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.

School-based vaccination program against HPV and Hepatitis B: A longitudinal analysis of vaccine coverage between 2015 and 2021 in Quebec.

BACKGROUND: HPV vaccination prevents cancers, including 90% of cervical cancer. Since 2008, a school-based HPV vaccination program has been implemented in Quebec, but vaccine coverage is suboptimal. The COVID-19 pandemic disrupted school-based vaccination programs. This study aimed to assess variation in HPV vaccination coverage in the school-based program between 2015 and 2022 in Quebec and to identify sociodemographic characteristics associated with non-vaccination. METHODS: HPV vaccine coverage data were extracted from the Quebec Immunization Registry for students in Grade 4 and matched to the 2016 Canadian census sociodemographic data. Descriptive analysis was conducted to explore individual-level vaccine coverage according to sociodemographic data. A Generalized Estimating Equations model assessed the independent association between non-vaccination and students' sociodemographic characteristics. RESULTS: HPV vaccine coverage (at least one dose) was 84% in 2018-2019 and 85% in 2019-2020. A decrease was observed during the pandemic. In 2020-2021, the HPV vaccine coverage (at least one dose) was 52% (at the end of the school year) and rose to 84% with intense catch-up activities. In 2021-2022, the coverage was slightly lower than before the pandemic (81%). Factors in the dissemination area were statistically significantly associated with non-vaccination: material (p-value = 0.0001) and social deprivation index (p-value = 0.0048), the proportion of immigration (p-value < 0.0001), and the language spoken at home (English (p-value = 0.0318), other than French or English (p-value = 0.0001). CONCLUSION: School-based vaccination programs offer equitable access to vaccination, and our analysis showed that some groups have consistently lower vaccine acceptance and uptake. Strategies to improve HPV vaccine coverage should target children living in areas with a higher proportion of immigrants, non-French speakers, and people from underprivileged backgrounds. Although it is too early to assess the full impact of COVID-19 on school-based programs in Quebec, it remains important to ensure that catch-up strategies are implemented for missed doses.

"The problem is not lack of information": A qualitative study of parents and school nurses' perceptions of barriers and potential solutions for HPV vaccination in schools.

BACKGROUND: HPV vaccination has been offered in school programs for over a decade in Quebec, Canada, but the vaccine coverages are not reaching the target coverage in several regions. This qualitative study aimed to describe barriers and enabling conditions of HPV vaccination as perceived by parents and school nurses and identify potential solutions to improve HPV vaccine uptake rates and acceptance in school-based programs. METHODS: Three focus group discussions were conducted with parents of children in Grades 2 or 3 who were unsure or unwilling to vaccinate. Individual interviews were conducted with 24 school nurses. A thematic content analysis was performed using N'Vivo. RESULTS: The main parental questions and concerns regarding the HPV vaccination were the children's young age, the possible side effects, the rationale behind boys' vaccination and the possible interaction with COVID-19 vaccination. Except for interaction with COVID-19 vaccination, these concerns remain similar to those identified before the pandemic. Interviews highlighted that the information on HPV vaccination provided by the public was not well understood by parents. Parents suggested different tools to access information tailored to their concerns and situation. From the nurses' perspective, HPV vaccination promotion tools such as decision-aids and social media communication campaigns were needed and could reduce their work. CONCLUSION: COVID-19 may have disrupted the acceptance of the vaccines. While strategies to catch up on missed doses and reduce access barriers to vaccines are urgently needed, our findings highlight that a shift in attitudes toward routine vaccines may pose further challenges even if HPV vaccine coverage appears to have returned to pre-pandemic levels.

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.

An equity-based assessment of immunization-related responses in urban Alberta during the 2014 measles outbreak: a comparative analysis between Calgary and Edmonton.

OBJECTIVES: This study investigates measles, mumps, and rubella (MMR) immunization rates during the measles outbreak in Calgary and Edmonton of 2014 stratified by four area-level socio-demographic indicators. This study also leverages this epidemiological data to assess the equity aspect of emergency measures instituted regarding immunization in those two cities. METHODS: A mixed-methods comparative case study analysis methodology was employed to assess the neighbourhood-level immunization statuses before (2013), during (2014), and after (2015) an active measles outbreak in Calgary and Edmonton, Alberta, Canada. The epidemiological one-dose by age-2 MMR coverage data were stratified using four socio-demographic indicators: median household income, %-homeownership, %-Aboriginal population, and %-immigrant population. Document and content analysis was utilized to investigate the outbreak mitigation strategies deployed in each city. RESULTS: The measles outbreak of 2013/2014 involved the entirety of Alberta and led to both provincial and city-specific interventions in which Calgary deployed three mass immunization clinics in 2014, where Edmonton did not. The Calgary coverage data showed an increase in coverage inequalities across all indicators and the Edmonton data showed mixed results in terms of equity gains/losses. Calgary's additive intervention of three mass immunization clinics in 2014 appears to have contributed to both the higher gross immunization rates in Calgary (90.77%) and an inequitable increase in coverage rates as compared with Edmonton (88.96%), in most cases. CONCLUSION: Public health policy-makers must be cognizant that large-scale public health efforts must be optimized for accessibility across all socio-economic levels to ensure public and population health gains are realized equitably.

RéSUMé: OBJECTIFS: Cette étude porte sur les taux de vaccination contre la rougeole, la rubéole et les oreillons (RRO) durant l'éclosion de rougeole de 2014 à Calgary et à Edmonton, stratifiés selon quatre indicateurs sociodémographiques régionaux. L'étude se sert aussi de ces données épidémiologiques pour évaluer l'équité des mesures de vaccination d'urgence instituées dans les deux villes. MéTHODE: À l'aide d'une analyse comparative d'études de cas à méthodes mixtes, nous avons évalué les statuts vaccinaux par quartier avant (2013), pendant (2014) et après (2015) une éclosion active de rougeole survenue à Calgary et Edmonton, en Alberta, au Canada. Les données épidémiologiques relatives à la couverture du vaccin RRO, administré en une dose avant l'âge de 2 ans, ont été stratifiées à l'aide de quatre indicateurs sociodémographiques : le revenu médian des ménages, le pourcentage d'accession à la propriété, le pourcentage de la population autochtone et le pourcentage de la population immigrante. Nous avons fait appel à l'analyse documentaire et à l'analyse de contenu pour étudier les stratégies d'atténuation de l'éclosion déployées dans chaque ville. RéSULTATS: L'éclosion de rougeole de 2013-2014 a sévi partout en Alberta et a donné lieu à des interventions à l'échelle de la province et des villes; trois cliniques de vaccination de masse ont été déployées à Calgary en 2014, mais aucune à Edmonton. Selon les données relatives à la couverture vaccinale à Calgary, il y a eu une augmentation des inégalités dans la couverture pour tous les indicateurs; selon les données pour Edmonton, les résultats en matière de gains ou de pertes d'équité ont été mitigés. L'ajout de trois cliniques de vaccination de masse à Calgary en 2014 semble avoir contribué à la fois aux taux de vaccination bruts plus élevés à Calgary (90,77 %) et à une hausse inéquitable des taux de couverture comparativement à Edmonton (88,96 %) dans la plupart des cas. CONCLUSION: Les responsables des politiques de santé publique doivent être conscients qu'il faut optimiser les efforts de santé publique à grande échelle pour que toutes les classes socioéconomiques en bénéficient, afin que les gains réalisés en santé publique et en santé des populations soient équitables.

Surveying the local public health response to COVID-19 in Canada: Study protocol.

BACKGROUND: Public health services and systems research is under-developed in Canada and this is particularly the case with respect to research on local public health unit operational functioning and capacity. The purpose of this paper is to report on a study that will collect retrospective information on the local public health response to COVID-19 throughout Canada between 2020 and 2021. METHODS/DESIGN: The goal of the study is to develop and implement a study framework that will collect retrospective information on the local public health system response to the COVID-19 pandemic in Canada. This study will involve administering a mixed-method survey to Medical Health Officers/Medical Officers of Health in every local and regional public health unit across the country, followed by a process of coding and grouping these responses in a consistent and comparable way. Coded responses will be assessed for patterns of divergent or convergent roles and approaches of local public health across the country with respect to interventions in their response to COVID-19. The Framework Method of thematic analysis will be applied to assess the qualitative answers to the open-ended questions that speak to public health policy features. DISCUSSION: The strengths of the study protocol include the engagement of Medical Health Officers/Medical Officers of Health as research partners and a robust integrated knowledge translation approach to further public health services and systems research in Canada.

Staff Perceptions of a Mealtime Management Educational Video for Training in Long-Term Care Homes.

The purpose of this study was to determine if staff perceive a mealtime management video to be a beneficial and useful training tool in long-term care (LTC) homes. An email invitation was sent to the Dietitians of Canada Gerontology Network inviting dietitians working in LTC homes to participate. A previously used and reliable 25-item questionnaire was used to assess sustained attention/mental effort, learner satisfaction, clinical experience/relevance, and information processing of the video. Dietitians were asked to show the video to LTC staff and distribute the questionnaire to staff after viewing the video. A total of 769 surveys were completed at 28 LTC homes across Canada. Eighty-seven percent (n = 637/736) of participants felt more knowledgeable after viewing the video and 91% (n = 669/738) found the video format easy for learning. Managers had a higher Likert scores (mean = 6.2 out of 7) than continuing care assistant (mean = 5.7, P = 0.02) and food service workers (mean = 5.5, P = 0.001) for the clinical relevance scales. No differences were found for age (χ2 = 5.52, P = 0.60), gender (χ2 = 2.65, P = 0.10), and size of home (χ2 = 3.34, P = 0.34). Staff perceived the video to be useful for their work with residents living in LTC homes and it raised awareness of the importance of their roles at mealtimes.

Public health physician perspectives on developing and deploying clinical practice guidelines during the 2009 H1N1 pandemic.

During the H1N1 outbreak of 2009, local public health units engaged in consultations with various levels of government to develop clinical practice guidelines. These guidelines provide specific clinical considerations around prevention, management, and treatment associated with the particular pathogen involved and are used by frontline healthcare professionals across many healthcare settings. In this article, we report on the lessons learned by Medical Officers of Health from across Canada on the guideline development and deployment processes and provide suggestions to improve guidelines development and deployment during future pandemic situations.

Promoting chronic disease management in persons with complex social needs: A qualitative descriptive study.

While there are both ethical and practical imperatives to address health inequity issues related to chronic disease management for persons with social complexity, existing programs often do not appropriately address the needs of these individuals. This leads to low levels of participation in programs, suboptimal chronic disease management, and higher health-care utilization. The aims of this project were to describe the challenges related to availability, accessibility, and acceptability faced by socially complex patients with Chronic Obstructive Pulmonary Disease (COPD) who were eligible, but declined enrollment in a traditional Chronic Disease Management Program (CDMP). Using a qualitative descriptive study approach informed by a health equity lens, interviews with participants, managers, and a focus group with providers were used to gather data addressing the above aims. Qualitative data were analyzed using Braun and Clarke's theoretical thematic analysis approach. The ability of participants to manage chronic disease was profoundly influenced by contextual and personal factors, such as poverty, disability, personal attitudes and beliefs (including shame, mistrust, and hopelessness), and barriers inherent in the organization of the health-care system. The existing chronic disease management program did not adequately address the most critical needs of socially complex patients. Challenges with accessibility and acceptability of chronic disease management and health services played important roles in the ways these socially complex participants managed their chronic illness. The individualistic approach to self-management of chronic illness inherent in conventional CDMP can be poorly aligned with the needs, capacity, and circumstances of many socially complex patients. Innovative models of care that promote incremental and guided approaches to enhancing health and improving self-efficacy need further development and evaluation.

Individual- and area-level socioeconomic inequalities in diabetes mellitus in Saskatchewan between 2007 and 2012: a cross-sectional analysis.

BACKGROUND: Improving our understanding of social inequalities may improve prevention and treatment efforts for diabetes mellitus. We examined the association between individual- and area-level socioeconomic measures and physician-diagnosed diabetes in Saskatchewan over time. METHODS: In this cross-sectional study, we linked health administrative data with individual-level socioeconomic data from the Canadian Community Health Survey and area-level data from the 2006 Canadian census. We used general linear mixed-models regression to analyze the effect of each factor, controlling for geographic and demographic measures. RESULTS: Area-level deprivation was associated with medically diagnosed type 2 diabetes mellitus after adjustment for the individual-level factors of age, sex, household income and education. Individuals residing in areas ranked in the least deprived quintile had a lower likelihood of diabetes than those in the most deprived quintile (odds ratio 0.40, 95% confidence interval 0.18-0.88). However, this disparity existed only in urban areas. This result may reflect less pronounced health inequalities in rural areas, greater socioeconomic heterogeneity, larger geographic units or some combination of these factors. INTERPRETATION: Individual- and area-level socioeconomic factors were associated with the likelihood of medically diagnosed diabetes; however, the strength of this association varied between urban and rural communities. Acknowledgement of area-level deprivation as a modifiable risk factor related to the prevalence of diabetes is important in the development of effective interventions for urban, but not rural, areas.

Do rapid deployment aortic valves improve outcomes compared with surgical aortic valve replacement?

A best evidence topic was written according to a structured protocol. The question addressed was 'In patients requiring an aortic valve replacement, are rapid deployment aortic valve systems better than conventional aortic valve prostheses in terms of mortality, morbidity and/or valve function?' A total of 508 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The rapid deployment valves (RDVs) implanted in these studies include balloon expandable [Intuity (Edwards Lifesciences, CA, USA) and 3F Enable (Medtronic, MN, USA)] and self-expanding [Perceval (Sorin, Saluggia, Italy)] stented bioprostheses. Available data from these studies demonstrate that rapid deployment valves are invariably associated with shorter aortic cross-clamp times (30-56 vs 49-88 min). Despite this, postoperative mortality (0-5.8 vs 0-6%), ICU (1-3 vs 0.9-2.8 days) and hospital length of stay (6-14.1 vs 6-15.9 days) are similar compared with conventional aortic valve replacement (AVR). However, reduced postoperative bleeding (328 vs 564 ml), blood transfusion requirements (1.4 vs 2.4 units), ventilation time (4.9-9.5 vs 7-16.6 h) and renal injury (5.3 vs 14.7%) have been demonstrated with RDVs indicating possible clinical benefit to shorter procedural time. Importantly, patient risk profiles were similar to or higher across studies in patients undergoing RDVs compared with conventional AVR. From a functional perspective, transvalvular gradients were frequently lower with rapid deployment valves compared with conventional AVR, indicating an improved haemodynamic profile. However, in some studies using the Perceval RDV, the transvalvular gradients were higher than with conventional AVR. Also, mean valve sizes were often larger in those receiving RDVs. Rates of paravalvular regurgitation were similar between RDVs and conventional AVR in most studies, although pacemaker implantation occurred more often with RDV in some studies (2-28.5 vs 0-8.5%). Accepting these limitations, and without long-term data, RDVs would appear to be a reasonable alternative to conventional aortic valve prostheses in selected cases.