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.

Factors influencing human papillomavirus school-based immunization in Alberta: A mixed-methods study protocol.

More than 1,300 Canadians are diagnosed with cervical cancer annually, which is nearly preventable through human papillomavirus (HPV) immunization. Across Canada, coverage rates remain below the 90% target set out by the Action Plan for the Elimination of Cervical Cancer in Canada (2020-2030). To support this Plan, the Canadian Partnership Against Cancer has commissioned the Urban Public Health Network (UPHN) to coordinate a quality improvement project with Canada's school-based HPV immunization programs. In Alberta, the UPHN partnered with Alberta Health Services (AHS) for this work. This study has one overarching research question: what are parent/guardian and program stakeholder perceived barriers, enablers and opportunities to immunization for youth as part of the school-based HPV immunization program in Alberta? This study uses a mixed-methods sequential explanatory design. A survey will be emailed to a sample of Albertans with children aged 11-17 years. Questions will be based on a Conceptual Framework of Access to Health Care. Subsequent qualitative work will explore the survey's findings. Parents/guardians identifying as vaccine hesitant in the survey will be invited to participate in virtual, semi-structured, in-depth interviews. Stakeholders of the school-based immunization program will be purposively sampled from AHS' five health zones for virtual focus groups. Quantitative data will be analyzed using SAS Studio 3.6 to carry out descriptive statistics and, using logistic regression, investigate if Framework constructs are associated with parents'/guardians' decision to immunize their children. Qualitative data will be analyzed using NVivo 12 to conduct template thematic analysis guided by the Framework. Study results will provide insights for Alberta's public health practitioners to make evidence-informed decisions when tailoring the school-based HPV immunization program to increase uptake in vaccine hesitant populations. Findings will contribute to the national study, which will culminate in recommendations to increase HPV immunization uptake nationally and progress towards the 90% coverage target.

Interactive Visualization Applications in Population Health and Health Services Research: Systematic Scoping Review.

BACKGROUND: Simple visualizations in health research data, such as scatter plots, heat maps, and bar charts, typically present relationships between 2 variables. Interactive visualization methods allow for multiple related facets such as numerous risk factors to be studied simultaneously, leading to data insights through exploring trends and patterns from complex big health care data. The technique presents a powerful tool that can be used in combination with statistical analysis for knowledge discovery, hypothesis generation and testing, and decision support. OBJECTIVE: The primary objective of this scoping review is to describe and summarize the evidence of interactive visualization applications, methods, and tools being used in population health and health services research (HSR) and their subdomains in the last 15 years, from January 1, 2005, to March 30, 2019. Our secondary objective is to describe the use cases, metrics, frameworks used, settings, target audience, goals, and co-design of applications. METHODS: We adapted standard scoping review guidelines with a peer-reviewed search strategy: 2 independent researchers at each stage of screening and abstraction, with a third independent researcher to arbitrate conflicts and validate findings. A comprehensive abstraction platform was built to capture the data from diverse bodies of literature, primarily from the computer science and health care sectors. After screening 11,310 articles, we present findings from 56 applications from interrelated areas of population health and HSR, as well as their subdomains such as epidemiologic surveillance, health resource planning, access, and use and costs among diverse clinical and demographic populations. RESULTS: In this companion review to our earlier systematic synthesis of the literature on visual analytics applications, we present findings in 6 major themes of interactive visualization applications developed for 8 major problem categories. We found a wide application of interactive visualization methods, the major ones being epidemiologic surveillance for infectious disease, resource planning, health service monitoring and quality, and studying medication use patterns. The data sources included mostly secondary administrative and electronic medical record data. In addition, at least two-thirds of the applications involved participatory co-design approaches while introducing a distinct category, embedded research, within co-design initiatives. These applications were in response to an identified need for data-driven insights into knowledge generation and decision support. We further discuss the opportunities stemming from the use of interactive visualization methods in studying global health; inequities, including social determinants of health; and other related areas. We also allude to the challenges in the uptake of these methods. CONCLUSIONS: Visualization in health has strong historical roots, with an upward trend in the use of these methods in population health and HSR. Such applications are being fast used by academic and health care agencies for knowledge discovery, hypotheses generation, and decision support. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/14019.

Scoping Review on the Impact of Outbreaks on Sexual and Reproductive Health Services: Proposed Frameworks for Pre-, Intra-, and Postoutbreak Situations.

INTRODUCTION: Recent experiences from global outbreaks have highlighted the severe disruptions in sexual and reproductive health services that expose women and girls to preventable health risks. Yet, to date, there is no review studying the possible impact of outbreaks on sexual and reproductive health (SRH). Methodology. Studies reporting outbreaks impacting sexual and reproductive health and pregnancy outcomes were identified using MEDLINE, Embase, and ISI-WoS. Reported impacts were reviewed at systems, community, and legislative levels. RESULTS: The initial run listed 4423 studies; the 37 studies that met all inclusion criteria were mainly from Latin America and Africa. Studies on outbreaks of diseases like Zika and Ebola have documented declines in facility-based deliveries, contraceptive use, and antenatal and institutional care due to burdened healthcare system. Service usage was also impacted by a lack of trust in the healthcare system and system shocks, including workforce capacity and availability. At the community level, poverty and lack of awareness were critical contributors to poor access to SRH services. Assessing the target population's knowledge, attitude, beliefs, and behavior and using health literacy principles for communication were fundamental for designing service delivery. Online resources for SRH services were an acceptable medium of information among young adults. In outbreak situations, SRH and pregnancy outcomes were improved by implementing laboratory surveillance, free-of-cost contraceptive services, improved screening through professional training, and quality of care. In addition, mobile health clinics were reported to be effective in remote areas. Knowledge Contribution. In outbreaks, the interventions are categorized into preoutbreak, during, and postoutbreak periods. The proposed steps can help to improve and do course correction in emergencies. Though conducted before the COVID-19 crisis, the authors believe that lessons can be drawn from the paper to understand and mitigate the impact of the pandemic on sexual and reproductive health services.

The context and limitations of female sterilization services in Pakistan.

INTRODUCTION: Female sterilization has long been the most popular method of family planning (FP) in Pakistan, and yet most public health experts feel it contributes little to controlling family size or to population welfare. We used Pakistan Demographic Health Survey (PDHS) data to understand the role female sterilization plays in the overall context of FP in Pakistan. METHODS: We performed a secondary analysis of data from the PDHS 1990-1 and 2006-7 to study factors that lead to sterilization and trends in the use of the procedure. In addition, census data were multiplied by proportions from PDHS data to estimate the number of women availing sterilization services. RESULTS: Around 1.9 million women in Pakistan are currently sterilized--up from 0.55 million in 1990-1, and around 173,867 undergo the procedure, annually. Women usually receive sterilization after 30 years of age (mean = 39) and after six children. The probability of sterilization increases with age, family size, and urban residence, and is unaffected by poverty, province of residence, or the woman or her husband's education. Most sterilizationis conducted in public sector facilities. CONCLUSIONS: Sterilization in Pakistan may be common, but occurs too late to have any significant effect on family size or benefit public health. Future avenues to make this option more useful to women and society would be to improve the repertoire and access and quality of FP services that are available, and to address governance issues that limit the performance and utility of government facilities.

Hepatitis B and C: prevalence and risk factors associated with seropositivity among children in Karachi, Pakistan.

BACKGROUND: Infections with hepatitis B virus (HBV) and hepatitis C virus (HCV) can lead to chronic liver disease and hepato-cellular carcinoma (HCC). This cross-sectional study estimated the prevalence and identified risk factors associated with Hepatitis B surface antigen (HBsAg) and HCV antibody (anti-HCV) sero-positivity among children 1 to 15 years of age. METHODS: The study targeted the low to middle socioeconomic population that comprises 80% to 85% of the population. Consent was obtained from parents of the eligible children before administering questionnaire and collected a blood sample for anti-HCV and HBsAg serology. RESULTS: 3533 children were screened for HBsAg and anti-HCV. 1826 (52 %) were males. 65 (1.8 %) were positive for HBsAg, male to female ratio 38:27; mean age 10 +/- 4 years. 55 (1.6 %) were positive for anti-HCV with a mean age 9 +/- 4 years. 3 (0.11%) boys were positive for both HBsAg and anti-HCV. The overall infection rate was 3.3 % in the studied population. Hepatitis BsAg was more prevalent in subjects who received therapeutic injections 45 (69.2%) positive [Odd Ratio OR = 2.2; 95% Confidence interval CI: 1.3-3.6] inspite of using new needle and syringe 44 (67.7%) positive [OR = 2.2; 95% CI: 1.3-3.7] and vaccination in the government healthcare facilities 46 (70.7 %) positive with [OR = 3.0; 95% CI: 1.4-6.4]. These factors were not significant in anti-HCV positive cases. CONCLUSION: There is a need to educate general population regarding HBV and HCV infection and risks associated with inappropriate therapeutic injections. Hepatitis B vaccine should be administered to all newborns regardless of maternal HBsAg status.