Healthcare provider perspectives on the uptake of the human papillomavirus vaccine among newcomers to Canada: a qualitative study

Figures & data

Table 1. Participant demographics.

	Participants, n(%)
Total participants	10 (100%)
Gender
Female	8 (80%)
Male	2 (20%)
Age range (years)
18–25	1 (10%)
26–35	2 (20%)
36–45	5 (50%)
46–55	0 (0%)
56+	2 (20%)
Area of service provision
Public health	5 (50%)
Primary care	4 (40%)
Hospital care	1 (10%)
Length of time in role (years)
0–5	1 (10%)
6–10	3 (30%)
11–15	2 (20%)
16–20	3 (30%)
21+	1 (10%)
Identify as a newcomer
Yes	1 (10%)
No	8 (80%)
Second generation	1 (10%)

Table 2. Health care provider perspectives on barriers and facilitators to HPV vaccination.

Categories	Themes	Supplementary Sample Quotes
Access Barriers	• Cost • Navigating a new healthcare system	“Then furthermore, they can’t afford paying for it. Most of my newcomers are unable to pay for it regardless of any of their cultural background. To be very honest, often I look at their social issues, and I just skip over HPV because I don’t want to also make them feel bad that there’s a vaccine that I can’t actually provide to them.” (HCP10) “So they maybe come here and they’re told that they need to start getting re-immunized, right. But, so, that’s good and all, and they may get their first set of vaccines from the community health centres that they’re directed to immediately upon coming to Canada, but they don’t know that they still need to be immunized further. So it’s like, they have the barrier of ok, well we don’t have a family doctor, we don’t know where to go to get our vaccines.” (HCP4)
Communication Barriers	• Not having a common language • Inappropriate information resources • Implications of communication barriers: • Difficulty obtaining informed consent	“… and when there’s language barriers, we can’t go into the details of anything. So it’s just a very brief intervention, letting them know that it’s there.” (HCP4) “But, because that’s where we’re offering the vaccine, and parents who want their child to get it, some of them actually do show up to the clinic, you know like, “I don’t understand”. And that’s an opportunity, but it’s also difficult that they had to come all the way in, do that just to – something’s not clear, right.” (HCP3) “So we’re not really bringing up this subject, we don’t really get the opportunity to encounter the parents face-to-face at all, it’s always over the phone, and it’s always gonna be like, as little information as possible, over the shortest amount of time possible, and to gain consent, like to get consent. So it’s not like the best opportunity to go into it.” (HCP3)
Knowledge barriers	• Limited knowledge and awareness of HPV and HPV vaccination	“In my experience, many of my female patients never had a pap smear. It may be that other techniques were used, like acetic acid staining to screen for cervical cancer, but they certainly weren’t aware of cervical cancer screening, the ones I’ve talked to.” (HCP5)
Cultural barriers	• Talking about sexuality is taboo • Religious beliefs around sex before marriage	“I find the HPV is kind of a tricky one, ‘cause when you start explaining what HPV is – you know, being the human papillomavirus, a virus that can be transmitted sexually – that tends to turn off a lot of people. And not just newcomers…” (HCP1)
Provider-level barriers	• Healthcare-seeking behaviours • Fewer chances to discuss preventative care • Not receiving a recommendation • There is no time to discuss HPV • Having to administer multiple vaccines at a time, priority setting	“They don’t come unless they have a cold or cough. Opportunistic approach, when they come just for cold and cough, we know opportunistic approaches are not effective in immunization.” (HCP10) “So if you’re only going one-third of the time that you used to for that cervical screening, the opportunity in the mind of the primary care may not be there.” (HCP8) “Because for most patients who we’ve known since birth, we rely on the school system to give them the Gardasil. We might not be making the link that a newcomer may not have been offered that through the school system.” (HCP5) “I think other barriers are things like, when you look at the catch-up schedule for refugees that are like “unimmunized”, HPV is not really on there. Like they’ve just got more mandatory ones so there’s that. So we’re not thinking about that.” (HCP9)
Facilitators: targeted health promotion	• Targeted health promotion	“Well, at one school for example, they provided an information night for parents. We were able to send one of our nurses and one of the school health nurses and they were able to explain about the vaccines, about the questions that they had around HPV, and provide consent forms there, explained the consent form process, and by the end of the night, we had many more consents. I think that if we can do that in every school, that would be ideal.” (HCP6)
Understanding the relevance of HPV vaccination	• Getting it for free now or paying for it later  • Changing eligibility criteria	“So I mean, when a mother and daughter, 16, decide not to and they’re Muslim, and they probably won’t be in that situation for a while, there’s no reason, there’s no problem in delaying it. I mean I would just encourage them to, you know, ask about it when they connect to their new health provider. But probably the only piece is the financial piece, right. Because it might be harder for them to get it later on.” (HCP7)
Trusting the healthcare system	• Openness to vaccination	“But I find more with new immigrants, they’re very like, ok, that’s fine, we’re good. They trust, like I find they have a high trust towards healthcare, so they’re often very easy to deal with when it comes to these things. And with HPV, as well as the other vaccines, like they have high trust. So they will take the vaccine.” (HCP4)
Cultural sensitivity	• Ensuring access to appropriate personnel • Culturally sensitive risk communication	“And if they understand that it’s not because we think their child is having sex, they’re very open to receiving it.” (HCP4)

Table 3. Recommendations from health care providers to improve HPV vaccine uptake among newcomers.

Sample Quotes
Recommendation 1: Publicly fund the HPV vaccine	“But if we could at least say that it would be offered to anyone, not just this vaccine, but other vaccines too would be offered, like if you have Hepatitis B, the same thing, that it would be offered to you, same as it’s offered in the school based program to all those kids, the same basic minimums would be offered upon entry, because that population is at much higher risk even than the people that already live here, ‘cause they haven’t had adequate screenings.” (HCP8)
Recommendation 2: Enhance language and culturally appropriate health promotion activities	“And if there was a little bit more, like, education in the school. Not necessarily by the school staff, but just like, even with a public health – we’re very stretched like, we have a lot of things we do in a year…but they’re just like the school health nurses that go in the schools. They currently do some of that like teaching and promotion, but I just find there could always be more.” (HCP4) “I would just think about language specific promotion, you know. Just about is there a role for public health messaging. I haven’t seen anything targeted to HPV that’s language specific” (HCP5)
Recommendation 3: Provide explicit catch-up opportunities in the school-based program	“Yeah, I would say it has to come from kind of the school environment because adolescents don’t come to see their family doctor, right? They come just for the 14 through 16 visit for their Adacel shot and the meningitis. That’s where I usually get them, but that’s the only opportunity I have. They don’t come unless they have a cold or cough. Opportunistic approach, when they come just for cold and cough, we know opportunistic approaches are not effective in immunization.” (HCP10)
Recommendation 4: Create a vaccine databank	“I would love to see like a national vaccination databank that all of us were inputting our vaccines to and were able to pull from and be able to look up. So I could see that that person from BC has had all of these vaccines, and then I could just give them the rest. Because right now, it’s so scattershot that everybody – there’s a lot of people getting extra vaccines they don’t need, and there’s people that fall behind because we’re just assuming that they’re updated and their not. So I’d love to see like a national, at least a provincial level one, at least a city level one. But right now it’s just not in place.” (HCP9)
Recommendation 5: Have the HPV vaccine on hand at primary care clinics	“I mean I would love to see [public health] just sending us the HPV vaccine the same way they send the tetanus vaccines, and we just have like 20 of them sitting in the fridge and I just give them to whoever I think is in the right age category” (HCP9)
Recommendation 6: Create reminder systems for HPV vaccine recommendation	“With electronic charting now being the norm, there are easy ways for you and the provider, or even the electronic chart company, to pop in a little flag that pops up saying, “Did you talk about all of the vaccination?” And it automatically looks at the age of the patient and then says this, and this, and this, and this. So there’s certainly ways, if you think about it, to change your practice” (HCP8)

Figure 1. Comparison of barriers to HPV vaccination reported by newcomers vs. healthcare providers.