title: Individual- and regional-level determinants of human papillomavirus (HPV) vaccine refusal: the Ontario Grade 8 HPV vaccine cohort study.
abstract: BACKGROUND
  Studies on the determinants of human papillomavirus (HPV) vaccine use have generally focused on individual-level characteristics, despite the potentially important influence of regional-level characteristics. Therefore, we undertook a population-based, retrospective cohort study to identify individual- and regional-level determinants of HPV vaccine refusal (non-receipt) in Ontario's (Canada) Grade 8 HPV Immunization Program.
  
  
  METHODS
  Ontario's administrative health and immunization databases were used to identify girls eligible for free HPV vaccination in 2007-2011 and to ascertain individual-level characteristics of cohort members (socio-demographics, vaccination history, health care utilization, medical history). The social and material characteristics of the girl's region (health unit) were derived from the 2006 Canadian Census. Generalized estimating equations (binomial distribution, logit link) were used to estimate the population-average effects of individual- and regional-level characteristics on HPV vaccine refusal.
  
  
  RESULTS
  Our cohort consisted of 144,047 girls, 49.3% of whom refused HPV vaccination. Factors associated with refusal included a previous diagnosis of Down's syndrome (OR = 1.37, 95% CI 1.16-1.63) or autism (OR = 1.60, 95% CI 1.34-1.90), few physician visits (OR = 1.45, 95% CI 1.35-1.55), and previous refusal of mandatory (OR = 2.23, 95% CI 2.07-2.40) and optional (OR = 3.96, 95% CI 3.87-4.05) vaccines. Refusal was highest among the lowest and highest income levels. Finally, a previous diagnosis of obesity and living in an area of high deprivation were associated with lower refusal (OR = 0.87, 95% CI 0.83-0.92 and OR = 0.82 95%, CI 0.79-0.86, respectively).
  
  
  CONCLUSIONS
  Studies on HPV vaccine determinants should consider regional-level factors. Efforts to increase HPV vaccine acceptance should include vulnerable populations (such as girls of low income) and girls with limited contact with the healthcare system.
authors.forename: Olivia
authors.initials: O
authors.lastname: Remes
authors.forename: Leah M
authors.initials: LM
authors.lastname: Smith
authors.forename: Beatriz E
authors.initials: BE
authors.lastname: Alvarado-Llano
authors.forename: Lindsey
authors.initials: L
authors.lastname: Colley
authors.affiliation: Department of Public Health Sciences, Queen's University, 21 Arch Street, Room 313, Kingston, Ontario, Canada. linda.levesque@queensu.ca.
authors.forename: Linda E
authors.initials: LE
authors.lastname: Lévesque
mesh_terms: D000293:Adolescent; D000328:Adult; D002170:Canada; D019352:Censuses; D002648:Child; D015331:Cohort Studies; D005260:Female; D006801:Humans; D009864:Ontario; D027383:Papillomaviridae; D030361:Papillomavirus Infections / Q000517:prevention & control* / Q000821:virology; D053918:Papillomavirus Vaccines; D010342:Patient Acceptance of Health Care; D011203:Poverty; D012189:Retrospective Studies; D016312:Treatment Refusal; D014611:Vaccination / Q000706:statistics & numerical data*
chemical_list: D053918:Papillomavirus Vaccines