title: Can high overall human papillomavirus vaccination coverage hide sociodemographic inequalities? An ecological analysis in Canada.
abstract: BACKGROUND
  Human papillomavirus (HPV) vaccination programs have been implemented in more than 50 countries. These programs offer tremendous promise of reducing HPV-related disease burden. However, failure to achieve high coverage among high-risk groups may mitigate program success and increase inequalities. We examined sociodemographic inequalities in HPV vaccination coverage in 4 Canadian provinces (Quebec (QC), Ontario (ON), Manitoba (MB), British Columbia (BC)).
  
  
  METHODS
  We obtained annual HPV vaccination coverage of pre-adolescent girls at provincial and regional levels, from the start of programs to 2012/2013. Regions refer to administrative areas responsible for vaccine implementation and monitoring (there are 18/36/10/16 regions in QC/ON/MB/BC). We obtained regions' sociodemographic characteristics from Statistics Canada Census. We used univariate weighted linear regression to examine the associations between regions' sociodemographic characteristics and HPV vaccination coverage.
  
  
  RESULTS
  Provincial HPV vaccination coverage is generally high (QC:78%; ON:80%; MB:64%, BC:69%, 2012/13). QC had the highest provincial vaccination coverage since the program start, but had the greatest inequalities. In QC, regional HPV vaccination coverage was lower in regions with higher proportions of socially deprived individuals, immigrants, and/or native English speakers (p<0.0001). These inequalities remained stable over time. Regional-level analysis did not reveal inequalities in ON, MB and BC.
  
  
  CONCLUSIONS
  School-based HPV vaccination programs have resulted in high vaccination coverage in four Canadian provinces. Nonetheless, high overall coverage did not necessarily translate into equality in coverage. Future work is needed to understand underlying causes of inequalities and how this could impact existing inequalities in HPV-related diseases and overall program success.
authors.affiliation: Centre de recherche du CHU de Québec, Axe SP-POS, Québec, Canada; Département de médecine sociale et préventive, Université Laval, Québec, Canada.
authors.forename: Melanie
authors.initials: M
authors.lastname: Drolet
authors.affiliation: Public Health Ontario, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
authors.forename: Shelley L
authors.initials: SL
authors.lastname: Deeks
authors.affiliation: CancerCare Manitoba, Manitoba, Canada; University of Manitoba, Manitoba, Canada; British Columbia Cancer Agency, British Columbia, Canada.
authors.forename: Erich
authors.initials: E
authors.lastname: Kliewer
authors.affiliation: CancerCare Manitoba, Manitoba, Canada.
authors.forename: Grace
authors.initials: G
authors.lastname: Musto
authors.affiliation: CancerCare Manitoba, Manitoba, Canada.
authors.forename: Pascal
authors.initials: P
authors.lastname: Lambert
authors.affiliation: Centre de recherche du CHU de Québec, Axe SP-POS, Québec, Canada; Département de médecine sociale et préventive, Université Laval, Québec, Canada; Department of Infectious Disease Epidemiology, Imperial College, London, UK. Electronic address: Marc.Brisson@crchudequebec.ulaval.ca.
authors.forename: Marc
authors.initials: M
authors.lastname: Brisson
mesh_terms: D000293:Adolescent; D001955:British Columbia; D002648:Child; D005260:Female; D054624:Health Status Disparities; D006801:Humans; D017589:Immunization Programs / Q000706:statistics & numerical data; D008297:Male; D008350:Manitoba; D009864:Ontario; D030361:Papillomavirus Infections / Q000517:prevention & control; D053918:Papillomavirus Vaccines / Q000008:administration & dosage / Q000627:therapeutic use*; D011792:Quebec; D012959:Socioeconomic Factors; D014611:Vaccination / Q000706:statistics & numerical data*
chemical_list: D053918:Papillomavirus Vaccines
keywords: Health inequalities; Human papillomavirus (HPV); Immunization