Development and pilot implementation of a novel protocol to assess capacity and readiness of health systems to adopt HPV detection-based cervical cancer screening in Europe.

BACKGROUND: Cervical cancer remains a significant public health concern in Europe. Effective introduction and scaling up of human papillomavirus (HPV) detection-based cervical cancer screening (CCS) requires a systematic assessment of health systems capacity. However, there is no validated capacity assessment methodology for CCS programmes, especially in European contexts. Addressing this gap, our study introduces an innovative and adaptable protocol for evaluating the capacity of CCS programmes across varying European health system settings. METHODS: Our research team developed a three-step capacity assessment framework, incorporating a health policy review checklist, a facility visit survey, and key informants' interview guide followed by a strengths, weaknesses, opportunities and threats (SWOT) analysis. Piloting this comprehensive approach, we explored the CCS capacity in three countries: Estonia, Portugal and Romania. These countries were selected due to their contrasting healthcare structures and resources, providing a diverse overview of the European context. RESULTS: Conducted over a period of 9 months, the capacity assessment covered multiple resources, 27 screening centres, 16 colposcopy and treatment centres and 15 key informant interviews. Our analysis highlighted both shared and country-specific challenges. A key common issue was ensuring high compliance to follow-up and management of screen-positive women. We identified considerable heterogeneity in resources and organization across the three countries, underscoring the need for tailored, rather than one-size-fits-all, solutions. CONCLUSIONS: Our study's novelty lies in the successful development of this capacity assessment methodology implementable within a relatively short time frame, proving its feasibility for use in various contexts and countries. The resulting set of materials, adaptable to different cancer types, is a ready-to-use toolkit to improve cancer screening processes and outcomes. This research marks a significant stride towards comprehensive capacity assessment for CCS programmes in Europe. Future directions include deploying these tools in other countries and cancer types, thereby contributing to the global fight against cancer.

Factors influencing human papillomavirus vaccination uptake in European women and adolescents: A systematic review and meta-analysis.

OBJECTIVE: Cervical Cancer (CC) lingers as a severe public health issue due to low vaccination coverage and poor screening addressability. Hence, this systematic review explored psychological factors influencing the Human Papilloma Virus (HPV) vaccination uptake in European women. METHODS: As of September 2022, PubMed, EMBASE, Scopus, and Web of Science were systematically searched to include English studies assessing diverse factors influencing vaccination uptake in European women. Only studies comparing vaccinated with unvaccinated women were included. Quality assessment, publication attrition assessment, and sensitivity analyses were performed. RESULTS: Eighteen studies were included, totaling a population of 18,611 participants. Results indicated that knowledge about HPV infection could positively influence vaccination rates with an Odds Ratio (OR) of 1.82 and a confidence interval (CI) between 1.27 and 2.61, showing statistical significance at a Z value of 3.24 with a p-value of 0.001. Neither knowledge about HPV vaccination (OR = 1.39, CI: 0.73-2.65, Z = 1.01, p = 0.31) nor knowledge about CC screening (OR = 1.05, CI: 0.55-1.98, Z = 0,14, p = 0.89) seem to affect vaccination rates. Regardless, intention to undertake CC screening (CCS) showed an OR = 1.68 in favor of the group intending to perform it, with a CI between 1.37 and 2.07, showing statistical significance at a Z = 4.94 and p = 0.00001. Other aspects affecting vaccination uptake were fear of side effects, insufficient information, and belief that chances of being infected are low. CONCLUSIONS: Results demonstrated that diverse aspects could affect the vaccination intent, while personalized interventions focusing on population and country characteristics need to be assembled to mitigate vaccination coverage.

Associations Between ADHD Symptoms and Maternal and Birth Outcomes: An Exploratory Analysis in a Multi-Country Cohort of Expectant Mothers.

OBJECTIVE: ADHD symptoms can adversely impact functioning in a range of domains relevant for maternal well-being and fetal development; however, there has been almost no research examining their impact during pregnancy. We aimed to address this gap. METHOD: We used data (n = 1,204) from a longitudinal birth cohort study spanning eight countries to address this gap. RESULTS: ADHD symptoms in the third trimester of pregnancy were associated with lower social support from family (b = -0.16, p = .031), friends (b = -0.16, p = .024), and significant others (b = -0.09, p = .001); higher stress (b = 0.34, p < .001) and depressive symptoms (b = 0.31, p < .001), and increased likelihood of an unwanted pregnancy (b = 0.30, p = .009). Significant associations with tobacco use (b = 0.36, p = .023) and premature birth (b = 0.35, p = .007) did not survive correction for multiple comparisons and there were no significant associations with alcohol use, low birth weight, or unplanned pregnancy. CONCLUSION: Results suggest that women with ADHD symptoms could benefit from earlier, more regular screening for mental health difficulties and greater mental health support during pregnancy.

Patterns of adverse childhood experiences and associations with prenatal substance use and poor infant outcomes in a multi-country cohort of mothers: a latent class analysis.

BACKGROUND: This paper enumerates and characterizes latent classes of adverse childhood experiences and investigates how they relate to prenatal substance use (i.e., smoking, alcohol, and other drugs) and poor infant outcomes (i.e., infant prematurity and low birthweight) across eight low- and middle-income countries (LMICs). METHODS: A total of 1189 mother-infant dyads from the Evidence for Better Lives Study cohort were recruited. Latent class analysis using the Bolck, Croon, and Hagenaars (BCH) 3-step method with auxiliary multilevel logistic regressions was performed. RESULTS: Three high-risk classes and one low-risk class emerged: (1) highly maltreated (7%, n = 89), (2) emotionally and physically abused with intra-familial violence exposure (13%, n = 152), (3), emotionally abused (40%, n = 474), and (4) low household dysfunction and abuse (40%, n = 474). Pairwise comparisons between classes indicate higher probabilities of prenatal drug use in the highly maltreated and emotionally abused classes compared with the low household dysfunction and abuse class. Additionally, the emotionally and physically abused with intra-familial violence exposure class had higher probability of low birthweight than the three remaining classes. CONCLUSION: Our results highlight the multifaceted nature of ACEs and underline the potential importance of exposure to childhood adversities on behaviors and outcomes in the perinatal period. This can inform the design of antenatal support to better address these challenges.

Mapping psychosocial interventions in familial colorectal cancer: a rapid systematic review.

BACKGROUND: Approximately 5% of colorectal cancer (CRC) cases are part of a well-defined inherited genetic syndrome and up to approximately 30% of these cases have a clinically defined familial basis. Psychosocial interventions in familial colorectal cancer address aspects mainly focused on affective, cognitive and behavioural outcomes. The present review aims to systematically map out the available psychosocial interventions for individuals with a family history of CRC and describe the current state of the research. METHODS: An extensive electronic search was conducted to investigate the literature published until June 2020. Inclusion criteria consisted of quantitative studies published in English that explored the impact of psychosocial interventions for familial CRC, clearly defined the psychosocial intervention offered and included participants with a family history of CRC. RESULTS: The analysis included 52 articles. Genetic counselling, educational interventions, psychological interventions and multimodal interventions were identified across the studies. In terms of diagnoses, Lynch Syndrome, Familial Adenomatous Polyposis, Familial Colorectal Cancer were the main conditions included in the studies. Affective, cognitive, behavioural aspects and quality of life emerged as the most frequently explored outcomes. The studies included individuals with both personal and familial history of CRC or family history alone. CONCLUSIONS: Our rapid review provides an overview of the literature exploring the impact of psychosocial interventions for familial CRC. The psychosocial interventions identified had an overwhelmingly positive impact across all types of outcomes measured. Genetic counselling appeared to be most beneficial, and this is expected as it is purposively designed to address genetic conditions. Further quantitative analysis of primary empirical research is needed to determine the efficacy and effectiveness of psychosocial interventions as well as the mechanisms through which they exert their effect.

Mental Health and Adherence to COVID-19 Protective Behaviors among Cancer Patients during the COVID-19 Pandemic: An International, Multinational Cross-Sectional Study.

A population-based cross-sectional study was conducted during the first COVID-19 wave, to examine the impact of COVID-19 on mental health using an anonymous online survey, enrolling 9565 individuals in 78 countries. The current sub-study examined the impact of the pandemic and the associated lockdown measures on the mental health, and protective behaviors of cancer patients in comparison to non-cancer participants. Furthermore, 264 participants from 30 different countries reported being cancer patients. The median age was 51.5 years, 79.9% were female, and 28% had breast cancer. Cancer participants reported higher self-efficacy to follow recommended national guidelines regarding COVID-19 protective behaviors compared to non-cancer participants (p < 0.01). They were less stressed (p < 0.01), more psychologically flexible (p < 0.01), and had higher levels of positive affect compared to non-cancer participants. Amongst cancer participants, the majority (80.3%) reported COVID-19, not their cancer, as their priority during the first wave of the pandemic and females reported higher levels of stress compared to males. In conclusion, cancer participants appeared to have handled the unpredictable nature of the first wave of the pandemic efficiently, with a positive attitude towards an unknown and otherwise frightening situation. Larger, cancer population specific and longitudinal studies are warranted to ensure adequate medical and psychological care for cancer patients.

Developing genetic counselling services in an underdeveloped healthcare setting.

Genetic counselling services are well established in North America, Western Europe and Australia. In other regions, genetic counselling services are still emerging. Where this is the case, an in-depth understanding of the main stakeholders' needs, challenges and opportunities will inform the changes and innovations required to bring genetic counselling closer to the community. The present study explored the needs and challenges of patients, family members and professionals with a view to setting up a cancer genetic counselling service in Romania. In order to get a comprehensive outlook, key stakeholders were interviewed using data source triangulation method. Thirty-four semi-structured interviews were conducted (13 patients, 11 family members and 10 professionals). Thematic analysis was used to explore and identify needs, barriers and opportunities in emerging cancer genetic counselling services. Three major themes were identified: (1) the "Needs" theme mainly focuses on various types of support that participants mentioned wanting: psychosocial, peer and additional support; (2) the "Challenges" theme includes aspects related to limited access to healthcare, lack of integrated services and pressure on the families; (3) the "Hopes" theme highlights the wish for integrated healthcare and an empathic rapport with healthcare providers. Our findings highlighted the main needs, challenges and hopes the patients, family members and professionals have and provides the groundwork for setting up cancer genetic counselling services.

Screeners vs. Non-screeners for Colorectal Cancer among People over 50 Years of Age: Factual and Psychological Discriminants.

BACKGROUND AND AIMS: Colorectal cancer (CRC) is the third most frequent form of cancer worldwide, and approximately one third of cases have a positive family history of CRC or associated cancers. Colonoscopy is one of the most effective methods of screening for CRC. Uptake of colonoscopy is suboptimal, and many countries lack a national screening programme. Our study aims at exploring and ranking several factual and psychological variables according to their accuracy in discriminating between screeners and non-screeners for CRC in a convenience sample of people over 50 years of age. METHODS: The study included 103 individuals aged over 50 years, recruited from day centres for the elderly. We explored socio-demographic variables, frequency of colonoscopy, previous recommendations for screening, health literacy and family history of cancer. Receiver operating characteristic (ROC) analysis was used to establish the discriminative value for each variable between the positive and negative decision for colonoscopy screening. Areas under the curve (AUC) and their equivalent Cohen's d values were calculated. RESULTS: Almost a quarter (25.75%) of participants reported previous colonoscopy screening. ROC curve analysis shows that colonoscopy uptake is best discriminated by perceived benefits of screening (AUC=0.71, d=0.78, p<0.001), previous recommendations for screening (AUC=0.68, d=0.69, p<0.001) and previous recommendations for preventive measures (AUC=0.67, d=0.64, p<0.001). CONCLUSIONS: Recommendations from healthcare professionals lead to improved colonoscopy uptake when emphasising the benefits of screening. Results can further inform psychosocial interventions by bringing empirical evidence to emphasize screening benefits and explicit recommendations for individuals at risk for CRC cancer.

The power of anticipated regret: Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians.

BACKGROUND: Understanding lay perceptions concerning vaccination and identifying the most important psychological determinants of vaccine acceptability are relevant for health promotion campaigns. METHODS: This cross-sectional study aimed to identify the psychological determinants of HPV vaccine and seasonal flu vaccine acceptability in a national sample of young adults. An extended version of the health belief model (HBM) provided the main theoretical framework. Four hundred and one adults aged 18-26 (79% women), completed the theory-based survey and were included in analyses. The main outcomes were intentions to vaccinate against HPV and the seasonal flu. Descriptive statistics, bivariate correlations and hierarchical multiple regression were used for data analysis. RESULTS: The models predicted 51% and 60% of the variability in intentions to vaccinate against HPV and the seasonal flu, respectively. For both decisional contexts, anticipated inaction regret (assuming one were unvaccinated and later contracted infection) was the strongest predictor of intentions, contributing above and beyond the role of traditional risk belief constructs (HBM constructs). Other shared predictors of intentions were perceived effectiveness of vaccine, perceived vaccine safety, perceived susceptibility to disease and previous vaccine refusal. The study also provides insights into young adults' vaccine-related knowledge and their information-seeking practices. CONCLUSION: Findings outline directions for future research and implications for health communication campaigns.

"Taking responsibility for my health": Health system barriers and women's attitudes toward cervical cancer screening in Romania and Bulgaria.

The study used mixed-methods to illustrate the complexity of the interplay between the contexts in Bulgaria and Romania and women's attitudes and behaviors related to screening. A secondary analysis of quantitative data from Romanian (n = 1053) and Bulgarian (n = 1099) women and qualitative interviews (n = 30 Romanian, n = 35 Bulgarian) was performed. Low rates of screening attendance were found in both countries. Regression analysis illustrates that attitudes and social norms significantly predicted intentions and screening behavior in both countries. Thematic analysis revealed that systemic barriers and cultural meanings were relevant to women's decisions to attend screening or avoid contact with the health-care system.

Medical students' perception on fecal microbiota transplantation.

BACKGROUND: Fecal microbiota transplantation (FMT) has become an emergent method in the therapy of several intestinal diseases, mainly in Clostridium difficile recurrence. The training of FMT in medical schools is at its beginning and in countries where FMT is only occasionally carried out, it is important to know the perception of medical students on FMT. METHODS: We undertook a survey of 3rd year medical students not exposed to official academic information on FMT in order to find out their knowledge, beliefs and attitude toward FMT. A number of 80 students were asked to fill a dedicated online questionnaire. RESULTS: 52 out of 80 third year medical students anonymously filled the questionnaire (65% response rate). 34% of respondents reported to have at least a medium level of knowledge regarding FMT. The top indication for FMT identified by 76.9% was C. difficile infection; however, 60% believed FMT to be a promising therapy for a high number of conditions and while almost all respondents (98.1%) would recommend it, 88.4% would explore other options first. Colonoscopy was considered the optimal method of delivery by 42.3%. Only 39% of participants believed that patients would accept FMT, however 71% considered that a more socially acceptable name for the procedure and anonymous donors would increase acceptance rate. The risk of transmitting a disease undetected by donor stool screening procedures to the recipient was the most worrying side effect considered by 75% of respondents. 54% believed that more research is required for FMT to enter clinical practice and 55.7% of respondents would enroll patients in controlled clinical trials. CONCLUSIONS: Medical students not exposed to educational information on FMT seem to be somewhat well informed about this method and would recommend it to their patients. Students, however, need to know more on the indications of FMT.

Adverse childhood experiences, childhood relationships and associated substance use and mental health in young Europeans.

BACKGROUND: Adverse childhood experiences (ACEs) can increase risks of health-harming behaviours and poor health throughout life. While increases in risk may be affected by resilience resources such as supportive childhood relationships, to date few studies have explored these effects. METHODS: We combined data from cross-sectional ACE studies among young adults (n = 14 661) in educational institutions in 10 European countries. Nine ACE types, childhood relationships and six health outcomes (early alcohol initiation, problem alcohol use, smoking, drug use, therapy, suicide attempt) were explored. Multivariate modelling estimated relationships between ACE counts, supportive childhood relationships and health outcomes. RESULTS: Almost half (46.2%) of participants reported ≥1 ACE and 5.6% reported ≥4 ACEs. Risks of all outcomes increased with ACE count. In individuals with ≥4 ACEs (vs. 0 ACEs), adjusted odds ratios ranged from 2.01 (95% CIs: 1.70-2.38) for smoking to 17.68 (95% CIs: 12.93-24.17) for suicide attempt. Supportive childhood relationships were independently associated with moderating risks of smoking, problem alcohol use, therapy and suicide attempt. In those with ≥4 ACEs, adjusted proportions reporting suicide attempt reduced from 23% with low supportive childhood relationships to 13% with higher support. Equivalent reductions were 25% to 20% for therapy, 23% to 17% for problem drinking and 34% to 32% for smoking. CONCLUSIONS: ACEs are strongly associated with substance use and mental illness. Harmful relationships are moderated by resilience factors such as supportive childhood relationships. Whilst ACEs continue to affect many children, better prevention measures and interventions that enhance resilience to the life-long impacts of toxic childhood stress are required.

Psychological stress and breast cancer incidence: a systematic review.

OBJECTIVE: Breast cancer is the world's leading cause of cancer mortality in women. Stress is an imminent risk factor with a documented negative impact on neuro-endocrine and immune system. Numerous epidemiological studies have investigated the link between stress and cancer, reporting contradictory results from no association to a close causal link. The impact of the topic and the lack of conclusion compelled this systematic review. METHODS: A systematic review was carried out, including all literature studies from 1966 to 2016, investigating the relationship between stress and the occurrence of breast cancer. Of the 1813 articles identified in the PubMed/Medline database, 52 were eligible and included in the analysis. RESULTS: A number of 17 retrospective, 20 limited prospective and 15 prospective studies were analyzed. The number of patients exceeded 29,000, for a total number of more than 700.000 women recruited from hospital, screening cohorts or population registers. We identified 26 positive articles linking personal traits, stressful events and breast cancer, 18 negative articles that did not confirm their hypothesis and 8 articles that could not be classified. Facing heterogeneity, all possible misguiding factors such as: study design, information gathering, stress type, moment of exposure, individual susceptibility and personality, were discussed independently. CONCLUSIONS: Qualitative analysis of articles has revealed a possible association between stress and cancer, especially regarding stressful life events. In the absence of a meta-analysis and taking into account the methodological heterogeneity of the studies, the results are difficult to interpret and the role of chance is difficult to exclude.

A couples-focused intervention for smoking cessation during pregnancy: The study protocol of the Quit Together pilot randomized controlled trial.

Tobacco smoking remains the leading global cause of preventable disease and death. Preconception and pregnancy smoking are high in Central and Eastern Europe. Quit Together is a partnership between a US university and a Romanian university, obstetrics and gynecology clinics in Romania, and other community partners in Romania. The objective of the Quit Together pilot study is to adapt, enhance and test the implementation feasibility and initial efficacy of an evidence-based pregnancy and postnatal couple intervention for smoking cessation in Romania. Quit Together builds on the Motivation and Problem Solving (MAPS) approach, enhanced by targeting the couples' smoking behavior and focusing on dyadic efficacy for smoking cessation. The study is an ongoing randomized controlled trial of 120 Romanian pregnant smokers and their partners. Participants are randomized to: 1) an intervention arm consisting, typically, of up to 8 prenatal and postnatal telephone counseling calls for the women and 4 for their partners, combining motivational strategies and problem-solving/coping skills to encourage the woman to quit smoking and the partner to support her decision; and 2) a control arm (usual care). The primary outcome is maternal biochemically verified smoking abstinence at 3 months postpartum. Quit Together has the potential to identify effective strategies to increase maternal smoking cessation during pregnancy and smoking abstinence after birth. If effective, Quit Together is expected to have a sustainable positive impact on the health of the child, mother and partner, and potentially reduced health system costs.

Psychological factors and psychosocial interventions for cancer related pain.

The present paper is aimed at briefly presenting psychological factors involved in cancer related pain and what psychosocial interventions are efficient in reducing it. Cancer related pain is a complex experience and the most integrative and recommended approach is the biopsychosocial model. It has been proved that chronic pain is more strongly related to psychological factors than to treatment or illness related factors. Psychological factors influencing pain experience can be intuitively grouped starting with awareness of pain (i.e., attentional factor), then with evaluation of pain (i.e., cognitive factors) which is leading to feelings (i.e., emotional factors), and behaviours (i.e., coping strategies) regarding pain. Psychosocial interventions (i.e., skill based and education based interventions) have strong evidence that is effective in reducing cancer related pain.

Burnout and health behaviors in health professionals from seven European countries.

OBJECTIVES: Within an underlying health-impairing process, work stressors exhaust employees' mental and physical resources and lead to exhaustion/burnout and to health problems, with health-impairing behaviors being one of the potential mechanisms, linking burnout to ill health. The study aims to explore the associations between burnout and fast food consumption, exercise, alcohol consumption and painkiller use in a multinational sample of 2623 doctors, nurses and residents from Greece, Portugal, Bulgaria, Romania, Turkey, Croatia and Macedonia, adopting a cross-national approach. METHODS: Data are part of the international cross-sectional quantitative ORCAB survey. The measures included the Maslach Burnout Inventory and the Health Behaviors Questionnaire. RESULTS: Burnout was significantly positively associated with higher fast food consumption, infrequent exercise, higher alcohol consumption and more frequent painkiller use in the full sample, and these associations remained significant after the inclusion of individual differences factors and country of residence. Cross-national comparisons showed significant differences in burnout and health behaviors, and some differences in the statistical significance and magnitude (but not the direction) of the associations between them. Health professionals from Turkey, Greece and Bulgaria reported the most unfavorable experiences. CONCLUSIONS: Burnout and risk health behaviors among health professionals are important both in the context of health professionals' health and well-being and as factors contributing to medical errors and inadequate patient safety. Organizational interventions should incorporate early identification of such behaviors together with programs promoting health and aimed at the reduction of burnout and work-related stress.

Mass media coverage of HPV vaccination in Romania: a content analysis.

Romania has the highest cervical cancer burden in Europe. Despite the implementation of two human papillomavirus (HPV) vaccination programmes, the uptake remained extremely low and the programmes were discontinued. Given that media are a common source of information for the public and may influence vaccination decisions, this article sought to explore the content and quality of HPV vaccine media coverage in Romania. We conducted a content analysis of 271 media reports (from newspapers, magazines, videos and informational websites) published online between November 2007 and January 2012. Overall, results indicated that 31.4% of the materials were neutral, 28% were negative or extremely negative, 17% were mixed, while 23.6% were positive towards the vaccine. The most dominant vaccine-related concerns were side effects and insufficient testing. Elementary information about the vaccine and HPV was constantly left out and sometimes inaccuracies were found. Negatively disposed reports were more likely to contain incorrect data about vaccine efficacy and less likely to provide comprehensive information about the vaccine and HPV-related diseases. Some dimensions of media coverage varied across time and media outlets. The present findings suggest that educational interventions are greatly needed as a response to suboptimal and incomplete media coverage of HPV vaccination.

The impact of a rural or urban context in eating awareness and self-regulation strategies in children and adolescents from eight European countries.

Complex relationships exist between eating behaviour and personal and environmental factors. Rural and urban geographic contexts seem to play a role in eating behaviour, and therefore deserve a deeper study. A healthy eating behaviour and the conditions that promote it are a major issue in the promotion of adolescent health. The study aims to investigate the associations between the area of residence (urban vs. rural), self-regulation strategies (TESQ-E) and eating behaviours among children and adolescents. A total of 11,820 adolescents (50.6% girls) participated in the study, with a mean age of 13.30 years (SD= 2.13). Nine countries (The Netherlands, United Kingdom, Poland, Portugal, Denmark, Romania, Germany, Finland and Belgium) completed a questionnaire in the school context, asking about the use of self-regulation strategies, eating behaviour awareness/care and sociodemographic questions such as age, gender and residential area. Both areas of residence (urban vs. rural) are associated with eating awareness/care in Romania and Portugal, controlling for age, gender and self-regulation strategies. In some European countries at least, and most probably around the world, health promotion should focus on an ecological approach that includes the understanding of the effect of both environmental factors and personal skills on eating behaviour/awareness.

Dangerous agent or saviour? HPV vaccine representations on online discussion forums in Romania.

PURPOSE: Whereas Romanian health officials have launched two national human papillomavirus (HPV) vaccination campaigns, the uptake rate remained insignificant. Understanding local perceptions of the vaccine is necessary, as they could inform future educational programmes. Given that social media provide new opportunities to communicate about vaccination, this paper sought to explore the public's constructions of the HPV vaccine as they were expressed on Internet discussion forums. METHODS: Twenty discussion forums, with a total sample size of 2,240 comments (2007-2012), were included. We conducted a thematic analysis with a focus on language, informed by a discourse analytic approach. RESULTS: Positive discourses relying on evidence-based arguments or cancer-related experiences battled with negative discourses that focused mostly on pseudo-scientific information and affect-based testimonials. Both camps made use of appeals to authority in order to provide powerful messages. Critics expressed high levels of mistrust in the health system and perceived the vaccine as dangerous, as part of a conspiracy, as unnecessary or as a promoter of promiscuity. By contrast, supporters considered the HPV vaccine to be helpful and criticized the irrationality of opponents. Ambivalence and uncertainty also emerged, along with criticism toward the suboptimal organization of the vaccination programmes. Findings highlight ways in which views about the vaccine are embedded in broader perspectives about science, the national medical system, society development and economic inequality. CONCLUSION: Online posts are likely to elicit fear and doubts around vaccination, which in turn may impair decisions. Findings indicate that targeted education campaigns are needed in order to address public concerns about vaccination.

"Who will take the blame?": understanding the reasons why Romanian mothers decline HPV vaccination for their daughters.

Because Romania has the highest incidence of cervical cancer in Europe, in 2008 a HPV vaccination campaign was introduced targeting 10-11 year old girls. However, only 2.5% of the eligible girls were given parental for vaccination. Campaign failure makes it important to look for possible reasons and investigate mothers' attitudes and perceptions of the HPV vaccine. Three focus groups and 11 interviews were conducted with mothers from urban areas. Data were transcribed verbatim and analysed with thematic analysis. Results show as main reasons for not vaccinating their daughters perceiving the vaccine as risky, the belief that the vaccine represents an experiment that uses their daughters as guinea pigs, the belief that the vaccine embodies a conspiracy theory that aims to reduce the world's population and general mistrust in the ineffective health system. Mothers stated they would need clear, factual information about the HPV vaccine and its link to cervical cancer in order to motivate them to accept it for their daughters. The study offers insight into the beliefs and attitudes towards the vaccine and provides ideas for structuring future health communication campaigns regarding the HPV vaccine.