Non-Adherence To Childhood HPV Vaccination Is Associated With Non-Participation In Cervical Cancer Screening – A Nationwide Danish Register-Based Cohort Study

Abstract

Background

The combination of organized cervical cancer screening and childhood HPV vaccination programs has the potential to eliminate cervical cancer in the future. However, only women participating in both programs gain the full protection, and combined non-attenders remain at high risk of developing cervical cancer. Our aim was to analyze the association between non-adherence to HPV vaccination and non-participation in cervical cancer screening for the total population and stratified by native background and parental education.

Participants

Women born in 1993 eligible for both childhood HPV vaccination and first cervical cancer screening.

Analysis

Logistic regression models were used to estimate the odds ratio (OR) of non-participation in cervical cancer screening with 95% confidence intervals (CI). Stratified and adjusted logistic regression models were used along with the Wald test in order to test for interaction.

Results

24,828 women were included in the study. Among vaccinated women, 61.4% participated in cervical cancer screening; only 39.0% of unvaccinated women participated in cervical cancer screening. Unvaccinated and unscreened women were often non-native and had the lowest socio-economic status, whereas vaccinated and screened women were often native and had the highest socio-economic status. The adjusted OR for non-participation in cervical cancer screening was 2.07 [95% CI: 1.88–2.28] for unvaccinated compared to vaccinated women. After stratifying by country of origin, unvaccinated natives had the highest adjusted OR of not participating in cervical cancer screening compared to non-native women from both western and non-western countries (adjusted ORs of 2.2 [95% CI: 2.0–2.4], 1.3 [95% CI: 0.6–2.8], and 1.5 [95% CI: 1.1–2.0], respectively) (Wald test p=0.019).

Conclusion

Among natives, non-adherence to HPV vaccination and non-participation in screening seem to be signs of generally poor health-preventive behavior, whereas among non-natives from non-western countries, non-attendance in HPV vaccination and cervical cancer screening seem to be influenced by unrelated factors. Therefore, a differentiated and culturally sensitive approach is needed to enhance overall cervical cancer preventive behavior across different nativities.

Keywords:

• human papilloma virus
• vaccination
• screening
• non-participation
• socio-economic status
• nationality

Acknowledgments

Data cleaning and initial analyses were performed with assistance from data manager Bo Søborg at the Department of Public Health Programmes, Randers Regional Hospital. This study was funded by the Family Hede Nielsen’s Foundation and Helsefonden. The sponsors had no influence on the scientific process.

Ethics Approval And Informed Consent

According to Danish legislation and the Central Denmark Region Committees on Biomedical Research Ethics, the study did not require ethical approval because it was based on register data. The same institutions waived patient consent for use of register data. In accordance with Danish law and the EU’s General Data Protection Regulation, the project was listed at the Central Denmark Region internal list of research projects (J. No.: 1-16-02-400-16).

Author Contributions

All authors made substantial contributions to both design, achievement of data, analysis, and interpretation of data; took part in drafting the article or revising it critically; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.

Disclosure

Andersen B has received HPV test kits and HPV self-sampling devices from Roche and Axlab for other studies. Andersen B reports grants from Helsefonden, grants from Familien Hede Nielsens fond, during the conduct of the study; non-financial support from Roche, non-financial support from Axlab, outside the submitted work. Pedersen LK has received speaker’s fee from Merck and Sanofi Pasteur in relation to lectures on HPV vaccines. The authors report no other conflicts of interest in this work.