Mapping sociodemographic and geographical differences in human papillomavirus non-vaccination among young girls in Sweden

The role of mental illness and neurodevelopmental conditions in human papillomavirus vaccination uptake within the Swedish school-based vaccination programme: a population-based cohort study

BACKGROUND

Despite documented mental illness-related disparities in cervical cancer screening and incidence, insufficient data exist on differences in cervical cancer prevention strategies, such as human papillomavirus (HPV) vaccination. We aimed to investigate the association of mental illness and neurodevelopmental conditions among girls and their parents with uptake of HPV vaccination in Sweden.

METHODS

This population-based cohort study was based on the Swedish school-based HPV vaccination programme, which offers the first vaccine dose to girls aged 10-13 years, with a second dose offered within 12 months. We identified all girls born between Jan 1, 2002, and March 1, 2004, using the Swedish Total Population Register-ie, those eligible for two vaccine doses in the vaccination programme from its initiation in autumn 2012, to March, 2019. Nationwide Swedish register data (National Patient Register, Prescribed Drug Register, HPV Vaccination Register, National Vaccination Register, Total Population Register, Multi-Generation Register, Longitudinal Integrated Database for Health Insurance and Labour Market Studies, Education Register, National Cervical Screening Registry, and Cancer Register) were used to define individual and parental mental health conditions, including mental illness and neurodevelopmental conditions (defined by a clinical diagnosis and prescribed psychotropic medication use), HPV vaccine uptake (first and second dose), and sociodemographic and clinical characteristics. The two outcomes were uptake of the first HPV vaccine dose by the girl's 14th birthday and uptake of the second dose by the 15th birthday in relation to individual and parental mental health conditions, calculated using multivariable Poisson regression models.

FINDINGS

115 104 girls were included in the study population. 2211 girls (1·9%) had a specialist diagnosis of any mental health condition. Uptake of the first HPV vaccine dose was 80·7% (92 912 of 115 104) and was lower among girls with versus without any mental health condition (adjusted relative risk 0·89 [95% CI 0·87-0·91]). The diagnosis of autism (0·79 [0·75-0·85]) or intellectual disability (0·78 [0·73-0·83]) were most strongly associated with lower HPV vaccine uptake. Vaccine uptake was also lower among girls with versus those without prescribed use of psychotropic medication (0·93 [0·92-0·95]), with the strongest association observed for antipsychotics (0·68 [0·56-0·82]). Uptake of the second dose was 95·0% (88 308 of 92 912), with no strong associations between uptake and mental health conditions in girls or their parents.

INTERPRETATION

Our findings suggest disparities in cervical cancer prevention among girls with mental health conditions, and call for further research to ensure equitable protection.

FUNDING

Swedish Cancer Society.

Understanding and tackling cancer inequities: What opportunities does intersectionality offer researchers, policymakers, and providers? A scoping review

PROBLEM IDENTIFICATION

We summarised the international evidence relating to the role of intersectionality in patients' lived experience of inequities along the cancer care pathway. We produced guidance to use intersectionality in future research.

LITERATURE SEARCH

We included 42 articles published between 1989 to 2023 that used intersectionality to guide the study and interpretation of inequities in cancer care.

DATA EVALUATION/SYNTHESIS

Articles predominantly comprised North American (n = 37), followed by European (n = 4) and Asian (n = 1) studies. Similar compounding effects of racism, homophobia, and discrimination across countries exacerbated inequities in cancer care experience and cancer outcomes particularly for women of color and sexual/gender minority groups. Professionals' knowledge, attitudes, and behaviors toward minoritised groups affected patient-provider relationships and influenced cancer patients' psychosocial responses.

CONCLUSION

Intersectionality provides a framework to assess the personal, interpersonal, and structural processes through which cancer inequities manifest within and across countries.

Evaluation of an early childhood caries preventive programme starting during pregnancy-Results after 3 and 6 years

BACKGROUND

Early childhood caries (ECC) has been found to be up to five times more common among children living in areas of low socio-economic status (SES) than among children in areas of higher SES.

AIM

To evaluate an ECC prevention programme from pregnancy to 3 and 6 years of age.

DESIGN

A prospective, controlled, intervention cohort study was initiated in 2013 in a low-SES area in Sweden. The intervention group received an individual interdisciplinary ECC prevention programme starting pre-birth, consisting of supportive oral health-promoting talks using motivational interviewing techniques and individual ECC preventive actions. A control group, consisting of pregnant women living in a comparable area, received ordinary routines.

RESULTS

Of the 336 pregnant women, 64 mothers (with 64 children) completed the programme, and 394 children were born in the control group. At the sixth year examination, the proportion of children with no caries was similar between the groups (53% resp. 52%, p = .976), whereas the proportion with decayed, missed, filled primary teeth (dmft = 1-5) was slightly lower (23% resp. 36%, p = .063), and the proportion with severe caries disease (dmft > 5) was higher (p = .013) in the intervention group (25%) than in the control group (12%).

CONCLUSION

No preventive effect regarding caries can be demonstrated at sixth year of age. Maternal behavioural change in dental care was not sufficient to even out inequalities in oral health in children, eventually due to difficulties in reaching the target group and the lack of effects among the families reached.

What does the MAIHDA method explain?

Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) is a new approach to quantitative intersectional modelling. Along with an outcome of interest, MAIHDA entails the use of two sets of independent variables. These include group demographics such as race, gender, and poverty status as well as strata which are constructs such as Black female poor, Black female wealthy, and White female poor. These constructs represent the combination of the demographic variables. To operationalize the approach, an initial random intercepts model with strata as a level 2 context is specified. Then, another model is specified that includes the strata as well as the demographic variables as level 1 fixed effects. As such, it is argued that MAIHDA uniquely identifies the additive and intersectional effects for any given outcome. In this paper we show that MAIHDA falls short of this promise: the strata are an individual-level composite variable not a level 2 context. Rather than being analogous to neighborhoods as contexts, strata are analogous to socio-economic status which is a combination of individual-level demographic variables, albeit often presented as a group-level characteristic. The result is that the demographic variables are inserted in both level 2 and 1. This duplication across the levels in MAIHDA means that there is a built-in collinearity across the levels and that the models are mis-specified and, therefore, redundant. We conclude that single-level models with the demographic variables and interactions or with the strata as fixed effects are still the more accurate models for quantitative intersectional analyses.

Understanding Prognostic Factors for Human Papillomavirus Vaccination: A Rural Community Case-Control Study

HPV vaccination coverage rates can vary depending on several factors. The main objective of this study is to identify possible independent prognostic factors that have an impact on HPV vaccination in a rural community, specifically related to sexual and reproductive health. A case-control, retrospective, community-based study was carried out on women aged 15 to 40 in the primary health centers of Southern Catalonia's Terres de l'Ebre region, Spain, from 1 January 2020 to 31 December 2022. A random sample of 520 women with an average age of 29.3 (SD 7.8) years old was included in the study. Independent prognostic factors: age OR 0.680 (95% CI: 0.635-0.729, p < 0.001), immigrant origin OR 0.215 (95% CI: 0.109-0.422, p < 0.001), and HPV PCR OR 7.402 (95% CI: 2.504-21.880, p < 0.001). The variables that showed a barrier effect for HPV vaccination were age (OR 0.680, 95% CI 0.635-0.729, p < 0.001), and immigrant origin (OR 0.215, 95% CI 0.109-0.422, p < 0.001). The variable that showed a facilitating effect for HPV vaccination was HPV PCR (OR 7.402, 95% CI 2.504-21.880, p < 0.001).

Integrated database-based Screening Cohort for Asian Nomadic descendants in China (Scan-China): Insights on prospective ethnicity-focused cancer screening

Established in 2017, the Screening Cohort for Asian Nomadic descendants in China (Scan-China) has benefited over 180,000 members of a multi-ethnic population, particularly individuals of Mongolian descent compared with the general population (Han ethnicity), in the Inner Mongolia Autonomous Region, China. This cohort study aims to evaluate the effectiveness of cancer screening and serve as a real-world data platform for cancer studies. The 6 most prevalent cancers in China are considered-namely, breast, lung, colorectal, gastric, liver and esophageal cancer. After baseline cancer risk assessments and screening tests, both active and passive follow-up (based on the healthcare insurance database, cancer registry, the front page of hospital medical records, and death certificates) will be conducted to trace participants' onset and progression of cancers and other prevalent chronic diseases. Scan-China has preliminarily found a disproportionately lower screening participation rate and higher incidence/mortality rates of esophageal and breast cancer among the Mongolian population than among their Han counterparts. Further research will explore the cancer burden, natural history, treatment patterns, and risk factors of the target cancers.

An intersectional analysis of sociodemographic disparities in Covid-19 vaccination: A nationwide register-based study in Sweden

BACKGROUND

Studies on sociodemographic disparities in Covid-19 vaccination uptake in the general population are still limited and mostly focused on older adults. This study examined sociodemographic differences in Covid-19 vaccination uptake in the total Swedish population aged 18-64 years.

METHODS

National Swedish register data within the SCIFI-PEARL project were used to cross-sectionally investigate sociodemographic differences in Covid-19 vaccination among Swedish adults aged 18-64 years (n = 5,987,189) by 12 October 2021. Using logistic regression models, analyses were adjusted for sociodemographic factors, region of residence, history of Covid-19, and comorbidities. An intersectional analysis approach including several cross-classified subgroups was used to further address the complexity of sociodemographic disparities in vaccination uptake.

FINDINGS

By 12 October 2021, 76·0% of the Swedish population 18-64 years old had received at least two doses of Covid-19 vaccine, an additional 5·5% had received only one dose, and 18·5% were non-vaccinated. Non-vaccinated individuals were, compared to vaccinated, more often younger, male, had a lower income, were not gainfully employed, and/or were born outside Sweden. The social patterning for vaccine dose two was similar, but weaker, than for dose one. After multivariable adjustments, findings remained but were attenuated indicating the need to consider different sociodemographic factors simultaneously. The intersectional analysis showed a large variation in vaccine uptake ranging from 32% to 96% in cross-classified subgroups, reflecting considerable sociodemographic heterogeneity in vaccination coverage.

INTERPRETATION

Our study, addressing the entire Swedish population aged 18-64 years, showed broad sociodemographic disparities in Covid-19 vaccine uptake but also wide heterogeneities in coverage. The intersectional analysis approach indicates that focusing on specific sociodemographic factors in isolation and group average risks without considering the heterogeneity within such groups will risk missing the full variability of vaccine coverage.

FUNDING

SciLifeLab / Knut & Alice Wallenberg Foundation, Swedish Research Council, Swedish government ALF agreement, FORMAS.

Attitudes Toward HPV Vaccination in Sweden: A Survey Study

Background

While HPV vaccination uptake in Sweden is quite high, at around 80%, vaccine hesitancy remains an issue in countries throughout Europe. The latter can be related to a contemporary context of increased contestation of expert knowledge and of a large share of information on health-related issues including vaccination today being sought via the internet. Still, there is a paucity of recent research on attitudes toward the HPV vaccine in a larger sample of the population in Sweden. This survey study assesses such attitudes and any correlations between vaccine hesitancy and sociodemographic characteristics, trust in healthcare and other societal institutions, and evaluation of the reliability of different sources of information.

Methods

The validated survey questionnaire was distributed to adult women in Sweden (n = 2,000), via a nationally representative web panel. The response rate was 37%. Aside from descriptive statistics, associations between vaccine hesitancy and sociodemographic and other variables were computed using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs).

Results

Our results show a positive attitude toward HPV vaccination overall. Still, some degree of HPV vaccine hesitancy was indicated by 33.8% of the respondents, and more pronounced hesitancy by 7.6%. Regarding vaccination in general, a very positive attitude was indicated by 55%. HPV vaccine hesitancy was associated with low education and low income and strongly associated with a lack of confidence in healthcare and other societal institutions. It was also correlated with a self-assessed lack of access to, and ability to assess the origin, quality and reliability of, information about the HPV vaccine.

Conclusion

Efforts to provide transparent information about HPV vaccination should be combined with healthcare providers being open to discuss vaccine concerns with patients and avoiding practices that do not promote trust.