Can high overall human papillomavirus vaccination coverage hide sociodemographic inequalities? An ecological analysis in Canada

Exploring vaccination attitudes in African communities in Canada: A mixed-methods study protocol

INTRODUCTION

Vaccine hesitancy is a complex issue influenced by many interacting factors. While literature on its contributing causes continues to expand, there is limited research on the contextual and cultural dynamics that shape vaccine hesitancy among African-born individuals in Canada. Identifying and understanding these factors is critical in developing targeted health interventions that address specific barriers to vaccination within this community. The study aims to explore the unique socio-cultural and context-specific elements of vaccine hesitancy among African community members living in Canada.

METHODS AND ANALYSIS

The study will use a mixed-methods approach to investigate vaccine hesitancy among African community members living in Southwestern Ontario. In the qualitative study, we will conduct semi-structured interviews and participatory focus groups within each of the selected study areas: London, Windsor and Chatham-Kent. The qualitative data will be collected, transcribed and then analyzed thematically using NVivo 12. For the quantitative study, we will provide participants with surveys to accurately assess the predictors of vaccine hesitancy. The quantitative data will be analyzed using logistic regression to explore how socio-cultural influences, trust, and accessible information impact vaccine hesitancy.

DISCUSSION

This study addresses a significant gap in existing literature by providing cultural and contextual insights on the drivers of vaccine hesitancy among African-born individuals. Using a mix-method design, the study offers a rich understanding of the influences shaping vaccine decision-making. The findings will support the development of health policies and interventions aimed at improving overall health outcomes for African communities within Canada.

Applying a Participatory Action Research Approach to Engage an Australian Culturally and Linguistically Diverse Community around Human Papillomavirus Vaccination: Lessons Learned

Globally, migrant and culturally and linguistically diverse (CALD) communities are known to have inequitable access to HPV vaccination. One participatory research approach used to engage CALD communities around vaccination is participatory action research (PAR), but we know little about the use of PAR to engage priority migrant and CALD communities around school and HPV vaccination. To address this gap, we partnered with our local Multicultural Health Service to understand how the largest CALD group in our region of New South Wales, Australia, engages with their local school and HPV vaccination program. Through a long-standing PAR relationship, we used a participatory research method (World Café) approach to explore the level of awareness and engagement a multi-generational community member had concerning HPV vaccination. We acted by sharing a co-designed information website to answer the community's questions about HPV vaccination. We then evaluated these engagements with surveys, focus groups and online analytic platforms. Last, we reflected with project partners and health service stakeholders on the overall project outcomes and shared our learnings. In our discussion, we shared our lessons learned and contributed to a wider conversation about the benefits, challenges, and practicalities of using PAR to engage a priority CALD community around HPV vaccination.

Individual and Geospatial Determinants of Health Associated With School-Based Human Papillomavirus Immunization in Alberta: Population-Based Cohort Study

BACKGROUND

Human papillomavirus (HPV) infection causes nearly all cervical cancer cases and is a cause of anogenital and oropharyngeal cancers. The incidence of HPV-associated cancers is inequitable, with an increased burden on marginalized groups in high-income countries. Understanding how immunization status varies by material and social deprivation, health system, and geospatial factors is valuable for prioritizing and planning HPV immunization interventions.

OBJECTIVE

The objective of this study was to describe school-based HPV immunization rates by individual and geospatial determinants of health in Alberta, Canada.

METHODS

Health administrative data for male and female individuals born in 2004 in Alberta were used to determine HPV immunization status based on age and the number of doses administered in schools during the 2014/2015-2018/2019 school years. Immunization status and its relationship with material and social deprivation and health system factors were assessed by a logistic regression model. Geospatial clustering was assessed using Getis-Ord Gi* hot spot analysis. Mean scores of material and social deprivation and health system factors were compared between hot and cold spots without full HPV immunization using independent samples t tests. A multidisciplinary team comprising researchers and knowledge users formed a co-design team to design the study protocol and review the study results.

RESULTS

The cohort consisted of 45,207 youths. In the adjusted model, the odds of those who did not see their general practitioner (GP) within 3 years before turning 10 years old and not being fully immunized were 1.965 times higher (95% CI 1.855-2.080) than those who did see their GP. The odds of health system users with health conditions and health system nonusers not being fully immunized were 1.092 (95% CI 1.006-1.185) and 1.831 (95% CI 1.678-1.998) times higher, respectively, than health system users without health conditions. The odds of those who lived in areas with the most material and social deprivation not being fully immunized were 1.287 (95% CI 1.200-1.381) and 1.099 (95% CI 1.029-1.174) times higher, respectively, than those who lived in areas with the least deprivation. The odds of those who lived in rural areas not being fully immunized were 1.428 times higher (95% CI 1.359-1.501) than those who lived in urban areas. Significant hot spot clusters of individuals without full HPV immunization exist in rural locations on the northern and eastern regions of Alberta. Hot spots had significantly worse mean material deprivation scores (P=.008) and fewer GP visits (P=.001) than cold spots.

CONCLUSIONS

Findings suggest that material and social deprivation, health system access, and rural residency impact HPV immunization. Such factors should be considered by public health professionals in other jurisdictions and will be used by the Alberta co-design team when tailoring programs to increase HPV vaccine uptake in priority populations and regions.

Barriers to and facilitators of human papillomavirus vaccination in an ethnically diverse group of migrant parents: A qualitative mixed methods study

A disparity in the uptake of the Human papillomavirus vaccine (HPVV) among immigrants and refugees leads to a social gradient in health. Recognizing that immigrants and refugees may encounter unique barriers to accessing prevention and care, this study seeks to determine barriers to and facilitators of HPVV among these subgroups to uncover high-resolution quality improvement targets of investment for under-immunized pockets of the population. The study undertook a qualitative inquiry into understanding immigrant and refugee parents' perspectives on HPV infection and HPVV experience through school-based programs. We collected data first through short online surveys (N = 15) followed by one-on-one interviews (N = 15) and then through detailed online surveys (N = 16) followed by focus group discussions (N = 3) with 4-6 participants per group discussion from different groups: Black, South Asian and West Asian. Analysis of surveys and interviews identified that: information, awareness, and education about HPV infection and HPVV were among the most cited barriers that impede the uptake of HPVV. Moreover, vaccine-related logistics were equally important, including not having immunization information packages in different languages and relying solely on the child to bring home packages in paper copies from school-based vaccine programs. A multi-component intervention remains instrumental in enhancing HPV immunization rates, given the inconsistent uptake of HPVV by these subgroups who voice unique barriers and facilitators. An educational campaign that involves educating parents who consent for their child(ren) for HPVV, the children receiving the vaccination, and training staff providing HPVV through school-based immunization programs would be paramount.

Obscured inequity: How focusing on rates of disparities can conceal inequities in the reasons why adolescents are unvaccinated

Traditional sociodemographic disparities in adolescent vaccination initiation for the HPV, Tdap, and MenACWY vaccines have declined in the United States of America. This decline raises the question of whether inequities in access have been successfully addressed. This paper synthesizes research on the resource barriers that inhibit vaccination alongside research on vaccine hesitancy where parents actively refuse vaccination. To do so, I classify the primary reason why teens are unvaccinated in the National Immunization Survey-Teen 2012-2022 into three categories: resource failure, agentic refusal, and other reasons. I use three non-exclusive subsamples of teens who are unvaccinated against the HPV (N = 87,163), MenACWY (N = 54,726), and Tdap (N = 10,947) vaccines to examine the relative importance of resource failure reasons and agentic refusal reasons for non-vaccination across time and teens' sociodemographic characteristics. Results indicate that resource failure reasons continue to explain a substantial portion of the reasons why teens are unvaccinated and disproportionately affect racially/ethnically and economically marginalized teens. Thus, even as sociodemographic inequalities in rates of vaccination have declined, inequities in access remain consequential.

Using World Cafés to engage an Australian culturally and linguistically diverse community around human papillomavirus vaccination

INTRODUCTION

Internationally, cultural factors are associated with vaccine uptake and completion in ethnic minority communities. Whilst Australia has achieved high human papillomavirus (HPV) vaccination, little is known about how culture or ethnicity influences HPV vaccination engagement. To address these gaps, we partnered with our Local Health District to explore how one culturally and linguistically diverse (CALD) community engages with school and HPV vaccination.

METHODS

We adapted a participatory research method (the World Café) to engage one local CALD community-the Macedonian community (Our bi-cultural researcher and participants preferred the term 'Macedonia' rather than The Republic of North Macedonia as outlined in the 2018 Prespa agreement) in New South Wales (Australia)-to discuss HPV and school vaccination. Our qualitative analysis combined deductive codes taken from the Tailoring Immunization Programme framework, inductive codes guided by narrative inquiry (temporality, sociality and place) and previously known vaccination 'trust' frameworks.

RESULTS

In late 2019, 31 local Macedonian community members were purposely recruited for two World Cafés (n = 15 mothers/grandmothers and n = 16 young adults). Our themes reveal a community narrative grounded in historical vaccine experiences, family views on vaccination and a general trust in schools. Participants collectively discussed how 'increasing knowledge' and 'tailoring health communications' could strengthen community vaccine decision-making.

CONCLUSION

This study demonstrates how research partnerships and participatory methods can be applied in CALD community settings to research engagement with school and HPV vaccination. Our World Café dialogues highlight a positive narrative about vaccines, where community vaccination behaviours were built on multilayer trust relationships despite low vaccine knowledge. Our findings further knowledge around 'public trust' in school vaccination, highlighting the importance of existing (or missing) trust relationships when tailoring vaccine communication to local CALD communities.

PATIENT OR PUBLIC CONTRIBUTION

Participants who took part in the World Cafes were all local Macedonian community parents or young adults who have been or will be exposed to the health services offered by school-based HPV vaccination. Thus, all the data collected came from their personal experiences with the school vaccination programme, or how they expect to participate in the programme. To ensure our study design was culturally appropriate and tailored to the Macedonian community, we engaged with the relevant local health stakeholders (the bi-cultural Multicultural Health Officer and Multicultural Health Service Manager Programme Director) to adapt and refine the World Café method for this context and setting. Our local health stakeholders also reviewed our preliminary findings, assisted with data interpretation and participated in manuscript editing.

COVID-19 Vaccine Uptake in Southeastern Ontario, Canada: Monitoring and Addressing Health Inequities

CONTEXT

Implementation of a population-based COVID-19 vaccine strategy, with a tailored approach to reduce inequities in 2-dose coverage, by a mid-sized local public health agency in southeastern Ontario, Canada.

PROGRAM

Coverage maps and crude and age-standardized coverage rates by material and social deprivation, urban/rural status, and sex were calculated biweekly and reviewed by local public health planners. In collaboration with community partners, the results guided targeted strategies to enhance uptake for marginalized populations.

EVALUATION

The largest gaps in vaccine coverage were for those living in more materially deprived areas and rural residents-coverage was lower by 10.9% (95% confidence interval: -11.8 to -10.0) and 9.3% (95% confidence interval: -10.4 to -8.1) for these groups compared with living in less deprived areas and urban residents, respectively. The gaps for all health equity indicators decreased statistically significantly over time. Targeted strategies included expanding clinic operating hours and availability of walk-in appointments, mobile clinics targeted to marginalized populations, leveraging primary care partners to provide pop-up clinics in rural and materially and socially deprived areas, and collaborating with multiple partners to coordinate communication efforts, especially in rural areas.

DISCUSSION

The scale and scope of monitoring and improving local vaccine uptake are unprecedented. Regular review of health equity indicators provided critical situational awareness for decision makers, allowing partners to align and tailor strategies locally and in collaboration with one another. Health care providers and pharmacies/pharmacists are key partners who require innovative support to increase uptake in marginalized groups. Continued engagement of other community partners such as schools, municipalities, and local service groups is also crucial. A "hyper local" approach is needed along with commitment from partners in all sectors and at all levels to reduce barriers to vaccination that lie further upstream for marginalized groups.

Tasas de cobertura vacunal contra el virus del papiloma humano en adolescentes andaluzas y su relación con el riesgo social y la estrategia vacunal

Objetivo: conocer las tasas de vacunación contra el virus del papiloma humano (VPH) y su relación con la estrategia vacunal y la pertenencia a zonas necesitadas de transformación social (ZNTS). Diseño: estudio descriptivo, auditoría de historias clínicas. Emplazamiento: cuatro centros de salud urbanos (2015-2018). Participantes: adolescentes susceptibles de vacunación contra el VPH. Mediciones principales: tasas vacunales de acceso, cobertura y deserción. Resultados: 366 adolescentes (12-16 años). Tasas: acceso 85,5%; cobertura 77,6%; deserción 9,3%. A mayor edad, mejores tasas de acceso (odds ratio [OR]: 6,1) y cobertura (OR: 1,4). La vacunación en el centro de salud se relaciona con una mejor tasa de cobertura (OR: 12,7), pero aumenta significativamente la tasa de deserción (OR: 75,6). Vivir en ZNTS disminuye la tasa de deserción (OR: 0,6). Conclusiones: la vacunación en centros de salud mejora la tasa de cobertura, pero con mayor riesgo de no completar la vacunación. La tasa de deserción es menor en ZNTS. Palabras clave: vacunas contra papilomavirus, cobertura de vacunación, áreas de pobreza.

HPV sampling options for cervical cancer screening: preferences of urban-dwelling Canadians in a changing paradigm

Introduction

Of women in Canada diagnosed with invasive cervical cancer, 50% have not been screened according to guidelines. Interventions involving self-collected samples for human papillomavirus (hpv) screening could be an avenue to increase uptake. To guide the development of cervical cancer screening interventions, we assessed ■ preferred sample collection options,■ sampling preferences according to previous screening behaviours, and■ preference for self-sampling among women not screened according to guidelines, as a function of their reasons for not being screened.

Methods

Data were collected in an online survey (Montreal, Quebec; 2016) and included information from female participants between the ages of 21 and 65 years who had not undergone hysterectomy and who had provided answers to survey questions about screening history, screening interval, and screening preferences (n = 526, weighted n = 574,392).

Results

In weighted analyses, 68% of all women surveyed and 82% of women not recently screened preferred screening by self-sampling. Among women born outside of Canada, the United States, or Europe, preference ranged from 47% to 60%. Nearly all women (95%-100%) who reported fear or embarrassment, dislike of undergoing a Pap test, or lack of time or geography-related availability of screening as one of their reasons for not being screened stated a preference for undergoing screening by self-sampling.

Conclusions

The results demonstrate a strong preference for self-sampling among never-screened and not-recently-screened women, and provides initial evidence for policymakers and researchers to address how best to integrate self-sampling hpv screening into both organized and opportunistic screening contexts.

Challenges and opportunities of school-based HPV vaccination in Canada

Primary prevention of human papillomavirus (HPV) through vaccination is a high priority in Canada's cancer prevention efforts. All Canadian provinces and territories have introduced publicly funded, school-based vaccination programs against HPV, but vaccine uptake remains suboptimal in some jurisdictions. We conducted a descriptive qualitative study to better understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance using the socio-ecological model. In Quebec, interviews and focus groups were held in 2015-2016 with 70 key informants including immunization managers, school nurses, school principals, teachers and parents of Grade 4 students (9 years of age). Our findings showed that HPV vaccine uptake was dependent on many interrelated factors at the individual and interpersonal level (e.g. knowledge and attitudes of the different players involved in the vaccination system), at the community level (e.g. social group values and norms, media coverage around the HPV vaccine), at the organizational level (e.g. allocated resources, information provision, consent process, immunization setting and environment) and at the policy level (e.g. changes in provincial HPV vaccine program). We are using the data collection and interpretation tools and approaches developed by our team and used in Quebec to expand our study to four other provinces (British Columbia, Alberta, Ontario and Nova Scotia). We are conducting environmental scans, semi-structured interviews and a survey to better understand the determinants of low HPV vaccine uptake and identify strategies to enhance vaccine acceptance. Having an in-depth understanding of the determinants of HPV vaccination in school settings is critical in order to identify root causes of the suboptimal vaccine uptake and to develop tailored interventions to address these on both supply- and demand-side issues.

Cervical cancer screening in Montreal: Building evidence to support primary care and policy interventions

In Canada, over 40% of invasive cervical cancers occur among women who have never been screened. Although 12% of Canadian women have never been screened, this number can be as high as 43% among certain social groups. Little is published on factors associated with screening uptake and inequalities among women residing in Quebec. Four waves of the Canadian Community Health Survey (2003, 2005, 2008, 2012, N = 6393) were utilized to assess lifetime screening and screening in the previous 3 years among women residing in Montreal. Chi-squared statistics were calculated, Poisson regression was utilized to model prevalence ratios, and prevalence differences were calculated. In total, 13.6% of women had never been screened and 12.1% had not been screened in the previous 3 years. Immigrant status was the strongest predictor of never being screened [recent vs non-immigrant: Prevalence Ratio (PR), 3.9 (95% Confidence Interval (CI): 2.9-5.4)] and not having a primary care physician (PCP) was the strongest predictors of not being screened recently [PR = 3.0 (95% CI: 2.3-3.9)]. The two most common reasons for not being screened were not "know[ing] it was necessary" and not "get[ting] around to it." These results provide a description of sub-populations which might benefit from cervical screening interventions: immigrants and women without a PCP. Interventions targeting access to PCPs, expanding training of non-physicians to conduct screening, organized screening, or autoadministered screening test may mitigate inequalities. Future work should assess their acceptability and feasibility, and evaluate the impact of these types of primary care and policy interventions.

Human papillomavirus vaccination coverage in Luxembourg - Implications of lowering and restricting target age groups

BACKGROUND

In Luxembourg, a national Human Papillomavirus (HPV) vaccination programme was introduced in 2008, targeting 12-17 year old girls offering a choice of bivalent or quadrivalent vaccine free of charge. In 2015, the programme was changed offering the bivalent vaccine only to 11-13 year old girls. The aim of this study was to evaluate the HPV vaccination coverage, to assess the impact of age target changes and compare vaccination coverage to other European countries.

METHODS

Anonymous HPV vaccination records consisting of individual vaccine doses obtained free of charge in pharmacies between 2008 and 2016 were extracted from the Luxembourgish Social Security database. Additional aggregate tables by nationality and municipality were analysed.

RESULTS

Of the target cohort of 39,610 girls born between 1991 and 2003 residing in Luxembourg, 24,550 (62.0%) subjects obtained at least one dose, 22,082 (55.7%) obtained at least two doses, and 17,197 (43.4%) obtained three doses of HPV vaccine. The mean age at first dose was 13.7 years during 2008-14 and 12.7 years in 2016 after the age target change. Coverage varied significantly by nationality (p < 0.0001): Portuguese (80%), former Yugoslavs (74%), Luxembourgish (54%), Belgian (52%), German (47%), French (39%) and other nationalities (51%). Coverage varied also by geographical region, with lower rates (<50%) noted in some Northern and Central areas of Luxembourg (range: 38% to 78%).

CONCLUSION

Overall HPV vaccination coverage in Luxembourg is moderate and varied by nationality and region. The policy changes in 2015 did not have a substantial impact except lowering age at initiating vaccination. Options to improve coverage deserve further investigation.

Association between mothers' screening uptake and daughters' HPV vaccination: a quasi-experimental study on the effect of an active invitation campaign

OBJECTIVES

In Emilia-Romagna, the Human Papillomavirus (HPV) vaccination campaign started in 2008 offering free vaccines for 1996 and 1997 cohorts. Systematic active invitation was implemented for the 1997 cohort. Our study aimed at measuring the impact of the active invitation campaign on HPV vaccine coverage and on coverage inequalities in 11-year-old girls. Second, we evaluated the effect of the HPV vaccination campaign on participation in cervical cancer screening by mothers of target girls.

METHODS

We collected information on vaccination status for girls residing in Reggio Emilia in 2008 and mothers' screening history, before and after the 2008 vaccination campaign. Log-binomial regression models were performed to estimate Relative Risk (RR) and 95% confidence intervals (CIs) of being vaccinated as regarded citizenship, siblings, mothers' education, marital status and screening history, stratified by birth cohort. We also calculated RR of receiving a Pap test after the vaccination campaign as regarded education, daughter's cohort and mothers' decision to have their daughter vaccinated. Interaction between education and cohort in mothers overdue for Pap testing was calculated.

RESULTS

Vaccination coverage was 46.3% for the uninvited cohort (1046/2260) and 77.9% for the invited cohort (1798/2307). In the uninvited cohort, daughters' vaccination showed association with mothers' education (8 to 11 years of education vs. graduated mothers, RR 1.61 95% CI 1.14-2.28), citizenship (foreigners vs. Italians, RR 0.45 95% CI 0.37-0.56) and screening history (regular vs. non-participant; RR 1.72 95% CI 1.26-2.36). In the invited cohort, only a slight association with screening history persisted (regular vs. non-participant; RR 1.20 95% CI 1.04-1.40). Highly educated under-screened mothers of the invited cohort showed a higher probability of receiving a Pap test after the vaccination campaign period (RR 1.27 95% CI 1.04-1.56) compared with those not invited, CONCLUSION: Active invitation could increase overall HPV immunisation coverage and reduce socio-demographic inequalities and the association with mothers' screening participation.

Human papillomavirus in oropharyngeal cancer in Canada: analysis of 5 comprehensive cancer centres using multiple imputation

BACKGROUND

The incidence of oropharyngeal cancer has risen over the past 2 decades. This rise has been attributed to human papillomavirus (HPV), but information on temporal trends in incidence of HPV-associated cancers across Canada is limited.

METHODS

We collected social, clinical and demographic characteristics and p16 protein status (p16-positive or p16-negative, using this immunohistochemistry variable as a surrogate marker of HPV status) for 3643 patients with oropharyngeal cancer diagnosed between 2000 and 2012 at comprehensive cancer centres in British Columbia (6 centres), Edmonton, Calgary, Toronto and Halifax. We used receiver operating characteristic curves and multiple imputation to estimate the p16 status for missing values. We chose a best-imputation probability cut point on the basis of accuracy in samples with known p16 status and through an independent relation between p16 status and overall survival. We used logistic and Cox proportional hazard regression.

RESULTS

We found no temporal changes in p16-positive status initially, but there was significant selection bias, with p16 testing significantly more likely to be performed in males, lifetime never-smokers, patients with tonsillar or base-of-tongue tumours and those with nodal involvement (p < 0.05 for each variable). We used the following variables associated with p16-positive status for multiple imputation: male sex, tonsillar or base-of-tongue tumours, smaller tumours, nodal involvement, less smoking and lower alcohol consumption (p < 0.05 for each variable). Using sensitivity analyses, we showed that different imputation probability cut points for p16-positive status each identified a rise from 2000 to 2012, with the best-probability cut point identifying an increase from 47.3% in 2000 to 73.7% in 2012 (p < 0.001).

INTERPRETATION

Across multiple centres in Canada, there was a steady rise in the proportion of oropharyngeal cancers attributable to HPV from 2000 to 2012.