title: Inequalities in the uptake of human papillomavirus vaccination: a systematic review and meta-analysis.
abstract: BACKGROUND
  The human papillomavirus (HPV) vaccine offers an opportunity to reduce health inequalities associated with cervical cancer provided the vaccine is delivered equitably at population level. Method We reviewed evidence of inequalities in HPV vaccine uptake in young women after undertaking a comprehensive search of databases from inception to March 2012. Studies that compared HPV vaccination initiation and/or completion by at least one ethnicity or socioeconomic-related variable in adolescent young women were included. There were no language restrictions. Data were extracted by two reviewers and pooled in a meta-analysis using a random-effects model; sub-analyses and meta-regression were undertaken to investigate sources of heterogeneity.
  
  
  RESULTS
  In all, 29 publications related to 27 studies were included in the review. Black young women were less likely to initiate HPV vaccination compared with White young women (combined OR: 0.89, 95% CI: 0.82-0.97). In the USA, young women without healthcare insurance were less likely to initiate (combined OR: 0.56, 95% CI: 0.40-0.78). There was no strong evidence that lower family income (combined OR: 1.16, 95% CI: 1.00-1.34) or lower parental education (combined OR 1.06, 95% CI: 0.92-1.22) influenced HPV vaccination initiation.
  
  
  CONCLUSIONS
  We found strong evidence for differences in HPV vaccination initiation by ethnicity and healthcare coverage, but did not find a strong association with parental education or family income variables. The majority of studies originated from the USA. Population-based studies reporting both initiation and completion of the HPV vaccination programme are required to establish patterns of uptake in different healthcare contexts.
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK. Harriet.Fisher@bristol.ac.uk
authors.forename: Harriet
authors.initials: H
authors.lastname: Fisher
authors.forename: Caroline L
authors.initials: CL
authors.lastname: Trotter
authors.forename: Suzanne
authors.initials: S
authors.lastname: Audrey
authors.forename: Kyle
authors.initials: K
authors.lastname: MacDonald-Wallis
authors.forename: Matthew
authors.initials: M
authors.lastname: Hickman
mesh_terms: D000293:Adolescent; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D017589:Immunization Programs / Q000706:statistics & numerical data; D030361:Papillomavirus Infections / Q000517:prevention & control*; D053918:Papillomavirus Vaccines / Q000008:administration & dosage*; D012959:Socioeconomic Factors; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control*; D014611:Vaccination
chemical_list: D053918:Papillomavirus Vaccines
keywords: HPV vaccine; ethnic disparity; immunization, adolescents; public health; socioeconomic factors