancer as an HPV-associated disease. Overall, 70% had never heard of HPV vaccination, and 45.8% believed it is effective to prevent cervical cancer. Among the age-eligible women for HPV vaccination, none reported to have undergone it, nor had talked about it with a physician in the previous year. Only 13.5% declared to have ever undergone cervical cancer screening, and adherence was significantly higher in those who were involved in a working activity in prison, who were aware that HPV infection is an STD and that can cause cervical and oral cancer, and who were older at their first sexual intercourse. Conclusion: These findings documented an extremely low awareness of HPV infection and an unsatisfactory adherence to prevention through HPV vaccination and cervical cancer screening. There is a need for evidence-based interventions for incarcerated women to promote participation in HPV vaccination and cervical cancer screening programs as routine activities. Infections with human papillomavirus (HPV) and associated diseases including oropharyngeal, anal, cervical, vaginal, vulvar, and penile cancers, are a public health concern worldwide. Nonetheless, the risk of HPV infection and the burden of associated diseases are influenced by geographic, socioeconomic, cultural, and viral-specific factors, as well as by subjective characteristics, such as age, gender, and health status . IncarcePrevention of HPV infection may rely on primary prevention through vaccination, which has demonstrated to be effective also against CIN and invasive cervical cancers ,5, and oDetained women often belong to disadvantaged and deprived social groups, who are less likely compared to the general population to have access to healthcare services, including preventive services . The heaThe World Health Organization (WHO) has set a framework for the assessment of prison health system performance and in the section on health services delivery, there is an extensive area dedicated to preventive services for disease prevention, health protection, and health promotion, where vaccinations and cancer screening provided to incarcerated subjects are included . HoweverTo date, there are no studies that have explored these issues in depth in Italian prisons. It was, therefore, of interest to conduct a study on detained women to assess awareness, attitudes, and behaviors concerning HPV infection and cervical cancer, with specific attention to preventive measures including HPV vaccination and cervical cancer screening.The present cross-sectional study was part of a larger project developed and conducted by the University of Campania “Luigi Vanvitelli” and the Joint Operational Unit for Health Protection at Prison Institutions focused on the investigation of several health-related issues in the incarcerated population ,22,23,24The study was carried out between April and June 2022 in four prisons hosting women in the geographical area of the Campania region, in the South of Italy.All directors of female prisons received an invitation letter containing the study aims, the research protocol, and a consent request to conduct the study.After having received the approval, an information sheet was distributed to all incarcerated women and each of them was informed about the study aims, that participation was voluntary, and that all data obtained by the survey were strictly confidential.The survey was compiled in the cells after informed consent was obtained and no incentives were offered for participation. The sample size was calculated assuming that 80% of women adhere to cervical screening programs in accordance with the literature ,26, a 95Overall, 214 detained women participated in the survey, out of 241 invited (88.8% response rate).The study was conducted using a self-administered questionnaire which could be filled out by respondents approximately in ten minutes . The surThe questionnaire was composed of five sections focused on several topics, including (1) sociodemographic characteristics of incarcerated women and information about the current detention , living in individual or shared cells); (2) anamnestic characteristics (presence or history of underlying chronic conditions and/or STDs) and lifestyle behaviors ; (3) knowledge about HPV infection and cervical cancer and related prevention strategies; (4) attitudes, behaviors and experience about HPV infection and cervical cancer and related prevention strategies, including HPV vaccination and cervical cancer screening; (5) having received information about prevention strategies against HPV infection and cervical cancer and need for additional general information about HPV and cervical cancer.In all sections, information was collected using closed-ended questions and multiple choices answers format; in the fourth section, information about attitudes was collected using a 5-point Likert-type scale with a strongly agree/agree/uncertain/disagree/strongly disagree response format. Furthermore, alcohol-related disorders were investigated using the audit-C scale, a validated and effective questionnaire for predicting hazardous alcohol drinking ,32,33, at-test for continuous variables and the chi-square test for categorical variables. Next, a multivariate stepwise logistic regression analysis was performed to evaluate the potential determinants associated with having had a PAP smear for cervical cancer screening . The independent variables that were shown to be associated at the univariate analysis or that were judged to potentially have an influence on the investigated outcome were included in the model. A detailed description of the independent variables included in the model and the related categories is reported in a First, data collected were analyzed by performing a descriptive analysis to explore the characteristics of the population; continuous and categorical variables were described using, respectively, means/standard deviations and absolute values and relative frequencies. Second, bivariate analyses were conducted to evaluate the association between having had a PAP smear for cervical cancer screening and potential determinants by using Student’s p-value equal to or less than 0.05. Furthermore, adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. All statistical analyses were performed using STATA software, version 15.1, Stata Corporation, College Station, TX, USA [The level of statistical significance was defined by a  TX, USA .Prior to the beginning of the survey, the questionnaire was pre-tested on 50 women to ensure correct interpretation, reliability, and feasibility of the questions, no changes were made to the survey instrument, and the results from these women were included in the final sample. The study was approved by the Ethics Committee of the Teaching Hospital of the University of Campania “Luigi Vanvitelli” .Detained women reported a mean age of 44.4 years (range 18–77), only 13.1% were not Italians, 91.6% reported a heterosexual orientation, and 86% had at least one son or daughter, 21.9% reported a high school or university degree, and 41.6% declared to have an occupation before detention. For almost two-thirds of the responders (65.4%), this was the first experience of incarceration, with 11.7% reporting to live in individual cells and 43.9% to be involved in working activities in the prison. The frequency of detained women reporting at least one chronic disease was 45.3%, whereas a diagnosis of STD was declared by 7% of participating women. The large majority reported current smoking (81.8%), with 4.6% having started within prison, and for 13.6% an alcohol use disorder was assessed through the audit-C score. Almost all had had sexual intercourse (99.1%), and the mean age at sexual debut was 16.9 years .Only 41.1% of responding women recognized HPV infection as an STD, with almost half (48.6%) declaring they do not know. Regarding the HPV-associated diseases, only 36.4% identified cervical cancer and 16.8% oral cancer, with most of the sample responding they do not know . Instead, most of the women have heard about the PAP test (85.9%) and 78.5% are aware that HPV infection usually goes away without any treatment. Poor knowledge was observed concerning HPV vaccination, with more than 70% who declare to have never heard about this vaccination, only 39.2% know that HPV vaccination is effective in the prevention of genital warts, and only 45.8% are aware that it is effective to prevent cervical cancer. Furthermore, only 19.2% and 10.8% are aware that it is effective in sexually active women and in those who have already been exposed to HPV, respectively. Finally, the composite variable on knowledge showed that only 11.2% of the women are aware that HPV infection is an STD, and that HPV may cause cervical and oral cancer .Only 15.9% and 9.3% believe they would get HPV infection throughout life, and that their lifestyle would increase the risk of HPV infection, respectively. The sexual transmission of HPV infection is quoted as easy by 71.5% of participants, and 71% would find it embarrassing to have genital warts. Three-quarters of respondents (75.7%) agree that being diagnosed with cervical cancer would have negative consequences on their lives, and 68.7% are aware that it can cause death. Moreover, 26.7% and 34.1% believe that their risk of HPV infection and of cervical cancer is the same of women who had never been incarcerated, respectively .Regarding vaccinations, 47.7% believe or are uncertain that vaccines in general are more dangerous than safe, 36.9% that the HPV vaccine is safe, while only 9.3% that it may cause serious side effects. Moreover, 80.4% believe or are uncertain that HPV vaccination is not necessary if one gets a PAP test and 46.8% agree that the HPV vaccine could save their lives .Among the age-eligible women for HPV vaccination, none reported to have undergone it, nor had talked about it with a physician in the previous year. Most respondents were eligible for cervical cancer screening, but only 13.5% reported to have ever undergone it. Among these women, 46.4% reported to have received a PAP test in prison, 39.3% in the community, and 14.3% in both; additionally, 14.3% declared at least one abnormal PAP test result, and 1.8% a diagnosis of cervical cancer .The results of the multiple logistic regression showed that women who had ever undergone a PAP smear in a screening program had significantly higher odds of having a familiar or friend history of HPV infection or cervical cancer , of being involved in a working activity in prison , of being aware that HPV infection is an STD and that can cause cervical and oral cancer , and of being older at their first sexual intercourse  .Only 5.1% reported to have been informed about HPV infection and cervical cancer prevention strategies during permanence in prison, and 93% declared to have a need for additional information on these topics.Detained subjects are an understudied population, and, among them, women are even less investigated. To our knowledge, this is one of the few studies assessing the awareness of detained women on the risks correlated to HPV infection, with specific attention to the prevention of cervical cancer through vaccination and screening tests, as well as participation in HPV infection and cervical cancer preventive activities.The results of this survey have revealed very poor knowledge of HPV infection and associated diseases, along with limited awareness of the role of HPV vaccination, whereas an expected higher knowledge, although unsatisfactory, was revealed on the role of the PAP test, probably related to the less recent introduction of this procedure as compared to HPV vaccination. These findings are even less satisfactory than those reported by Moore et al. in detained women in the USA, as regards to knowledge of the association of HPV infection with cervical cancer (57% vs. 36.4% in this study), with oral cancer (19% vs. 16.8%), as well as on awareness that HPV infection is an STD (61% vs. 41.1%) ,37. ThesConsistently with knowledge, more concern is related to statements involving cervical cancer, whereas lower interest is devoted to HPV infection and vaccination. Overall, there is a low perception of the risk of HPV infection and associated health consequences, and specifically on the potential of lifestyle-related behaviors, although the sexual transmission of HPV is reported to be easy by the majority of women. Moreover, the finding that almost half of respondents expressed concerns about the safety of vaccinations is alarming and mirrors perceptions on HPV vaccination, since only one-fifth of women disagreed with the statement that it can cause serious side effects.The findings of this study demonstrate that in detained women the availability of preventive measures against HPV infection and cervical cancer still represents a missed opportunity even in the context of a universal healthcare coverage system; indeed, it is unacceptable that none of the eligible women had undergone HPV vaccination and only 13.5% had ever had a PAP smear in a screening program. It has been described that detained women report less access to preventive activities in the community , but theAn even more worrisome result is provided by the absence of HPV-vaccinated women among those who were eligible, coupled with the reporting that none of the eligible women had been informed about the vaccination by a prison physician in the previous year. There is a dearth of information on HPV vaccination in incarcerated women, with only two studies reporting 34%  and 35% A low prevalence of HPV vaccination and of cervical cancer screening was expected in this population, but the results of this survey are far below most of the findings reported in the literature and stimulate the implementation of preventive interventions targeted at incarcerated women to promote HPV vaccination and cervical cancer screening, thus catching the opportunity within prison to increase the adherence to these preventive measures in a population which is hard to reach in the community. Assessing HPV vaccination and cervical cancer screening status in clinical records at entry may then address women to dedicated health promotion activities to understand the indications and benefits of HPV vaccination and cervical cancer screening, followed by promotion of access to these preventive activities. Indeed, studies that have implemented targeted health promotion activities in this population have been successful , and thoOne of the main objectives of the study was to evaluate the predictors of PAP smear uptake among the surveyed population. According to previous investigations on incarcerated women, sociodemographic and detention characteristics were not found to be significantly associated with PAP smear uptake ,49, wherThe results of this study showed that the adherence to preventive measures against HPV infection and cervical cancer among incarcerated women is worryingly inadequate. Therefore, there is plenty of room for health policymakers and those responsible for providing care to women deprived of liberty to more effectively implement prevention strategies within the prison. This would fulfill the healthcare gap between incarcerated women and citizens at liberty, which is responsible for inequity in health even in a country where health is a constitutional right. Therefore, detention conditions in prisons represent an emergency in terms of rights and public health and there is an urgent need got more efforts to counter this emergency by governments, and social and healthcare services.The findings of this study should be examined taking into account limitations that may influence the interpretation of the results. First, this study adopted a cross-sectional design, and thus it allows only to determine associations, but not causality between determinants and outcomes. Second, the survey relied on self-reporting and there was no objective verification through chart review as regards HPV vaccination or cervical cancer screening adherence. Third, the sample of incarcerated women is small, and results on determinants may have been affected by low power, reducing our ability to find associations between determinants and outcomes. However, the population of detained women is small compared to detained males and recruitment involved the majority of prisons in our area, and the study has provided novel information on a poorly investigated population. Moreover, the large participation with a very high response rate reduces the risk of selection bias and allows generalizability of results to the southern Italy population of detained women. Future research involving a larger geographic sample would be of interest.The results of the study have documented an extremely low awareness of the risks correlated to HPV infection and an absolutely unsatisfactory adherence of incarcerated women to prevention through HPV vaccination and cervical cancer screening. Future research focusing on evidence-based interventions to incorporate and promote participation in HPV vaccination and cervical cancer screening programs as routine activities offered to incarcerated women would be valuable for this population to reduce disparities of access to preventive services in the community.


Human papillomavirus (HPV) genotypes differ by geographic location. With the advent of HPV vaccination and HPV-based cervical screening tests in Ethiopia, a nationwide dataset on the genotype distribution of HPV among women has paramount importance in the fight against cervical cancer. However, there is limited data in this regard in the northwest part of the country. Therefore, this study aimed to identify the genotype distribution of high-risk HPVs among women presenting with cervical abnormalities.A health facility-based cross-sectional study was conducted at Felege Hiwot Comprehensive Specialized Hospital (FHCSH), Bahir Dar–Ethiopia. Women aged ≥ 30 years who visited the hospital gynecology unit from 01 March 2019 to 30 October 2021 were included. Following general and pelvic examinations, a senior gynecologist collected cervical punch biopsies for histopathological examinations and cervical swabs for HR-HPV detection using the Abbott Alinity m system . Extended genotyping was carried out with the INNO-LiPA HPV Genotyping Extra II assay  as per the manufacturer protocols at the Institute of Virology, Leipzig University Hospital, Germany.We included 355 women with a mean age of 46.4 ± 11.4 years. The majority of the participants, 277 (79.4%) were sexually active before the age of 18 years and 180 (51.6%) had multiple sexual partners. Forty-eight (13.5%) of the participants were HIV positive. The proportion of HR-HPV was 53.0% . From these samples, 13 different HR-HPV types with a total of 258 sequences were identified. The detection of HR-HPV increased significantly with an increase in the age of the participants. The predominant identified HR-HPV was HPV16, 50.4% followed by HPV31 (9.7%), HPV33 (8.5%), HPV39, and HPV68 each (5.8%) and HPV18 (4.7%). Of the total HR-HPV-positive women, 23.9% (45/188) were infected with multiple HR-HPV types. All HPV16, HPV18, HPV35, and HPV45 genotypes (as a single or in coinfections) were found to be associated with either high-grade lesions or cervical cancer.HR-HPV infection was reportedly higher among women in the present study area. Based on our findings, we strongly recommend the nonavalent HPV vaccine for immunization and any HPV-based screening method to take into consideration the predominant genotypes circulating in the country. The role of multiple HPV infections in high-grade cervical lesions entails further study in Ethiopia. Cervical cancer is one of the most frequent malignancies worldwide. Almost nine out of ten deaths occur in developing countries, where there is inefficient vaccination and cervical screening . CervicaEpidemiological, clinical, and molecular-based studies confirmed that persistent infection with oncogenic types or high-risk (HR) human papillomaviruses (HPVs) is the main cause of cervical cancer , 5. HR-HCervical cancer is preventable. Early detection of precancerous lesions and vaccinating schoolchildren with optimal coverage could save lives. HPV-based screening is rarely available in Ethiopia. Vaccination was introduced in 2018 using Gardasil-4® recombinant vaccine that targets HPV 6, 11, 16, and HPV18 for 14-year-old girls and according to the 2020 estimation, the first and last dose coverage was 76% and 95%, respectively [HPV types differ by geographical location and the host’s background . The burTherefore, this study was conducted to identify the HR-HPV genotype circulating in northwest Ethiopia among women presenting with various cervical lesions. The finding will be an important input to help guide in the revision of the current national cervical screening and vaccination program as national data and context is important in planning full-pledged cervical cancer prevention services.A hospital-based cross-sectional study was conducted at Felege Hiwot Comprehensive Specialized Hospital (FHCSH) between 01 March 2019 and 30 Oct 2021. The hospital is located in Bahir Dar city, northwest Ethiopia, which is the capital of Amhara National Regional State, positioned about 565 km away from Addis Ababa. The FHCSH, with more than 500 beds, is a tertiary health care facility that provides several types of specialized referral services for more than ten million people of northwest Ethiopia.Cervical specimens were collected from 355 women presented with suggestive signs and symptoms of abnormal cervical lesions including abnormal vaginal discharge, vaginal bleeding, and women complaining of painful sexual intercourse , 33. ParAn interviewer-administered structured questionnaire was used to collect data on the participants’ demographic and gynecologic history. The tool was prepared following previous similar works , 34–39. The molecular detection and characterization of HPVs from cervical lesions were based on the principle that the viral DNA is present in the epithelial layers of the affected tissue and can be detected easily with PCR-based technologies . HR-HPV The steps of the Alinity m HR HPV assay consist of sample preparation, real-time PCR assembly, amplification/detection, and result calculation and reporting. All steps of the assay are performed automatically by the Alinity m system. During sample preparation, 400 µL of cervical swabs were pretreated and lysed with chaotropic reagents, allowing HPD DNA to be captured on magnetic microparticles. The bound purified DNA was then washed and eluted. A lyophilized amplification master mix consisting of DNA polymerase, primers, probes, and dNTPs rehydrated using the eluate and activation reagent. The resultant PCR mixture was then transferred to a reaction vessel, which was subsequently capped and transferred to the amplification and detection unit. Results are reported automatically , 45.Samples (n = 49) that tested positive for HR-HPV A and HR-HPV B with the Abbott Alinity m test were further processed using the INNO-LiPA HPV Genotyping Extra II assay  for identification of the specific genotypes following the manufacturer instructions and as described previously , 47.With regard to the histological examination, after collection, cervical biopsies were placed in screw-capped and labeled bottles that contained 20 ml of 10% formol-saline fixative solution and transported to the hospital pathology laboratory for downstream processing by the senior pathologist as described previously . Lastly,Generated data were entered and analyzed using SPSS V25. Descriptive statistics were used to describe the demographic and clinical characteristics of the study participants. The type distribution of the identified HR-HPVs with a 95% confidence interval (CI) was calculated. The results are presented as simple counts, percentages, and mean with standard deviations.In this study, 355 women were included. At enrolment, the study participants were in the age range of 30–80 years with a mean age of 46.4 ± 11.4 years. The majority of the participants were married 272 (76.6%), housewives 314 (88.5%), were from rural settings 232 (65.9%), and did not have formal education 272 (76.6%) (Table The majority of the participants 277 (79.4%) were sexually active before the age of 18 years. The mean age at first sexual intercourse was 15.7 ± 2.6. Furthermore, 48 (13.5%), 106 (30.0%), and 180 (51.6%) of the participants were HIV positive, had a history of vaginal discharge, and multiple sexual partners, respectively.More than half of the participants 211 (59.4) were unaware of cervical cancer. The participants’ cervical screening practice and screening in the last five years were 97 (27.3%) and 88 (24.8%), respectively. Besides, their knowledge about the disease was very limited and only 11 (8.9%) of them know that the disease is caused by a sexually transmitted pathogen   was 53.0% . From the processed samples, 13 different HR-HPVs with a total of 258 sequences were identified. The detection of HR-HPV increased significantly with an increase in the age of participants. Similarly, HR-HPV detection was different based on the educational status and screening history of the study participants (The predominant identified HR-HPV was HPV16 that accounted for 50.4% (130/258: 95% CI: 29.4–39.2%) followed by HPV31 9.7% (25/258: 95% CI: 6.7–13.9%), HPV33 8.5% (22/258: 95% CI: 5.7–12.6%), HPV39 and HPV68 each 5.8% (15/258: 95% CI: 3.6–9.4%) and HPV18 4.7% (12/258: 95% CI: 2.7–8.0%). The least detected genotype was HPV58 (0.4%). The combined prevalence of HPV 16 and HPV18 was 55.1% (142/258: 95% CI: 48.9–61.0%) , mono-infection was documented in 143 (76.1%) whereas 27 (14.4%) and 18 (9.6%) samples were positive for two and multiple (≥ 3) HR-HPV types, respectively. We noted up to five different HR-HPVs infecting a single patient. The most common HR-HPV coinfection was HPV31 with HPV33 followed by HPV39 with HPV59 and HPV68.Concerning the types of HR-HPVs involved in different histopathological grades, all HPV16, HPV18, HPV35, and HPV45 genotypes (as a single or in coinfections) were found to be associated with either high-grade lesions (CIN2+) or cervical cancer. Likewise, 79 (80.6%), 7 (87.5%), 3 (75%), and 5 (100%) of HPV16, HPV18, HPV35, and HPV45 mono infections were identified in histopathologically confirmed cancer cases, respectively. Similarly, 11 (78.6%) HPV31&33 coinfections were recovered from cancer cases.Specifically, the detection of rate of HPV16 was increased with an increase in the degree of cervical lesions in which the proportion was 12.5% (n = 5), 16.7% (n = 2), 41.7% (n = 5), and 85.3% (n = 58) in Cervical Intraepithelial Neoplasia (CIN) 1, CIN2, CIN3, and cancer cases, respectively. In 9.7% (13/133) of cervical cancer cases, HR-HPVs were not detected . In this regard, previously conducted similar studies in Ethiopia revealed wide-ranging findings. The proportion of HR-HPV among women who visited the gynecology clinics and who were recruited from the general population in different parts of Ethiopia previously ranged from 16 to 100% , 31, 50.. . The HR-. , and Zim. . Variati. , 31, 50p-value < 0.005)  Table . This imIn the present study, the leading identified HR-HPV was HPV16 50.4%). In other similar reported series in Ethiopia, other parts of Africa, and globally at large, HPV16 was the single most common genotype identified in cervical samples. The second, third, fourth, and the rest most commonly reported genotypes were usually different. Specifically, HR-HPV types from cervical samples in Ethiopia were reported to be diverse , 31, 50..4%. In oGlobally, HPV18 is the most frequently detected HR-HPV next to HPV16 from advanced cervical lesions including cancer . The reaThe understanding that persistent infection with certain HR-HPVs is mainly a cause of cervical cancer has resulted in the development of new prospects for cervical screening and vaccination globally. HPV-based testing for cervical screening is becoming a cost-effective approach in most countries around the world . In 2020The current vaccine cocktail used in the country since 2018 for schoolgirls is Gardasil-4® that targets HPV6, 11, 16, and 18. The vaccine does not target other HR-HPVs circulating in the country. In the present study, for example, the combined prevalence of HPV16 and HPV18 was 55.1%, which implies that a significant proportion of girls might not be protected against other types even though they are vaccinated. So far, HPV vaccination is not part of the national immunization program in Ethiopia. One reason may be the cost of the vaccine. A recent study revealed that compared to the Gardasil-4™, a nonavalent Gardasil®9 that targets close to 90% of all HR-HPVs is a profitable option for Ethiopia .. reported up to 14 HPV types from a single cervical specimen although they did not observe type interactions among multiple HPVs [A large proportion of HPV infections are sustained by multiple genotypes . Of the ple HPVs . In the ple HPVs .. showed that multiple HPV infections were found significantly associated with high-grade cervical lesions compared to infections with single HPV types. Furthermore, according to Kim et al. report, patients with multiple HPV infections exhibited a persistent and longer duration of the infection compared to patients with a single HPV infection [There are contradicting reports about the role of multiple HR-HPV infections in cervical carcinogenesis. Adcock and his colleague reported that HPV genotype and viral load, but not a multiplicity of HPV infections are important predictors of high-grade lesions including cervical cancer . In contnfection .. in China also discovered that the prevalence of HPV16 and HPV33 increased significantly with the degree of cervical lesions [Concerning the identified HR-HPVs and histopathologic grades, all HPV16, HPV18, HPV35, and HPV45 were associated with either high-grade lesions (CIN2+) or cervical cancer in the present study. Likewise, 79 (80.6%), 7 (87.5%), 3 (75%), and 5 (100%) of HPV16, HPV18, HPV35, and HPV45 were respectively noted in histopathologically confirmed cervical cancers. Specifically, the detection of HPV16 was increasing with the degree of cervical lesions in which the proportion was 5 (12.5%), 2 (16.7%), 5 (41.7%), and 58 (85.3%) in Cervical intraepithelial neoplasia (CIN)1, CIN2, CIN3, and cancer, respectively. A statistically significant association between HPV16 and the progression of cervical lesions was reported by a previous study . Similar lesions .Finally, according to the latest WHO report (2022), a large proportion of cervical cancer cases (> 95%) are due to infection with HPV . In our This study provided a health facility-based estimate of HR-HPV infection of the uterine cervix and the common genotypes associated with the infection in northwest Ethiopia. More than half of the study participants tested positive for HR-HPV mainly infected with HPV16, HPV31 and HPV33. About 24% of cervical samples were found to be infected with two and more (up to five) multiple HR-HPV types. The HR-HPV proportion was higher among women aged above 50 years and HIV-positive once. Therefore, all forms of cervical cancer prevention strategies including multivalent HPV vaccination and screening should be expanded in the study area. Community-based similar studies with better HPV detection methods should be considered for a better appreciation of the HPVs circulating in northwest Ethiopia.