Barriers and facilitators in uptake of human papillomavirus vaccine across English Canada: A review

Figures & data

Figure 1. PRISMA flow diagram.

Figure 2. Analytical framework.

Table 1. A summary of salient features of the 33 studies meeting inclusion criteria.

First author, year, reference	Data years	Study methods	Study setting	Study location	Study population	Factors around HPVV uptake and/or completion	Study limitations
Ogilvie, 2010^Citation42	2008–2009	Surveys; interviews	School-based	British Columbia	2025 Parents of girls enrolled in grade 6	Barriers – Concerns about HPVV safety, preference to wait until the daughter is older, not enough information to make an informed decision.	Inability to access parents in two health services areas, use of telephone methodology, language barriers (telephone surveys were biased toward English speakers)
Fernandes, 2018^Citation35	2013	Cross-sectional study; Web-based surveys	School-based	Ottawa	401 Undergraduate University women (Both Canadian born and immigrant)	Barriers – Lack of knowledge about vaccines, potential efficacy and side effects, and vaccination cost. Facilitators – Positive perceptions about HPVV	A response rate of 17% only, self-reported information (recall and reporting errors), theory (theory of planned behavior) around vaccine uptake might not be fully explained
Ferrer, 2014^Citation27	2009–2010	Qualitative systematic review & evidence synthesis; interviews based mostly	Healthcare based	Canada (as one of the high-income countries)	Young women; their parents and/or primary caregivers, relevant healthcare professionals & stakeholders	Barriers – Social norms & values, vaccine cost, availability & delivery, parents decision-making & consent, sexual mores, trust issue, women’s autonomy, and healthcare professional recommendation & provision	Non-English studies & few observational methodology studies were excluded, lacked additional reviewer at the analysis stage, some accounts by participants might not reflect actual practice
Shapiro, 2017^Citation51	2016–2017	Searched Academic & Grey Literature	School based	Canadian jurisdictions (all)	Female and Male students/school-goers (grade 4–7)	Barriers – Certain groups receive HPVV outside school i.e., children with fear of needles; Facilitators – info on HPVV uptake rate might be useful in identifying regions of Canada that may benefit from psychosocial or economic intervention & elucidate emerging issues for policymakers	Some jurisdictions did not respond to inquiries or report information differently or inconsistently, they also have differences in data collection procedures, vaccine target age, study years reported conflicting information on the type of vaccine.
Dube, 2019^Citation3	2015–2016	Descriptive qualitative study; interviews & focus groups	School based	Quebec	70 Key informants (school nurses, principals, teachers, parents of grade 4 students, and immunization manager)	Barriers – Knowledge & attitudes of the different players involved in vaccination system, social group values & norms, media coverage around HPVV, allocated resources, information provision, consent process, immunization setting & environment, changing provincial HPVV program	Participation was voluntary (people who did not participate might have different opinions from those recruited OR the participants might have provided socially desirable responses)
Dube, 2012^Citation51	2009	Self-administered anonymous mail-based questionnaire	School based	Atlantic, Prairies, Ontario, British Columbia, Quebec	Canadian Pediatricians (n = 1283/2959)	Factors – Variables found statistically significantly associated with Physicians’ intention to recommend HPV were perceived acceptability by vaccine providers [OR:2.3] and by the public [OR:4.7], self-estimated sufficiency of knowledge on vaccines (i.e., HPV) [OR:2.9], perceived efficacy of the HPV vaccines [OR:2.2]	Possibility of missing some eligible physicians, the response rate was 43% plus a nonparticipation bias cannot be excluded, no information on non-respondents was available, the possibility of self-reporting biases
Grace, 2019^Citation28	2016–2018	Qualitative study; semi-structured interviews	Publicly funded vaccine programs	Ontario, British Columbia	25 HIV Positive older GBM (gay, bisexual & other men who have sex with men) - patients (>26 years), service providers (physicians)	Barriers – Physicians’ HPV vaccine recommendation practices limited by: a) cost/insurance coverage for some older patients & how the vaccine was discussed, b) physicians’ perspective on prevention & therapeutic benefits of vaccinating older GBM (over 26 years)	Limited to speaking to physicians who were anal dysplasia specialists themselves, or highly networked with anal dysplasia clinics & their clientele were predominantly made up of HIV-positive patients &/or GBM patients
Whelan, 2014^Citation52	2010–2011	Quantitative study; structured questionnaire	School based	Nova Scotia	Female students/school-goers (n = 3291), Public Health Nurses [PHNs] (n = 16)	Factors – HPVV uptake was significantly associated with PHNs providing reminder calls for; consent return [p = .017], missed school clinics (p = .004); teachers’ education (p < .001), a thank-you note to teachers (p < .001). HPVV completion with consent being returned (p = .003), PHN being assigned to a school (p = .025)	The role of PHNs was not examined very closely and clearly in HPV school-based immunization programs to be able to determine the mechanism for engaging school personnel & parents
Auguston, 2019^Citation36	2018	Qualitative study; semi-structured interviews	School-based	Ottawa	Newcomers to Canada (foreign-born individuals immigrants or refugees, ± students & undocumented migrants), Health care providers - (n = 10)	Barriers – Access, communication, knowledge, culture, and provider-related factors. Facilitators – Targeted health promotion, understanding the relevance of HPVV, trusting healthcare system, and cultural sensitivity	Newcomer definition was not predefined, data collection also focused on non-newcomers because healthcare providers also worked with non-newcomers, a small sample size of 10 healthcare providers
Grace, 2018^Citation29	2016–2017	Qualitative study; semi-structured interviews	Publicly funded vaccine programs	Toronto, Ontario	25 Gay men living with HIV (HIV Positive GMB [gay, Bisexual, other men who have sex with men])	Barriers – Lack of knowledge, financial barriers to vaccine access, beliefs that HPV was predominantly/exclusively a risk for females, uncertain about the availability of vaccines & their knowledge, HPV Health literacy levels particularly around the longstanding gendered association with HPV	The study exclusively focused on HIV-positive GBM, participants were recruited from a clinical trial on anal pap testing thus they might be more active than the general GBM population, also the study did not interview transgender males
Scott, 2016^Citation30	2000–2015	Searched Academic & Grey Literature	Publicly funded & School-based	Canada wide	Canadian males and females	Barriers – Family’s’ lack of knowledge about the vaccine, and attitudes that are not informed by science & epidemiology, health providers’ recommendation of HPVV, nurse practitioners’ position to collaborate with public health agencies to expand knowledge & coverage across Canada	n/a
Stanley, 2018^Citation43	2016	Quantitative study; internet-based survey	n/a	Ontario	63 Male residents & physicians with the departments of Obstetrics Gynecology, Otolaryngology from 6 Ontario Universities	Barriers – Personal cost, perceived lack of data on efficacy & concerns about being over the recommended age, Facilitators – Personal protection from HPV disease was the most common motivating factor (43.4%). Participants’ response: most would recommend HPVV	A small number of participants, attitude examined might not be representative of other Canadian provinces & territories, lack of data on specific practices (i.e. sexual orientations etc), the lower response rate among the staff, and selection bias
Markowitz, 2012^Citation31	2010–2011	Demonstration projects with systematic evaluation (special supplement article to comprehensive control of HPV infections & diseases)	Publicly funded & school-based	Canada (overall) as one of the countries	High income, Middle and Low-income Countries	Barriers – Concerns about vaccine safety benefits, wanting to wait until the daughter is older, not having enough information, cost & affordability, uncertainty around which of the 2 vaccine types to be used, the extent of catch-up vaccine programs, & role of manufacturers & esp. interest group in the promotion	The passive monitoring systems used might have limitations including reporting of events that might have occurred coincidentally following vaccination as well as incomplete reporting
Bird, 2017^Citation37	2006 and later	A Systematic Review and Meta-analysis	Publicly funded vaccine programs	Saskatchewan	Human population in Canada involved in HPVV intervention/General Canadian Population	Vaccine uptake: females was 57.23% higher than males (47.01%), school-based program (69.62%) compared to community-based (18.66%), publicly funded (66%) compared to pay out of pocket (13.5%). Information extracted can be used for identifying areas where gaps lie in the system w.r.t HPVV uptake and/or delivery and administration	The study assessed uptake of a relatively new vaccine, amount of available data in literature was scarce, data analysis revealed significant heterogeneity, little or no data available w.r.t Aboriginal population of Canada
Remes, 2014^Citation44	2007–2011	Population-based, Retrospective Cohort Study	Ontario’s grade 8 HPVV program	Ontario	ALL grade 8 girls in the province of Ontario, Canada (n = 144,047)	Factors – High HPVV refusal rates with Hx of Down’s syndrome (OR = 1.37) and Autism (OR = 1.60), Few physicians visit (OR = 1.45), Hx of previous refusal of mandatory (OR = 2.23) or optional (OR = 3.96) vaccines. Lower HPVV refusal rates with Hx of obesity (OR = 0.87), & living in a deprived area (OR = 0.82)	Uncertainty around area deprivation as a determinant of HPVV refusal due to lack of information on individual-level deprivation, also, girl’s vaccination status might be misclassified as refused if she moved out of participating units during follow-up
Shapiro, 2017^Citation38	2016–2017	Longitudinal design; self-reported data through the online questionnaire	Publicly funded & school-based	Center in Montreal with participants from all of Canada	Parents and Guardians of school-aged girls & boys i.e., 9 to 16 years old (n = 4606)	Facilitators – Information on HPVV programs, improve field’s understanding of influencers of decision-making around HPVV, enhance the delivery of publicly funded HPVV programs, facilitate HPVV uptake & in turn decrease Canada’s cancer burden associated with human & economic cost	The study relied mainly on self-reported data, also the study assessed the same population at two-time points – it did not control for knowledge change that occurs as a result of the 1st survey
McComb, 2018^Citation45	Not found	Qualitative study; semi-structured interviews	n/a	Western Canadian Provinces	New immigrants & refugees (women who were born in a country other than Canada without a prior Hx of HPVV) [n = 11]	Barriers – Participants had limited knowledge about HPV and the vaccine, most women perceived that their risk of HPV was low, women expressed willingness to receive HPV vaccine if it were recommended by their physicians	Among study participants the duration of residence in Canada was variable but most resided in the country <5 years, also the views captured might not be representative of all young immigrant women
Mrklas, 2018^Citation39	Date of inception − 2017	Systematic review protocol – Searched Academic & Grey Literature	All types of HPV related vaccine programs	Calgary	Canadian & global Indigenous peoples (vaccine recipients, youth, parents, grandparents, guardians, elders, knowledge holders, healthcare provider)	Interventions tailored to address specific barriers to HPV vaccination and contextual differences may be required to encourage HPVV acceptability & uptake and reduce hesitancy around it	n/a
Wilson, 2012^Citation32	2010	Semi-structured questionnaire; telephone interviews	Publicly funded & school-based	Ontario	Vaccine-Preventable Disease (VPD) Managers from 36 Health units (Ontario’s Public Health Units)	Barriers – Difficulties receiving agreement from local school boards to administer HPVV in schools, refusal from some catholic schools for HPVV clinics in their school except for certain years/grades. Facilitators – Parental as well as students consent to receive HPVV at the school clinic, Grade 8 student without parental consent if the student requested immunization to HPV & was judged capable of providing informed consent	The study used a self-report approach of VPD managers to describe the program’s implementation, the possibility of incomplete program description due to difficulty in recalling, interviews were not audio-taped for transcription, analysis conducted by 1 person only
Krawczyk, 2015^Citation46	2010	A mail-in questionnaire composed of qualitative & quantitative questions	Publicly funded & School-based	Quebec	Parents of 9–10 years old girls (n = 806)	Barriers – Parental refusal due to fear of side effects, low susceptibility (i.e., their daughter is not at risk). Facilitators – Parental acceptance due to perceived benefits (e.g., cancer/HPV prevention), physician recommendation, & trusting the school vaccine program	The overall response rate was relatively modest (33%), only a small proportion of the study sample had refused the vaccine for their daughters – yielding only a modest amount of data for this study group, sample was composed of mothers predominantly
Krawczyk, 2015^Citation46	2010	Mail-in questionnaire; a cross-sectional survey	Publicly funded & school-based	Quebec	Parents of grade 4 girls/daughters (n = 774)	Parents whose daughters had received the HPVV & those whose daughters had not were distinguished by the following factors: Susceptibility of daughters to HPV Infection (OR = 1.07), Perceived -benefits of vaccine (OR = 1.03), -barriers (OR = 0.94), -vaccine safety (OR = 1.73), cues to action (OR = 1.19), parent’s general vaccination knowledge (OR = 0.87)	Limitations related to the retrospective study design i.e., whether the effects were seen were a cause or consequence of parents’ decisions, recall bias. Also, low response rate & fathers’ under-representation in the study sample
Isenor, 2018^Citation33	2014	Quantitative study; web-based self-administered survey	Publicly funded vaccine programs	New Brunswick	Licensed pharmacists in New Brunswick working either full- or part-time in a clinical pharmacy setting (community pharmacy, ambulatory clinic, or hospital)	Barriers – Reimbursement concerns, managing adverse effects, liability concerns, cost of certification, insufficient staffing, lack of space for vaccine administration, issues around record-keeping, lack of support from physicians and lack of support from management	The study’s response rate was lower than anticipated, more respondents from the study sample identified themselves as owners or managers and community practitioner as compared to practicing in clinical settings
Rambout, 2014^Citation47	2008–2011	A Systematic Review; Searched Academic & Grey Literature	Community & school-based	Ottawa	8079 females (adolescent girls & young women aged 9–26 years) in North America	Barriers – Cost, feelings that vaccination was unnecessary, being sexually inactive, concerns regarding vaccine safety and side effects. Facilitators – perceived benefit of vaccination, health care provider recommendations, and social norms	The study pooled data from small samples of participants with different characteristics, thus limiting the ability to assess whether diverse interventions might be needed for subgroups; also, there were several limitations in the included studies.
Carpiano, 2019^Citation48	2016–2017	Quantitative study; cross-sectional analysis	Publicly funded & school-based	British Columbia, Ottawa, Quebec	Female receipts of HPV vaccination [ages 12–14] (n = 5213)	Factors: SES was associated inconsistently with knowledge, attitude & belief (KAB). Vaccine receipts’ differences in KAB mostly center on vaccine-specific side effects & safety concerns, lower education & income level were associated with higher odds of being concerned. Non-receipt of the vaccine was associated with concerns about vaccine effectiveness & lower perceived importance of immunizing a child	Cross-sectional design limited causal conclusion, the findings based on 2013 National data might not reflect current patterns, the study analysis excluded few parents who refused all child vaccinations
Musto, 2013^Citation49	2008–2011	Quantitative study; cross-sectional cohort design	Publicly funded & school-based	Alberta	All grade 5 and 9 girls	Factors – A girl’s neighborhood SES was related to the likelihood of being HPV vaccinated depending on the service delivery model i.e., in-school OR in-community available to her. Girls with lower SES were differentially disadvantaged by not having access to an “in-school” vaccination delivery model	The study used an area-based material deprivation index as a proxy measure for individual SES as individual data were not available – so the potential for misclassification of SES and thus misclassification bias cannot be eliminated
Shapiro, 2018^Citation50	2016	Quantitative study; cross-sectional design, self-reported survey data	Publicly funded & school-based	Quebec	National sample of Canadian parents (n = 3779)	Factors – Lack of confidence, HPVV related risks, VHS subscales were associated with HPV vaccine refusal and refusing another vaccine (p < .001), sociodemographic differences in the VHS were found, however, effect sizes were small (<0.02), significant differences in the VHS subscales by parents’ vaccine decision-making stages (p < .001)	All ‘lack of confidence’ items were worded positively and all ‘risks’ items were worded negatively, also on the Vaccine Hesitancy Scale (VHS) the identified questions do not address all determinants of vaccine hesitancy
HPV ad hoc scientific committee, 2012^Citation26	2007	A review of the published & unpublished literature & its references	Publicly funded & school-based	Quebec	Qubecians (women, men, girls, boys from the province of Quebec)	Factors – Approval of the vaccines for individuals <15 years for bridging immunogenicity, vaccine cost, physician’s recommendation, organizing delivery of vaccination services, ethical issues of social justice, risks of stigmatization if HPV vaccines were offered only to certain subgroups of the population	The model predictions are still subject to the limitations imposed by the lack of some epidemiological data and uncertainty surrounding the existing data.
Janeczek, 2019^Citation40	2007- and later	A review & search of synthesized published and gray literature	School-based	Ontario	Children and youth 9–18 years old	Facilitators – Reminder interventions, vaccine requirements in schools & national permissive recommendations. For improving HPV vaccine uptake among children & youth; school-based clinics were deemed effective, reminder, healthcare provider & social marketing interventions had mixed effects on uptake	Most of the studies were conducted in the United States, which may limit the generalizability of the findings, the quality of included studies across the reviews was not clearly reported, and heterogeneity of the included studies was high.
RHAs Regional Health Authority, 2015^Citation23	2015–2016	Data collection from RHAs & summarization for preparing a report	Publicly funded & school-based	New Brunswick	All pre-schooler girls and boys meeting immunization requirements during a school year in licensed day-cares of New Brunswick	Factors – Reasons for no immunization: consent not returned, reasons of conscience or religious beliefs, safety concerns, allergy to the vaccine, thinking not at risk or not needing a vaccine, no reasons given. Reasons for incomplete series of immunization: consent withdrew, no show, other reasons	This report does not include immunization coverage rates for specific vaccines, ages, & other categories, no comprehensive immunization registry in New Brunswick therefore accurate tracking was not possible, also immunization systems are not integrated
RHAs Regional Health Authority, 2018^Citation24	2017–2018	Data collection from RHAs & summarization for preparing a report	Community & school-based	New Brunswick	All pre-schoolers’ girls & boys meeting immunization requirements during a school year in licensed day-cares of NB	Factors – Reasons for incomplete or no immunization with HPVV among grade 7 female & male students; consent not returned, no show, other reasons, safety concerns, reasons of conscience or religious beliefs, think not at risk or do not need a vaccine, no reasons	This report does not include immunization coverage rates for specific vaccines, ages, & other categories, no comprehensive immunization registry in NB therefore accurate tracking was not possible, also immunization systems are not integrated.
RHAs Regional Health Authority, 2019^Citation25	2018–2019	Data collection from RHAs & summarization for preparing a report	Publicly funded & school-based	New Brunswick	All pre-schoolers’ girls and boys meeting immunization requirements during a school year in licensed day-cares of NB	Factors – Reasons for incomplete or no immunization with HPV vaccine among grade 7 female & male students; consent not returned, no show, other reasons, safety concerns, reasons of conscience or religious beliefs, think not at risk or do not need vaccine, consent withdrawn, no reasons given	This report does not include immunization coverage rates for specific vaccines, ages, & other categories, no comprehensive immunization registry in NB therefore accurate tracking was not possible, also immunization systems are not integrated
Henderson, 2018^Citation34	2017	Community driven study	Publicly funded & school-based	Alberta, Canada – wide	First Nation Communities (including community elders, parents, health directors, and cancer survivors) (n = 24)	Barriers to HPV vaccination include resource constraints & service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, & community sensitivities regarding sexual health promotion. Facilitators – Supports to strengthen intergenerational relationships in communities	Members from only 6 partnered First Nation communities attended, while a representation of elders & health directors from each was uneven and predominantly women, the absence of youth voices was also noted
Canadian Immunization Committee, 2014^Citation41	2013	A systematic review of the literature & input from CIC meetings	Publicly funded & school-based	Ottawa	Canadian females and males (population)	Facilitators – Consideration of new and unresolved research priorities, evaluation & set of indicators (i.e. adequate measures be taken to prioritize the evaluation of new and ongoing HPV immunization programs, National HPV vaccine coverage rates among immunization program recipients), integration of new population groups into HPV immunization programs be considered using a thoughtful risk-based approach examining issues around equity & ethics, upgrading existing immunization programs & tracking the impact of HPVV programs on cervical cancer screening	Limitations in determining HPV status in males might have contributed to informing certain aspects of this report differently, limitations inherent to conducting a systematic review, and its synthesis.

HPVV = Human papillomavirus vaccination, SES = Socioeconomic status, VHS = Vaccine hesitancy scale, CIC = Canadian Immunization Committee, Hx = History.

Table 2. Descriptive characteristics of findings from studies meeting eligibility criteria based on publication date, study settings & design/method.

Canadian Provincial Jurisdictions & Territories	ALL(N = 33)		AB(N = 5)		BC(N = 5)		MB(N = 2)		NB(N = 4)		NL(N = 0)		NS(N = 2)		ON(N = 12)		PE(N = 0)		QC(N = 8)		SK(N = 3)		Territories*		Total Row
Characteristic	No.	%	No.	%	No.	%	No.	%	No.	%	No	%	No.	%	No.	%	No.	%	No.	%	No.	%	No.	%	No.
PUBLICATION DATE
2010–2014	11	33.3	2	40.0	2	40.0	1	50.0	0	0	0	0	2	100	5	42.0	0	0	4	50	1	33.3	0	0	17
2015–2019	22	66.7	3	60.0	3	60.0	1	50.0	4	100	0	0	0	0	7	58.0	0	0	4	50	2	66.6	0	0	24
STUDY SETTING
School-based	8	24.2	1	20.0	2	40.0	1	50.0	0	0	0	0	2	100	4	33.3	0	0	2	25.0	1	33.3	0	0	13
Community-based/Publicly	3	9.1	1	20.0	1	20.0	0	0	1	25.0	0	0	0	0	2	16.7	0	0	0	0	1	33.3	0	0	6
Hybrid	22	66.7	3	60.0	2	40.0	1	50.0	3	75.0	0	0	0	0	6	50.0	0	0	6	75.0	1	33.3	0	0	22
STUDY DESIGN/METHOD
Survey	5	15.0	1	20	2	40	1	50	1	25	0	0	2	100	2	16.7	0	0	3	37.5	1	33.3	0	0	13
Qualitative	6	18.0	1	20	2	40	1	50	0	0	0	0	0	0	4	33.3	0	0	1	12.5	1	33.3	0	0	10
Cohort	2	6.0	0	0	0	0	0	0	0	0	0	0	0	0	1	8.3	0	0	1	12.5	0	0	0	0	2
Cross-sectional	5	15.0	1	20	1	20	0	0	0	0	0	0	0	0	2	16.7	0	0	1	12.5	0	0	0	0	5
Mixed-Method	1	3.0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1	12.5	0	0	0	0	1
Community-Driven	1	3.0	1	20	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1
Review/Reports	13	40.0	1	20	0	0	0	0	3	75	0	0	0	0	3	25	0	0	1	12.5	1	33.3	0	0	9

The total row values might not sum to the corresponding row total due to the following reasons: 1) Some studies examine more than one province at a time (causing province overlap or repetition), 2) The column – Canadian Jurisdictions (ALL) displays a discrete break down of all the 33 included studies inclusive of Canada-wide/ overall studies. Due to the same reason, the individual cell values might not sum to the corresponding column total. Territories* include Northwest Territories, Yukon, and Nunavut. AB: Alberta, BC: British Columbia, MB: Manitoba, NB: New Brunswick, NL: Newfoundland and Labrador, NS: Nova Scotia, ON: Ontario, PE: Prince Edward Island, QC: Quebec, SK: Saskatchewan.

Table 3. Descriptive characteristics of findings from studies meeting eligibility criteria based on vaccine receiver and provider subgroups, HPVV status, and factors around HPV immunization.

Canadian Provincial Jurisdictions & Territories	ALL(N = 33)		AB(N = 5)		BC(N = 5)		MB(N = 2)		NB(N = 4)		NL(N = 0)		NS(N = 2)		ON(N = 12)		PE(N = 0)		QC(N = 8)		SK(N = 3)		Territories*		Total Row
Characteristic	No.	%	No.	%	No.	%	No.	%	No.	%	No	%	No.	%	No.	%	No.	%	No.	%	No.	%	No.	%	No.
SUB-GROUPS OF VACCINE RECEIVERS
School/University goers	7	21.2	1	20	0	0	0	0	3	75	0	0	0	0	2	16.7	0	0	0	0	0	0	0	0	6
Young girls & boys (age>9)	3	9.0	0	0	1	20	0	0	0	0	0	0	0	0	3	25	0	0	1	12.5	0	0	0	0	5
Parents of kids in grade>4	5	15.1	0	0	1	20	0	0	0	0	0	0	0	0	0	0	0	0	4	50	0	0	0	0	5
Newcomers	1	3.1	1	20	1	20	1	50	0	0	0	0	0	0	0	0	0	0	0	0	1	33.3	0	0	4
Canadian population	5	15.1	0	0	0	0	0	0	0	0	0	0	0	0	1	8.3	0	0	1	12.5	1	33.3	0	0	3
SUB-GROUPS OF VACCINE PROVIDERS
Physicians	2	6.1	1	20	1	20	1	50	0	0	0	0	1	50	2	16.7	0	0	1	12.5	1	33.3	0	0	8
Pharmacists	1	3.1	0	0	0	0	0	0	1	25	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1
Public Health Professionals	1	3.1	0	0	0	0	0	0	0	0	0	0	0	0	1	8.3	0	0	0	0	0	0	0	0	1
Others	8	24.2	2	40	1	20	0	0	0	0	0	0	1	50	3	25	0	0	1	12.5	0	0	0	0	8
HPV VACCINATION STATUS
Uptake	22	66.7	5	100	5	100	2	100	0	0	0	0	2	100	9	75	0	0	4	50	3	100	0	0	30
Completion	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Catch-up	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Hybrid	11	33.3	0	0	0	0	0	0	4	100	0	0	0	0	3	25	0	0	4	50	0	0	0	0	11
FACTORS AROUND HPV IMMUNIZATION
Personal	13	39.4	2	40	2	40	0	0	3	75	0	0	0	0	5	41.7	0	0	4	50	0	0	0	0	16
System	11	33.3	2	40	2	40	1	50	0	0	0	0	2	100	3	25	0	0	2	25	2	66.7	0	0	14
Hybrid	9	27.3	1	20	1	20	1	50	1	25	0	0	0	0	4	33.3	0	0	2	25	1	33.3	0	0	11

The total row values might not sum to the corresponding row total due to the following reasons: 1) Some studies examine more than one province at a time (causing province-overlap or repetition), 2) The column – Canadian Jurisdictions (ALL) displays a discrete break down of all the 33 included studies inclusive of Canada-wide/ overall studies. Due to the same reason, the individual cell values might not sum to the corresponding column total.

Territories* include Northwest Territories, Yukon, and Nunavut.

AB: Alberta, BC: British Columbia, MB: Manitoba, NB: New Brunswick, NL: Newfoundland and Labrador, NS: Nova Scotia, ON: Ontario, PE: Prince Edward Island, QC: Quebec, SK: Saskatchewan.

Table 4. Barriers and facilitators around human papillomavirus immunization uptake across English Canada.

REFERENCES	CODES: The 5 A’s	PROVIDER-LEVEL BARRIERS
Ferrer, 2014^Citation27	Acceptability	Healthcare professional recommendation & provision
Dube, 2019^Citation3	Approachability, Affordability	Allocated resources, information provision, consent process, immunization setting & environment, changes in provincial HPVV program.
Grace, 2019^Citation28	Affordability, Acceptability	Physicians’ HPVV recommendation practices limited by a) cost/insurance coverage for some older patients & how the vaccine was discussed, b) physicians’ perspective on prevention & therapeutic benefits of vaccinating older GBM (over 26 years)
Grace, 2018^Citation29	Acceptability	HPV Health literacy levels particularly the longstanding gendered association with HPVV
Scott, 2016^Citation30	Approachability	Health provider’s recommendation, Nurse practitioners’ position to collaborate with public health agencies to expand knowledge & coverage across Canada
Markowitz, 2012^Citation31	Affordability, Acceptability, Appropriateness	Cost & affordability, uncertainty around the use of 2 vaccine types, the extent of catch-up vaccine programs, the role of manufacturers & interest group in the promotion
Wilson, 2012^Citation32	Acceptability	Difficulties receiving agreement from local school boards to administer HPVV in schools, refusal from some catholic schools for HPVV clinics in their school except for certain years/grade
Isenor, 2018^Citation33	Availability	Insufficient staffing, lack of space for vaccine administration, record keeping, lack of support from physicians, and lack of support from management
HPV ad hoc SC, 2012	Approachability	Approval of the vaccines for individuals<15 y. for bridging immunogenicity, organizing delivery of vaccination services
Henderson, 2018^Citation34	Affordability, Approachability, Acceptability	Resource constraints & service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication & community sensitivities regarding sexual health promotion
Frequency of appearance of a particular theme identified as Provider-Level Barrier: Acceptability = 6, Approachability = 4, Affordability = 3, Availability = 1, Appropriateness = 1,
REFERENCES	CODES: The 5 A’s	PROVIDER-LEVEL FACILITATORS
Fernandes, 2018^Citation35	Acceptability	Positive perceptions about HPVV
Auguston, 2019^Citation36	Appropriateness	Targeted health promotion
Bird, 2017^Citation37	Appropriateness	The following information can be used for identifying areas where gaps lie in the system w.r.t HPVV uptake and/or delivery and administration: Vaccine uptake; females was 57.23% higher than males (47.01%), school-based programs (69.625) compared to community-based (18.66%), publicly funded (66%) compared to pay out of pocket (13.5%).
Shapiro, 2017^Citation38	Availability	Enhance the delivery of publicly funded HPVV programs
Shapiro, 2017^Citation38	All 5 A’s	Information on HPVV uptake rate might be useful in identifying regions of Canada that may benefit from psychosocial or economic intervention
Mrklas, 2018^Citation39	Availability, Appropriateness	Interventions tailored to address specific barriers to HPVV, contextual differences may be required to encourage HPVV acceptability & uptake and reduce hesitancy
Wilson, 2012^Citation32	Appropriateness	Grade 8 student without parental consent if the student requested immunization to HPV & was judged capable of providing informed consent
Janeczek, 2019^Citation40	Appropriateness, Availability	School-based clinics were deemed effective, interventions tailored to address specific barriers to HPVV, and healthcare provider & social marketing interventions
Dube, 2008,^Citation32	Appropriateness, Affordability	HPVV preferable before the onset of sexual relations, and in a primary school environment to obtain a higher immunization coverage, at a lower cost. Benefits from a universal vaccination program, equity of the new programs including universality, accessibility & free services for the population groups which are most vulnerable
Henderson, 2018^Citation34	Acceptability, Appropriateness	Supports to strengthen intergenerational relationships in communities
CIC, 2014^Citation41	Appropriateness, Availability	Consideration of new and unresolved research priorities, Evaluation & setting of indicators (i.e., Adequate measures be taken to prioritize the evaluation of new and ongoing HPV immunization programs), National HPV vaccine coverage rates among immunization program recipients
Frequency of appearance of a particular theme identified as Provider-Level Facilitator: Appropriateness = 9, Availability = 5, Acceptability = 3, Affordability = 1, Approachability = 1
REFERENCES	CODES: The 5 A’s	PATIENT-LEVEL BARRIERS
Ogilvie, 2010^Citation42	Ability to perceive	Concerns about HPVV safety, preference to wait until the daughter is older, not enough info to make an informed decision
Fernandes, 2018^Citation35	Ability to perceive	Lack of knowledge about vaccines, potential efficacy and side effects, and vaccination cost
Ferrer, 2014^Citation27	Ability to engage, Ability to pay	Social norms & values, vaccine cost, availability & delivery, parents decision-making & consent, sexual mores, trust, women’s autonomy
Shapiro, 2017^Citation38	Ability to reach	Certain groups receive HPVV outside school i.e., children with fear of needles
Dube, 2019^Citation5	Ability to perceive	Knowledge & attitudes of the different players involved in the vaccination system, social group values & norms, media coverage around HPVV
Auguston, 2019^Citation36	Ability to seek, Ability to perceive, Ability to reach	Access, communication, knowledge, culture, & provider-related factors
Grace, 2018^Citation29	Ability to perceive, Ability to pay	Lack of knowledge, financial barriers to vaccine access, beliefs that HPV was predominantly/exclusively a risk for females, uncertain about the availability of vaccine
Stanley, 2018^Citation43	Ability to pay, Ability to perceive	Personal cost, Perceived lack of data on efficacy & concerns about being over the recommended age
Scott, 2016^Citation30	Ability to perceive	Family’s lack of knowledge about the vaccine, and attitudes that are not informed by science & epidemiology
Markowitz, 2012^Citation31	Ability to perceive, Ability to seek	Concerns about vaccine safety & benefits, wanting to wait until the daughter is older, not having enough information
Remes, 2014^Citation44	Ability to perceive	HPVV high refusal rates; Hx of Down’s syndrome and Autism, few physicians visit, Hx of the previous refusal of the mandatory or optional vaccine
McComb, 2018^Citation45	Ability to perceive	Participants had limited knowledge about HPV and the vaccine, also most women perceived that their risk of HPV was low
Krawczyk, 2015^Citation46	Ability to perceive	Parental refusal due to fear of side effects, low susceptibility (e.g., their daughter is not at risk)
Krawczyk, 2015^Citation46	Ability to perceive, Ability to seek	Low susceptibility (i.e., their daughter is not at risk, feelings that vaccination was unnecessary, being sexually inactive), parents general knowledge about HPVV
Isenor, 2018,^Citation23	Ability to pay, Ability to engage	Reimbursement concerns, managing adverse effects, liability concerns, and cost of certification
Rambout, 2014^Citation47	Ability to pay, seek, and perceive	Cost, feelings that vaccination was unnecessary, being sexually inactive, concerns regarding vaccine safety and side effects
Carpiano, 2019^Citation48	Ability to pay, Ability to engage	SES was associated inconsistently with Knowledge, Attitude & Belief (KAB), differences in KAB mostly center on vaccine-specific S/E & safety concerns, lower education & income level was associated with higher odds of being concerned
Musto, 2013^Citation49	Ability to reach	A girl’s neighborhood SES was related to the likelihood of being HPV vaccinated depending on the service delivery model i.e. in-school OR in-community availability i.e. girls with lower SES were differentially disadvantaged by not having access to an “in-school” vaccination delivery model
Shapiro, 2018^Citation50	Ability to seek	Vaccine Hesitancy Scale (VHS); VHS subscales were associated with HPV vaccine refusal and refusing another vaccine
RHAs, 2018^Citation25	Ability to seek	Consent not returned, reasons of conscience or religious beliefs, safety concerns, allergy to the vaccine, think not at risk or do not need the vaccine, no reasons given; for incomplete series of immunization: consent withdrawn, no show, other reasons.
Frequency of appearance of a particular theme identified as Patient-Level Barrier: Ability to perceive = 12, Ability to seek = 6, Ability to engage = 3, Ability to pay = 5, Ability to reach = 3
REFERENCES	CODES: The 5 A’s	PATIENT-LEVEL FACILITATORS
Dube, 2012^Citation51	Ability to perceive, Ability to seek	Perceived acceptability by vaccine providers and by the public, self-estimated sufficiency of knowledge on HPVV, perceived efficacy of the HPVV
Whelan, 2014^Citation52	Ability to engage, Ability to perceive, Ability to reach	Public Health Nurses (PHNs) being assigned to a school, reminder calls, consent returns, missed school clinics, teachers’ education, and a thank-you note to teachers
Auguston, 2019^Citation36	Ability to perceive, Ability to seek	Understanding relevance of HPVV; trusting healthcare system, & cultural sensitivity
Stanley, 2018^Citation43	Ability to perceive, Ability to seek	Personal protection from HPV disease was the most common motivating factor
Remes, 2014^Citation44	Ability to engage, Ability to reach	Factors associated with HPVV Lower refusal rates; Hx of obesity, & living in a deprived area
McComb, 2018^Citation45	Ability to seek	Women expressed willingness to receive HPV vaccine if it were recommended by their physicians
Krawczyk, 2015^Citation46	Ability to perceive, Ability to seek	Parental acceptance due to perceived benefits e.g., health protection, cancer/HPV prevention, trusting the school vaccine program, and physician recommendation
Rambout, 2014^Citation24	Ability to perceive	Perceived benefit of vaccination, health care provider recommendations, and social norms
Frequency of appearance of a particular theme identified as Patient-Level Facilitator: Ability to perceive = 6, Ability to seek = 5, Ability to engage = 2, Ability to reach = 2, Ability to pay = 0
REFERENCES	CODES: CCCAP	SYSTEM-LEVEL BARRIERS
Dube, 2012^Citation51	Attitudes	Physicians’ intention to recommend HPVV were perceived acceptability by vaccine providers and by the public, self-estimated sufficiency of knowledge on vaccines, perceived efficacy of the HPV vaccines
Fernandes, 2018^Citation35	Cost	Lack of knowledge about vaccines, potential efficacy and side effects, and vaccination cost.
Grace, 2019^Citation28	Cost Catch-up Program Attitudes	Physicians’ HPV vaccine recommendation practices limited by a) cost/insurance coverage for some older patients & how the vaccine was discussed, b) physicians’ perspective on prevention & therapeutic benefits of vaccinating older GBM (over 26 years)
Dube, 2019^Citation5	Attitudes, Cost, Provision, Supply-Chain maintenance	Knowledge & attitudes of the different players involved in vaccination system, social group values & norms, media coverage around HPVV, allocated resources, information provision, consent process, immunization setting & environment, changing provincial HPVV program
Shapiro, 2017^Citation38	Provision	Certain groups receive HPVV outside school i.e., children with fear of needles
Whelan, 2014^Citation52	Attitudes, Catch-up Program	HPVV uptake was significantly associated with PHNs providing reminder calls for; consent return, missed school clinics; teachers’ education, a thank-you note to teachers, HPVV completion with consent being returned, PHN being assigned to a school
Auguston, 2019^Citation36	Attitudes, Provision	Access, communication, knowledge, culture, and provider-related factors.
Ferrer, 2014^Citation27	Cost, Supply-Chain maintenance, Provision	Social norms & values, vaccine cost, vaccine availability & delivery, parents decision-making & consent, sexual mores, trust issue, women’s autonomy, and healthcare professional recommendation & provision
Grace, 2018^Citation29	Attitudes, Cost, Provision	Lack of knowledge, financial barriers to vaccine access, beliefs that HPV was predominantly/exclusively a risk for females, uncertain about the availability of vaccines & their knowledge, HPV Health literacy levels particularly around the longstanding gendered association with HPV
Scott, 2016^Citation30	Attitudes, Provision	Family’s’ lack of knowledge about the vaccine, and attitudes that are not informed by science & epidemiology, health providers’ recommendation of HPVV, nurse practitioners’ position to collaborate with public health agencies to expand knowledge & coverage across Canada
Stanley, 2018^Citation43	Cost, Attitudes	Personal cost, perceived lack of data on efficacy & concerns about being over the recommended age
McComb, 2018^Citation45	Attitudes	Participants had limited knowledge about HPV and the vaccine, most women perceived that their risk of HPV was low, women expressed willingness to receive HPV vaccine if it were recommended by their physicians
Markowitz, 2012^Citation31	Attitudes, Cost, Catch-up Program, Supply-Chain maintenance	Concerns about vaccine safety benefits, wanting to wait until the daughter is older, not having enough information, cost & affordability, uncertainty around which of the 2 vaccine types to be used, the extent of catch-up vaccine programs, & role of manufacturers & esp. interest group in the promotion
Wilson, 2012^Citation32	Attitudes	Difficulties receiving agreement from local school boards to administer HPVV in schools, refusal from some catholic schools for HPVV clinics in their school except for certain years/grades
Krawczyk, 2015^Citation46	Attitudes	Parental refusal due to fear of side effects, low susceptibility (i.e., their daughter is not at risk).
Isenor, 2018^Citation23	Provision, Cost	Reimbursement concerns, managing adverse effects, liability concerns, cost of certification, insufficient staffing, lack of space for vaccine administration, issues around record-keeping, lack of support from physicians and lack of support from management
Rambout, 2014^Citation47	Cost, Attitudes	Cost, feelings that vaccination was unnecessary, being sexually inactive, concerns regarding vaccine safety and side effects
Carpiano, 2019^Citation48	Attitudes, Cost	SES was associated inconsistently with knowledge, attitude & belief (KAB). Vaccine receipts’ differences in KAB mostly center on vaccine-specific side effects & safety concerns; lower education & income level were associated with higher odds of being concerned. Non-receipt of the vaccine was associated with concerns about vaccine effectiveness & lower perceived importance of immunizing a child
Musto, 2013^Citation49	Provision, Cost	A girl’s neighborhood SES was related to the likelihood of being HPV vaccinated depending on the service delivery model, i.e., in-school OR in-community available to her. Girls with lower SES were differentially disadvantaged by not having access to an “in-school” vaccination delivery model
Shapiro, 2018^Citation50	Attitudes Cost, Provision	Lack of confidence, HPVV-related risks, VHS subscales were associated with HPV vaccine refusal and refusing another vaccine (p < .001), sociodemographic differences in the VHS were found; however, effect sizes were small (<0.02), significant differences in the VHS subscales by parents’ vaccine decision-making stages (p < .001)
RHAs Regional Health Authority, 2015^Citation23	Attitudes	Reasons for no immunization: consent not returned, reasons of conscience or religious beliefs, safety concerns, allergy to the vaccine, thinking not at risk or not needing a vaccine, no reasons given. Reasons for incomplete series of immunization: consent withdrawn, no show, other reasons
Henderson, 2018^Citation34	Cost, Provision, Attitudes	Barriers to HPV vaccination include resource constraints & service infrastructure gaps, historical mistrust in healthcare systems, impacts of changing modes of communication, & community sensitivities regarding sexual health promotion.
Frequency of appearance of a particular theme identified as System-Level Barrier: Attitude = 17, Cost = 13, Provision = 10, Catch-up Program = 3, Supply Chain Maintenance = 3
REFERENCES	CODES: CCCAP	SYSTEM-LEVEL FACILITATORS
Shapiro, 2017^Citation38	Provision	Info on HPVV uptake rate might be useful in identifying regions of Canada that may benefit from psychosocial or economic intervention & elucidate emerging issues for policymakers
Bird, 2017^Citation37	Cost, Provision	Vaccine uptake: females was 57.23% higher than males (47.01%), school-based program (69.62%) compared to community-based (18.66%), publicly funded (66%) compared to pay out of pocket (13.5%). Information extracted can be used for identifying areas where gaps lie in the system w.r.t HPVV uptake and/or delivery, and administration
Remes, 2014^Citation44	Attitudes, Cost	High HPVV refusal rates with Hx of Down’s syndrome and Autism, Few physicians visit, Hx of previous refusal of mandatory or optional (OR = 3.96) vaccines. Lower HPVV refusal rates with Hx of obesity, & living in a deprived area
Shapiro, 2017^Citation38	Attitudes, Provision, Cost	Information on HPVV programs, improve field’s understanding of influencers of decision-making around HPVV, enhance the delivery of publicly funded HPVV programs, facilitate HPVV uptake & in turn decrease Canada’s cancer burden associated with human & economic cost
Wilson, 2012^Citation32	Attitudes, Provision	Parental as well as students consent to receive HPVV at the school clinic, Grade 8 student without parental consent if the student requested immunization to HPV & was judged capable of providing informed consent
Mrklas, 2018^Citation39	Attitudes, Provision	Interventions tailored to address specific barriers to HPV vaccination and contextual differences may be required to encourage HPVV acceptability & uptake and reduce hesitancy around it
Krawczyk, 2015^Citation46	Attitudes	Parental acceptance due to perceived benefits (e.g., cancer/HPV prevention), physician recommendation, & trusting the school vaccine program
Auguston, 2019^Citation36	Attitudes, Provision	Targeted health promotion, understanding the relevance of HPVV, trusting healthcare system, and cultural sensitivity
Krawczyk, 2015^Citation46	Attitudes	Parents whose daughters had received the HPVV & those whose daughters had not were distinguished by the following factors: Susceptibility of daughters to HPV Infection (OR = 1.07), Perceived -benefits of vaccine (OR = 1.03), -barriers (OR = 0.94), -vaccine safety (OR = 1.73), cues to action (OR = 1.19), parent’s general vaccination knowledge
Rambout, 2014^Citation47	Attitudes	Perceived benefit of vaccination, health care provider recommendations, and social norms
HPV ad hoc scientific committee, 2012^Citation26	Attitudes, Provision	Approval of the vaccines for individuals<15 years for bridging immunogenicity, vaccine cost, physician’s recommendation, organizing delivery of vaccination services, ethical issues of social justice, risks of stigmatization if HPV vaccines were offered only to certain subgroups of the population
Janeczek, 2019^Citation40	Attitudes, Provision	Reminder interventions, vaccine requirements in schools & national permissive recommendations. For improving HPV vaccine uptake among children & youth, school-based clinics were deemed effective, reminder, healthcare provider & social marketing interventions had mixed effects on uptake
Henderson, 2018^Citation34	Attitudes	Supports to strengthen intergenerational relationships in communities
Stanley, 2018^Citation43	Attitudes	Personal protection from HPV disease was the most common motivating factor (43.4%).
Canadian Immunization Committee, 2014^Citation40	Provision, Supply-Chain maintenance, Catch-up Program, Cost, Attitudes	Consideration of new and unresolved research priorities, evaluation & set of indicators (i.e. adequate measures be taken to prioritize the evaluation of new and ongoing HPV immunization programs, National HPV vaccine coverage rates among immunization program recipients), integration of new population groups into HPV immunization programs be considered using a thoughtful risk-based approach examining issues around equity & ethics, upgrading existing immunization programs & tracking the impact of HPVV programs on cervical cancer screening
Frequency of appearance of a particular theme identified as System-Level Facilitator: Attitudes = 13, Provision = 9, Cost = 4, Catch-up Program = 1, Supply Chain Maintenance = 1

CIC = Canadian Immunization Committee, RHAs = Regional Health Authorities, SC = Scientific committee, HPVV = Human papillomavirus vaccination, SES = Socioeconomic status, VHS = VaccineHesitancy Scale,Hx = History.

CODES: The 5 A’s in provider level barriers and facilitator reflect themes from Leveque’s conceptual framework i.e. Appropriateness, Affordability, Availability, Acceptability, and Approachability.

CODES: The 5A’s in patient-level barriers and facilitators reflect themes from Leveque’s conceptual framework, i.e., Ability to engage, Ability to pay, Ability to reach, Ability to seek, and Ability to perceive.

CODES: CCCAP reflects system-level determinants of HPVV uptake, i.e., Cost, Catch-up programs, vaccine supply Chain, vaccine Attitudes and Provision.

Frequency of appearance of a particular theme identified as Provider-, Patient-, and System -Level provides an idea of the number of times we used that code for the selected text.

Using the pre-identified themes (at the patient, provider, and system levels), the selected text is bolded to signify the units and categories based on their presence in the selected text and frequency of appearance.

Table

Search statement or topic
Barriers against HPVV uptake and Interventions that enhance HPVV uptake in Canada.
Major concepts
Identify the main concepts of your topic.
1. Human Papilloma Virus Vaccination/immunization	2. Barriers and Interventions	3. Age group	4. Health Equity	5. Developed Countries

Table

Search strategy
Use the main concepts and translate these into keywords and synonyms (don’t forget about “” and *).
	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5
	Human Papilloma virus	Barrier*	“teenage girls”	“Health equity”	“Developed countries”
OR	HPVV	Intervention*	Adolescent*	Equity	“Industrialized countries”
OR	HPV	Support*	pediatric	Inequity	“developed world”
OR	Cervarix	Acceptability	“school aged”	Equality	“industrialized world”
OR	Gardasil	Accessibility	“Pediatric group”	Inequality	Canada
OR	“Gardasil 9”	Feasible	teenage	Disparity	USA
OR	“Viral wart”	Feasibility	teenager*	Inequalities	“North America”
OR	“HPV Vaccine”	Available	child	Justice	“Scandinavian countries”
OR	“Papillomavirus vaccine”	Availability	children	Injustice	Scandinavians
OR	“HPV immunization”	Challenge*	Girl*	Colonized	“Great Britain”
OR	“Papillomavirus infection”	Hesitancy	Female*	Colonization	Europe
OR	“virus disease”	Acceptance	Boy*	“Socioeconomic status”	Australia
OR	“uterine cervical neoplasm”	“Decision-making”	Male*	“Socio-economic status”	Netherland
OR	“preventable cancer”	“Decision making”	“school goers”	SES	UK
OR	“cancer prevention”	“Decision maker”	Women	Social determinant*	“The UK”
OR	“cervical cancer”	Mass screening*/	Men	“First Nation”	“The USA”
OR	“HPV-related cancers”	Sexual behavior*	“9 through 45 years”	Inconsistency*	Sweden
OR	“HPV related cancers”	Sex factor*	“females in grade 4”	Determinant*	Norway
OR	“HPV-related diseases”	Sex Psychology	“females in grade 5”	“Health disparity”	Germany
OR	“HPV related diseases”	“Directive counseling”	“females in grade 6”	Income*	France
OR	Immunization	Adj, health knowledge, attitude, and practice/[ethnology]	“females in grade 7”	Salary	“United States of America”
OR	“Immunization policy”	Trust issue*	“females in grade 8”	Wage*	“United Kingdom”
OR	“Immunization program”	“Health care personnel”	“teenage boys”	subsidy	“New Zealand”
OR	“vaccination coverage”	“Acceptance of health care”	Middle age	unemployment	“PAN European”
OR	“school-based immunization programs”	“vaccination psychology”	Adult/	Job*	Denmark
OR	“community- based immunization programs”	Adj, vaccination method*/	Humans/	Occupation*
OR	“school-based vaccination programs”	Sex factor	Young Adult/	Migration
OR	“community based vaccination programs”	Consumer behavior	Students/	Immigration
OR	“Vaccination up take”	Age factor*	University student*/	Immigrant*
OR	“Vaccine Completer”	Vaccine approach	College goer*/	Subgroup*
OR	“primary cancer prevention”	Needle approach	Middle aged/	Sub-group
OR	“HPV types”	Needle hesitancy		Subpopulation
OR	“HPV-9”	Vaccine hesitancy		Newcomer*
OR	“HPV 9 Vaccine”			Refugee*
OR	“HPV-4”			“Healthcare providers”
OR	“HPV-4 Vaccine”			Poor
OR	HPV2			Poverty
OR	“Nine-valent HPV vaccine”			Aboriginal*
OR	“nonvalent vaccine”			Indigenous
OR	“quadrant vaccine”			“Communities at reserve”
OR	“Sexually transmitted infections”			Native*
OR	STI*			Race
OR	AGW*			Racism
OR	“Anogenital warts”			Racial
OR	“anal cancers”			Racist
OR	“Precancerous lesions”			Ethnic*
OR	“vaginal cancers”			Sex*
OR	“penile cancers”			Gender*
OR	“oropharyngeal cancers”			Neighborhood*
OR	“throat cancers”			Neighborhood*
OR	“nose cancers”			Environment
OR	“mouth cancers”			Rural AND Urban
OR	CIN			Gap*
OR	“Cervical intraepithelial neoplasia”			Marginalization
OR	“Cervical dysplasia”			Marginalized
OR	“uterine cervix tumor”			Worst-off
OR	Papillomaviridae			Culture*
OR	“Head and neck cancers”			Cultural*
OR	Viral verruca/			Religion*
OR	Warts/			“Health care accessibility”
OR	Viral verrucas/			“Healthcare accessibility”
OR	Papillomavirus infections/			“Health services availability”
OR	HPV infection/			“Health care availability”
OR	HPV infections/			“Healthcare availability”
OR	Papillomavirus infection/			“Health services delivery”
OR	Papillomavirus infection, human/			“Delivery of health services”
OR	Papillomavirus infections, human/			“Health care delivery”
OR	DNA Virus Infections/			“Healthcare delivery”
OR	Tumor virus infections/			“Right to health”
OR	HPV immunization schedule/			“Universal health care”
OR	Immunization programs/			“Universal healthcare”
OR	Adj, human papillomavirus 16/immunology*			Insurance
OR	Adj, human papillomavirus 18/immunology*			“Health provision”
OR	Adj, papillomavirus vaccines/immunology			Ethnic group/
OR	Adj, papillomavirus infections/prevention & control*			Health services accessibility/
OR	Adj, papillomavirus vaccines/administration & dosage*			Health status disparities/
OR	Adj, Uterine cervical neoplasms/prevention & control			Social determinant of health/
OR	Adj, Uterine cervical neoplasms/virology			Health equity/organization & administration
OR	Virus, Human Papilloma/			Health equity/standards
OR	Adj, papillomavirus vaccines/therapeutic use			living standard/
OR	Adj, Oropharyngeal neoplasm/etiology			Housing standard/
OR	Adj, Papillomaviridae/pathogenicity			Health status/
OR	Adj, papillomavirus infections/complications			health equity/trend*
OR	Adj, Uterine cervical neoplasms/diagnosis*			Insurance coverage/
OR	Adj, Uterine cervical neoplasms/immunology			Health insurance/
OR	Adj, papillomavirus vaccines/virology			Health expenditure/
OR	Adj, papillomavirus vaccines/diagnosis			Health funding/
OR	Adj, Papillomaviridae/drug effects
OR	Adj, Papillomaviridae/isolation & purification
OR	Adj, papillomavirus infections/diagnosis*
OR	Adj, papillomavirus infections/epidemiology
OR	Adj, Uterine cervical neoplasms/epidemiology
OR	Adj, papillomavirus infections/prevention & control*
OR	Adj, papillomavirus vaccines/administration & dosage*
OR	Adj, Neoplasms/virology*
OR	Adj, Adj, Papillomaviridae/physiology
OR	Adj, penile neoplasm/virology
OR	Adj, penile neoplasm/prevention & control*
OR	Adj, vaginal neoplasm/virology
OR	Adj, vaginal neoplasm/prevention & control*
OR	Adj, Oropharyngeal neoplasm/virology
OR	Adj, Oropharyngeal neoplasm/prevention & control*
OR	Adj, Anus neoplasm/virology
OR	Adj, Anus neoplasm/prevention & control*
OR	Adj, vulvar neoplasm/virology
OR	Adj, vulvar neoplasm/prevention & control*

Table

Data base	Syntax	Articles found (n)
MEDLINE - OVID Upper-case letters for key terms and lower-case letters for MeSH terms SEARCH FILTERS: Dropped broad key terms (un- stabilizing the results – some too broad in scope) Search Limited to: English (only), last ten years, publications types included journal articles (excluded: news, conference papers, clinical trials, letters, handouts, Webcast etc.)	Key terms search syntax: 1# ((HUMAN PAPILLOMA VIRUS or HPVV or HPV or CERVARIX or GARDASIL or GARDASIL 9 or VIRAL WART or HPV VACCINE or PAPILLOMAVIRUS VACCINE or HPV IMMUNIZATION or PAPILLOMAVIRUS INFECTION or VIRUS DISEASE or UTERINE CERVICAL NEOPLASM or PREVENTABLE CANCEROR CANCER PREVENTION or CERVICAL CANCER or HPV-RELATED CANCER or HPV RELATED CANCER or HPV-RELATED DISEASES or HPV RELATED DISEASES or IMMUNIZATION or IMMUNIZATION POLICY or IMMUNIZATION PROGRAM or VACCINATION COVERAGE or SCHOOL-BASED IMMUNIZATION PROGRAMS or COMMUNITY-BASED IMMUNIZATION PROGRAMS or SCHOOL-BASED IMMUNIZATION PROGRAMS or COMMUNITY BASED VACCINATION PROGRAMS or VACCINATION UPTAKE or COMPLETER or PRIMARY CANCER PREVENTION or HPV TYPES or HPV-9 or HPV 9 VACCINE or HPV-4 VACCINE or HPV2 or NINE-VALENT HPV VACCINE or NONVALENT VACCINE or QUADRANT VACCINE or SEXUALLY TRANSMITTED INFECTIONS or STI or AGW or ANOGENITAL WARTS or ANAL CANCERS or PRECANCEROUS LESIONS or VAGINAL CANCERS or PENILE CANCERS or OROPHARANGEAL CANCERS or THROAT CANCERS or NOSE CANCERS or MOUTH CANCER or CIN or CERVICAL INTRAEPITHELIAL NEOPLASM or CERVICAL DYSPLASIA or UTERINE CERVIX TUMOR or PAPILLOMAVIRIDAE or HEAD) and NECK CANCERS). MeSH Term search syntax: 2# Viral verruca/or Viral verrucas/or Warts/or Papillomavirus infections/or HPV infection/, 3# HPV infections/or Papillomavirus infection/or HPV infections/or HPV infection/or Papillomavirus infections/or papillomavirus infections/, 5# Uterine cervical neoplasms virology/or Virus, Human Papilloma/or papillomavirus vaccines/, 6# Oropharyngeal neoplasm/or etiology/or Papillomaviridae/or pathogenicity/, 7# papillomavirus infections/or Uterine cervical neoplasms/or Uterine cervical neoplasms/or papillomavirus vaccines/, 8# papillomavirus vaccines/or Papillomaviridae/or drug effects/or Papillomaviridae/, 9# papillomavirus infections/or epidemiology/or “Uterine cervical neoplasms”/or epidemiology/or papillomavirus infections/,12# Anus neoplasm/or virology/or Anus neoplasm/or vulvar neoplasm/or virology/or vulvar neoplasm/, 10# papillomavirus vaccines/or administration.mp. or dosage*/or Neoplasms/or virology*/or penile neoplasm/or virology/, 11# vaginal neoplasm/or prevention.mp. or control*/or Oropharyngeal neoplasm/or virology/or Oropharyngeal neoplasm/[mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms], AND 13# (BARRIER or INTERVENTION or SUPPORT or ACCEPTIBILITY or ACCESSIBILITY or FEASIBLE or FEASIBILITY or AVAILABE or AVAILABILITY or CHALLENGE or HESITANCY or ACCEPTANCE or DECISION-MAKING or DECISION MAKING or DECISION MAKER).tw, 14# Mass screening*/, 15# vaccination method*/AND 16# (TEENAGE GIRL or ADOLESCENT or PEDIATRIC or SCHOOL AGED or PAEDIATRIC GROUP or TEENAGE or TEENAGER or CHILD or CHILDREN or GIRL or FEMALE or BOY or MALE or SCHOOL GOERS or WOMEN or MEN or 9 THROUGH 45 YEARS or FEMALES IN GRADE 4 or FEMALES IN GRADE 5 or FEMALES IN GRADE 6 or FEMALES IN GRADE 7 or FEMALES IN GRADE 8 or TEENAGE BOYS or MIDDLE AGED).tw., 17# Middle aged/, 19# Adult/, 20# Young Adult/, 21# Students/, 22# University student*/23# College goer*/AND 24# (((HEALTH EQUITY or EQUITY or INEQUITY or EQUALITY or INEQUALITY or DISPARITY or INEQUALITIES or JUSTICE or INJUSTICE or COLONIZED or COLONIZATION or SOCIOECONOMIC STATUS or SOCIOECONOMIC STATUS or SOCIAL DETERMINANT or FIRST NATION or INCONSISTENCY or DETERMINANT or HEALTH DISPARITY or INCOME or SALARY or WAGE or SUBSIDY or UNEMPLOYMENT or JOB or OCCUPATION or MIGRATION or IMMIGRATION or IMMIGRANT or SUBGROUP or SUBGROUP or POPULATIONS or NEWCOMER or REFUGEE or HEALTHCARE PROVIDERS or POOR or POVERTY or ABORIGINAL or INDIGENOUS or COMMUNITIES AT RESERVE or NATIVE or RACE or RACISM or RACIAL or RACIST or ETHNIC or SEX or GENDER NEIGHBORHOOD or NEIGHBORHOOD or ENVIRONMENT or RURAL) and URBAN) or GAP or MARGINALIZATION or MARGINALIZED or WORST OFF or CULTURE or CULTURAL or RELIGION or HEALTH CARE ACCESSIBILITY or HEALTHCARE ACCESSIBILITY or HEALTH SERVICES AVAILABILITY or HEALTH CARE AVAILABILITY or HEALTHCARE AVAILABILITY or HEALTH SERVICES AVAILABILITY or DELIVERY OF HEALTH SERVICES or HEALTH CARE DELIVERY or HEALTHCARE DELIVERY or RIGHT TO HEALTH or UNIVERSAL HEALTH CARE or UNIVERSAL HEALTHCARE or INSURANCE or HEALTH PROVISION).tw, 25# Ethnic group/, 26# Health status disparities/, 27# Health services accessibility/, 28# Health equity/or organization.mp. or administration/, 29# Health equity/or standards/, 30# living standard/or Housing standard/, 31# Health status/or health equity trend*/, 32# Insurance coverage/or Health insurance/, 33# Health expenditure/or Health funding/, AND 34# (DEVELOPED COUNTRIES or INDUSTRIALIZED COUNTRIES or DEVELOPED WORLD or INDUSTRIALIZED WORLD or CANADA or USA or NORTH AMERICA or SCANDINAVIAN COUNTRIES or SCANDINAVIAN or GREAT BRITAIN or EUROPE or AUSTRALIA or NETHER LAND or NEW ZEALAND or UK or THE UK or THE USA or SWEDEN or NORWAY or GERMANY or FRANCE or UNITED STATES OF AMERICA or UNITED KINGDOM or NEW ZEALAND or PAN EUROPEAN).tw, 35# developed countries/ From Ovid search history, the following combination was used to obtain final “n” = 36 and 37 and 38 and 39 and 44 Whereas, 36 (34 or 35), 37 (13 or 14 or 15), 38 (1 or 2 or 3 or 5 or 6 or 7 or 8 or 9 or 12), 39 (16 or 17 or 19 or 20 or 21 or 22 or 23), and 44 (24 or 25 or 26 or 27 or 29 or 30 or 31 or 32 or 33)	69
PubMed ALL FIELDS SERACH RESULTS RESTRICTED SEARCH Text availability Full text, free full text. (excluded: abstract only papers) Article type Included; Meta-analysis, systematic reviews, and reviews. Excluded; books, commentary, clinical trials. Study period: Last ten years only.	((((HUMAN PAPILLOMA VIRUS OR HPVV OR HPV OR CERVARIX OR GARDASIL OR GARDASIL 9 OR VIRAL WART OR HPV VACCINE OR PAPILLOMAVIRUS VACCINE OR HPV IMMUNIZATION OR PAPILLOMAVIRUS INFECTION OR VIRUS DISEASE OR UTERINE CERVICAL NEOPLASM OR PREVENTABLE CANCEROR CANCER PREVENTION OR CERVICAL CANCER OR HPV-RELATED CANCER OR HPV RELATED CANCER OR HPV-RELATED DISEASES OR HPV RELATED DISEASES OR IMMUNIZATION OR IMMUNIZATION POLICY OR IMMUNIZATION PROGRAM OR VACCINATION COVERAGE OR SCHOOL-BASED IMMUNIZATION PROGRAMS OR COMMUNITY-BASED IMMUNIZATION PROGRAMS OR SCHOOL-BASED IMMUNIZATION PROGRAMS OR COMMUNITY BASED VACCINATION PROGRAMS OR VACCINATION UPTAKE OR COMPLETER OR PRIMARY CANCER PREVENTION OR HPV TYPES OR HPV-9 OR HPV 9 VACCINE OR HPV-4 VACCINE OR HPV2 OR NINE-VALENT HPV VACCINE OR NONVALENT VACCINE OR QUADRANT VACCINE OR SEXUALLY TRANSMITTED INFECTIONS OR STI OR AGW OR ANOGENITAL WARTS OR ANAL CANCERS OR PRECANCEROUS LESIONS OR VAGINAL CANCERS OR PENILE CANCERS OR OROPHARANGEAL CANCERS OR THROAT CANCERS OR NOSE CANCERS OR MOUTH CANCER OR CIN OR CERVICAL INTRAEPITHELIAL NEOPLASM OR CERVICAL DYSPLASIA OR UTERINE CERVIX TUMOR OR PAPILLOMAVIRIDAE OR HEAD AND NECK CANCERS)) AND ((BARRIER OR INTERVENTION OR SUPPORT OR ACCEPTIBILITY OR ACCESSIBILITY OR FEASIBLE OR FEASIBILITY OR AVAILABE OR AVAILABILITY OR CHALLENGE OR HESITANCY OR ACCEPTANCE OR DECISION-MAKING OR DECISION MAKING OR DECISION MAKER))) AND ((TEENAGE GIRL OR ADOLESCENT OR PEDIATRIC OR SCHOOL AGED OR PAEDIATRIC GROUP OR TEENAGE OR TEENAGER OR CHILD OR CHILDREN OR GIRL OR FEMALE OR BOY OR MALE OR SCHOOL GOERS OR WOMEN OR MEN OR 9 THROUGH 45 YEARS OR FEMALES IN GRADE 4 OR FEMALES IN GRADE 5 OR FEMALES IN GRADE 6 OR FEMALES IN GRADE 7 OR FEMALES IN GRADE 8))) AND ((HEALTH EQUITY OR EQUITY OR INEQUITY OR EQUALITY OR INEQUALITY OR DISPARITY OR INEQUALITIES OR JUSTICE OR INJUSTICE OR COLONIZED OR COLONIZATION OR SOCIOECONOMIC STATUS OR SOCIO-ECONOMIC STATUS OR SES OR SOCIAL DETERMINANT OR FIRST NATION OR INCONSISTENCY OR DETERMINANT OR HEALTH DISPARITY OR INCOME OR SALARY OR WAGE OR SUBSIDY OR UNEMPLOYMENT OR JOB OR OCCUPATION OR MIGRATION OR IMMIGRATION OR IMMIGRANT OR SUBGROUP OR SUB-GROUP OR SUB POPULATION OR NEWCOMER OR REFUGEE OR HEALTHCARE PROVIDERS OR POOR OR POVERTY OR ABORIGINAL OR INDEGINOUS OR COMMUNITIES AT RESERVE OR NATIVE OR RACE OR RACISM OR RACIAL OR RACIST OR ETHNIC OR SEX OR GENDER NEIGHBORHOOD OR NEIGHBORHOOD OR ENVIRONMENT OR RURAL AND URBAN OR GAP OR MARGINALIZATION OR MARGINALIZED OR WORST-OFF OR CULTURE OR CULTURAL OR RELIGION OR HEALTH CARE ACCESSIBILTY OR HEALTHCARE ACCESSIBILITY OR HEALTH SERVICES AVAILABILITY OR HEALTH CARE AVAILABILITY OR HEALTHCARE AVAILABILITY OR HEALTH SERVICES AVAILABILITY OR DELIVERY OF HEALTH SERVICES OR HEALTH CARE DELIVERY OR HEALTHCARE DELIVERY OR RIGHT TO HEALTH OR UNIVERSAL HEALTH CARE OR UNIVERSAL HEALTHCARE OR INSURANCE OR HEALTH PROVISION))) AND ((DEVELOPED COUNTRIES OR INDUSTRIALIZED COUNTRIES OR DEVELOPED WORLD OR INDUSTRIALIZED WORLD OR CANADA OR USA OR NORTH AMERICA OR SCANDINAVIAN COUNTRIES OR SCANDINAVIAN OR GREAT BRITAIN OR EUROPE OR AUSTRALIA OR NETHER LAND OR NEW ZEALAND OR UK OR THE UK OR THE USA OR SWEDEN OR NORWAY OR GERMANY OR FRANCE OR UNITED STATES OF AMERICA OR UNITED KINGDOM OR NEW ZEALAND OR PAN EUROPEAN)) Filters: Abstract, in the last 10 years	29
Scopus (Initial Search by TITLE-ABS-KEY RESULTS) SEARCH FILTERS INCLUDED: Last 10 years, Canada (only), English (only) EXCLUDED: Document types: Book chapters, Letters, Notes, Conference Papers Subject Area: Psychology, Veterinary, Undefined	TITLE-ABS-KEY ({HUMAN PAPILLOMA VIRUS}) OR TITLE-ABS-KEY (hpvv) OR TITLE-ABS-KEY-AUTH (hpv) OR TITLE-ABS-KEY (cervarix) OR TITLE-ABS-KEY (gardasil) OR TITLE-ABS-KEY (gardasil-9) OR TITLE-ABS-KEY ({VIRAL WART}) OR TITLE-ABS-KEY ({HPV VACCINE}) OR TITLE-ABS-KEY ({PAPILLOMAVIRUS VACCINE}) OR TITLE-ABS-KEY ({HPV IMMUNIZATION}) OR TITLE-ABS-KEY ({PAPILLOMAVIRUS VACCINE}) OR TITLE-ABS-KEY ({HPV IMMUNIZATION}) OR TITLE-ABS-KEY ({PAPILLOMAVIRUS INFECTION}) OR TITLE-ABS-KEY ({VIRUS DISEASE}) OR TITLE-ABS-KEY ({UTERINE CERVICAL NEOPLASM}) OR TITLE-ABS-KEY ({PREVENTABLE CANCER}) OR TITLE-ABS-KEY ({CANCER PREVENTION}) OR TITLE-ABS-KEY ({CERVICAL CANCER}) OR TITLE-ABS-KEY ({HPV-RELATED CANCERS}) TITLE-ABS-KEY ({HPV RELATED CANCERS}) OR TITLE-ABS-KEY ({HPV-RELATED DISEASES}) OR TITLE-ABS-KEY ({HPV RELATED DISEASES}) OR TITLE-ABS-KEY (immunization) AND TITLE-ABS-KEY ({IMMUNIZATION POLICY}) OR TITLE-ABS-KEY ({IMMUNIZATION PROGRAM}) OR TITLE-ABS-KEY ({VACCINATION COVERAGE}) OR TITLE-ABS-KEY ({SCHOOL-BASED IMMUNIZATION PROGRAMS}) OR TITLE-ABS-KEY ({COMMUNITY-BASED IMMUNIZATION PROGRAMS}) OR TITLE-ABS-KEY ({SCHOOL-BASED VACCINATION PROGRAMS}) OR TITLE-ABS-KEY ({COMMUNITY-BASED VACCINATION PROGRAMS}) OR TITLE-ABS-KEY ({VACCINATION UPTAKE}) OR TITLE-ABS-KEY ({VACCINE COMPLETER}) OR TITLE-ABS-KEY ({PRIMARY CANCER PREVENTION}) OR TITLE-ABS-KEY ({HPV TYPES}) OR TITLE-ABS-KEY (hpv-9) OR TITLE-ABS-KEY ({HPV 9 VACCINE}) OR TITLE-ABS-KEY (hpv-4) OR TITLE-ABS-KEY ({HPV-4 VACCINE}) OR TITLE-ABS-KEY (hpv2) OR TITLE-ABS-KEY ({NINE-VALENT HPV VACCINE}) OR TITLE-ABS-KEY ({NONVALENT VACCINE}) OR TITLE-ABS-KEY ({QUADRANT VACCINE}) OR TITLE-ABS-KEY ({SEXUALLY TRANSMITTED INFECTIONS}) OR TITLE-ABS-KEY (sti*) OR TITLE-ABS-KEY (agw*) OR TITLE-ABS-KEY ({ANOGENITAL WARTS}) OR TITLE-ABS-KEY ({ANAL CANCERS}) OR TITLE-ABS-KEY ({PRECANCEROUS LESIONS}) OR TITLE-ABS-KEY ({VAGINAL CANCERS}) OR TITLE-ABS-KEY ({PENILE CANCERS}) OR TITLE-ABS-KEY ({OROPHARANGEAL CANCERS}) OR TITLE-ABS-KEY ({THROAT CANCERS}) OR TITLE-ABS-KEY ({NOSE CANCERS}) OR TITLE-ABS-KEY ({MOUTH CANCERS}) OR TITLE-ABS-KEY (cin) OR TITLE-ABS-KEY ({CERVICAL INTRAEPTHELIAL NEOPLASIA}) OR TITLE-ABS-KEY ({CERVICAL DYSPLASIA}) OR TITLE-ABS-KEY ({UTERINE CERVIX TUMOR}) OR TITLE-ABS-KEY (papillomaviridae) OR TITLE-ABS-KEY ({HEAD AND NECK CANCERS}) OR TITLE-ABS-KEY (barrier) * OR TITLE-ABS-KEY (intervention*) OR TITLE-ABS-KEY (support*) acceptability OR accessibility OR feasible OR feasibility OR available OR availability OR TITLE-ABS-KEY (challenge*) OR TITLE-ABS-KEY (hesitancy) OR TITLE-ABS-KEY (acceptance) OR TITLE-ABS-KEY (decision-making) OR TITLE-ABS-KEY ({DECISION MAKING}) OR TITLE-ABS-KEY ({DECISION MAKER}) AND TITLE-ABS-KEY ({TEENAGE GIRL}) OR (adolescent*) OR TITLE-ABS-KEY (pediatric) OR TITLE-ABS-KEY ({SCHOOL AGED}) OR TITLE-ABS-KEY (pediatric AND group) OR TITLE-ABS-KEY (teenage) OR TITLE-ABS-KEY (teenager) OR TITLE-ABS-KEY (child) OR TITLE-ABS-KEY (children) OR TITLE-ABS-KEY (girl*) OR TITLE-ABS-KEY (female*) OR TITLE-ABS-KEY (boy*) OR TITLE-ABS-KEY (male*) OR TITLE-ABS-KEY ({SCHOOL GOERS}) OR TITLE-ABS-KEY (women) OR TITLE-ABS-KEY (men) OR TITLE-ABS-KEY ({9 THROUGH 45 YEARS}) OR TITLE-ABS-KEY ({FEMALES IN GRADE 4}) OR TITLE-ABS-KEY ({FEMALES IN GRADE 5}) OR TITLE-ABS-KEY ({FEMALES IN GRADE 6}) OR TITLE-ABS-KEY ({FEMALES IN GRADE 7}) OR TITLE-ABS-KEY ({FEMALES IN GRADE 8}) OR TITLE-ABS-KEY ({TEENAGE BOYS}) OR TITLE-ABS-KEY ({HEALTH EQUITY}) OR TITLE-ABS-KEY (equity) OR TITLE-ABS-KEY (inequity) OR TITLE-ABS-KEY (equality) OR TITLE-ABS-KEY (inequality) OR TITLE-ABS-KEY (disparity) OR TITLE-ABS-KEY (inequalities) OR TITLE-ABS-KEY (justice) OR TITLE-ABS-KEY (injustice) OR TITLE-ABS-KEY (colonized) OR TITLE-ABS-KEY (colonization) OR TITLE-ABS-KEY ({SOCIOECONOMIC STATUS}) OR TITLE-ABS-KEY ({SOCIO-ECONOMIC STATUS}) OR TITLE-ABS-KEY (ses) OR TITLE-ABS-KEY ({SOCIAL DETERMINANT}) OR TITLE-ABS-KEY ({FIRST NATION}) OR TITLE-ABS-KEY (inconsistency*) OR TITLE-ABS-KEY (determinant*) OR TITLE-ABS-KEY ({HEALTH DISPARITY}) OR TITLE-ABS-KEY (income*) OR TITLE-ABS-KEY (salary) OR TITLE-ABS-KEY (wage*) OR TITLE-ABS-KEY (subsidy) OR TITLE-ABS-KEY (unemployment) OR TITLE-ABS-KEY (job*) OR TITLE-ABS-KEY (occupation*) OR TITLE-ABS-KEY (migration) OR TITLE-ABS-KEY (immigration) OR TITLE-ABS-KEY (immigrant*) OR TITLE-ABS-KEY (subgroup*) OR TITLE-ABS-KEY (sub-group*) OR TITLE-ABS-KEY ({SUB POPULATION*}) OR TITLE-ABS-KEY (newcomer*) OR TITLE-ABS-KEY (refugee*) OR TITLE-ABS-KEY ({HEALTHCARE PROVIDERS}) OR TITLE-ABS-KEY (poor) OR TITLE-ABS-KEY (poverty) OR TITLE-ABS-KEY (aboriginal*) OR TITLE-ABS-KEY (indeginous) OR TITLE-ABS-KEY ({COMMUNITIES AT RESERVE}) OR TITLE-ABS-KEY (native*) OR TITLE-ABS-KEY (race) OR TITLE-ABS-KEY (racism) OR TITLE-ABS-KEY (racial) OR TITLE-ABS-KEY (racist) OR TITLE-ABS-KEY (ethnic*) OR TITLE-ABS-KEY (sex*) OR TITLE-ABS-KEY (gender*) OR TITLE-ABS-KEY (neighborhood*) OR TITLE-ABS-KEY (neighbourhood*) OR TITLE-ABS-KEY (environment) OR TITLE-ABS-KEY ({RURAL AND URBAN}) OR TITLE-ABS-KEY (gap*) OR TITLE-ABS-KEY (marginalization) OR TITLE-ABS-KEY (marginalized) OR TITLE-ABS-KEY (worst-off) OR TITLE-ABS-KEY (culture*) OR TITLE-ABS-KEY (cultural*) OR TITLE-ABS-KEY (religion*) OR TITLE-ABS-KEY ({HEALTH CARE ACCESSIBILTY}) OR TITLE-ABS-KEY ({HEALTHCARE ACCESSIBILITY}) OR TITLE-ABS-KEY ({HEALTH SERVICES AVAILABILITY}) OR TITLE-ABS-KEY ({HEALTH CARE AVAILABILITY}) OR TITLE-ABS-KEY ({HEALTHCARE AVAILABILITY}) OR TITLE-ABS-KEY ({HEALTH SERVICES AVAILABILITY}) OR TITLE-ABS-KEY ({DELIVERY OF HEALTH}) OR TITLE-ABS-KEY ({SERVICES}) OR TITLE-ABS-KEY ({HEALTH CARE DELIVERY}) OR TITLE-ABS-KEY ({HEALTHCARE DELIVERY}) OR TITLE-ABS-KEY ({RIGHT TO HEALTH}) OR TITLE-ABS-KEY ({UNIVERSAL HEALTH CARE}) OR TITLE-ABS-KEY ({UNIVERSAL HEALTHCARE}) OR TITLE-ABS-KEY (insurance) OR TITLE-ABS-KEY ({HEALTH PROVISION}) AND TITLE-ABS-KEY ({DEVELOPED COUNTRIES}) OR TITLE-ABS-KEY ({INDUSTRIALIZED COUNTRIES}) OR TITLE-ABS-KEY ({DEVELOPED WORLD}) OR TITLE-ABS-KEY ({INDUSTRIALIZED WORLD}) OR TITLE-ABS-KEY (canada) OR TITLE-ABS-KEY (usa) OR TITLE-ABS-KEY ({NORTH AMERICA}) OR TITLE-ABS-KEY ({SCANDINAVIAN COUNTRIES}) OR TITLE-ABS-KEY (scandinavian*) OR TITLE-ABS-KEY ({GREAT BRITAIN}) OR TITLE-ABS-KEY (europe) OR TITLE-ABS-KEY (australia) OR TITLE-ABS-KEY ({NETHER LAND}) OR TITLE-ABS-KEY ({NEW ZEALAND}) OR TITLE-ABS-KEY (uk) OR TITLE-ABS-KEY ({THE UK}) OR TITLE-ABS-KEY ({THE USA}) OR TITLE-ABS-KEY (sweden) OR TITLE-ABS-KEY (norway) OR TITLE-ABS-KEY (germany) OR TITLE-ABS-KEY (france) OR TITLE-ABS-KEY ({UNITED STATES OF AMERICA}) OR TITLE-ABS-KEY ({UNITED KINGDOM}) OR TITLE-ABS-KEY ({NEW ZEALAND}) OR TITLE-ABS-KEY ({PAN EUROPEAN}) OR TITLE-ABS-KEY (denmark) AND (LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019) OR LIMIT-TO (PUBYEAR, 2018) OR LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016) OR LIMIT-TO (PUBYEAR, 2015) OR LIMIT-TO (PUBYEAR, 2014) OR LIMIT-TO (PUBYEAR, 2013) OR LIMIT-TO (PUBYEAR, 2012) OR LIMIT-TO (PUBYEAR, 2011) OR LIMIT-TO (PUBYEAR, 2010)) AND (LIMIT-TO (DOCTYPE, “ar”) OR LIMIT-TO (DOCTYPE, “re”)) AND (LIMIT-TO (AFFILCOUNTRY, “Canada”)) AND (LIMIT-TO (LANGUAGE, “English”)) AND (LIMIT-TO (SUBJAREA, “MEDI”) OR LIMIT-TO (SUBJAREA, “IMMU”) OR LIMIT-TO (SUBJAREA, “BIOC”) OR LIMIT-TO (SUBJAREA, “PHAR”) OR LIMIT-TO (SUBJAREA, “AGRI”) OR LIMIT-TO (SUBJAREA, “MULT”) OR LIMIT-TO (SUBJAREA, “SOCI”))	42
Web of science (Search by TOPIC which contains KEYWORDS, TITLE, ABSTRATC – BY DEFAULT) FILTERS: RESTRICTED TO: English (only), Canada (only) Open Access (All open Access) Documents types; Articles (only) Excluded: (Art exhibit reviews, abstracts (only) of published items, biographical item, book chapter, book review, correction, chronology, data paper, fiction, commentary, film review, excerpt, letters, meeting summary notes, etc.)	(“Human papilloma virus” OR HPVV OR HPV OR Cervarix OR Gardasil OR “Gardasil 9” OR “Viral wart” OR “HPV Vaccine” OR “Papillomavirus vaccine” OR “HPV immunization” OR “Papillomavirus infection” OR “Virus disease” OR “uterine cervical neoplasm” OR “Preventable cancer” OR “cancer prevention” OR “cervical cancer” OR “HPV-RELATED CANCER” OR “HPV RELATED CANCER” OR “HPV-RELATED DISEASES” OR “HPV RELATED DISEASES” OR IMMUNIZATION OR “IMMUNIZATION POLICY” OR “IMMUNIZATION PROGRAM” OR “VACCINATION COVERAGE” OR “SCHOOL-BASED IMMUNIZATION PROGRAMS” OR “COMMUNITY-BASED IMMUNIZATION PROGRAMS” OR ’SCHOOL-BASED IMMUNIZATION PROGRAMS“OR “COMMUNITY BASED VACCINATION PROGRAMS” OR “VACCINATION UPTAKE” OR COMPLETER* OR “PRIMARY CANCER PREVENTION” OR “HPV TYPES” OR “HPV-9” OR “HPV 9 VACCINE” OR “HPV-4 VACCINE” OR HPV2 OR “NINE-VALENT HPV VACCINE” OR “NONVALENT VACCINE” OR “QUADRANT VACCINE” OR “SEXUALLY TRANSMITTED INFECTIONS” OR STI* OR AGW* OR “ANOGENITAL WARTS” OR “ANAL CANCERS” OR “PRECANCEROUS LESIONS” OR “VAGINAL CANCERS” OR “PENILE CANCERS” OR “OROPHARANGEAL CANCERS” OR “THROAT CANCERS” OR “NOSE CANCERS” OR “MOUTH CANCERS” OR CIN* OR “CERVICAL INTRAEPITHELIAL NEOPLASM” OR “CERVICAL DYSPLASIA” OR “UTERINE CERVIX TUMOR” OR PAPILLOMAVIRIDAE OR “HEAD AND NECK CANCERS”) AND TOPIC: (BARRIER* OR INTERVENTION* OR SUPPORT* ACCEPTIBILITY OR ACCESSIBILITY OR FEASIBLE OR FEASIBILITY OR AVAILABE OR AVAILABILITY OR CHALLENGE* OR HESITANCY OR ACCEPTANCE OR “DECISION-MAKING” OR “DECISION MAKING” OR ’DECISION MAKER“) AND TOPIC: (TEENAGE GIRL* OR ADOLESCENT* OR PEDIATRIC OR “SCHOOL AGED” OR “PEDIATRIC GROUP” OR TEENAGE OR TEENAGER* OR CHILD OR CHILDREN OR GIRL* OR FEMALE* OR BOY* OR MALE* OR “SCHOOL GOERS” OR WOMEN OR MEN OR “9 THROUGH 45 YEARS” OR “FEMALES IN GRADE 4” OR “FEMALES IN GRADE 5” OR “FEMALES IN GRADE 6” OR “FEMALES IN GRADE 7” OR ’FEMALES IN GRADE 8“) AND TOPIC: (“HEALTH EQUITY” OR EQUITY OR INEQUITY OR EQUALITY OR INEQUALITY OR DISPARITY OR INEQUALITIES OR JUSTICE OR INJUSTICE OR COLONIZED OR COLONIZATION OR “SOCIOECONOMIC STATUS” OR “SOCIO-ECONOMIC STATUS” OR SES OR “SOCIAL DETERMINANT* OR “FIRST NATION” OR INCONSISTENCY* OR DETERMINANT* OR ’HEALTH DISPARITY’ OR INCOME* OR SALARY OR WAGE* OR SUBSIDY OR UNEMPLOYMENT OR JOB* OR OCCUPATION* OR MIGRATION OR IMMIGRATION OR IMMIGRANT* OR SUBGROUP* SUB-GROUP* OR SUB POPULATION* OR NEWCOMER* OR REFUGEE* OR “HEALTHCARE PROVIDERS” OR “POOR” OR ’POVERTY“OR ABORIGINAL* OR INDEGINOUS OR “COMMUNITIES AT RESERVE” OR NATIVE* OR RACE OR RACISM OR RACIAL OR RACIST OR ETHNIC* OR SEX* GENDER* NEIGHBORHOOD* OR NEIGHBORHOOD* OR ENVIRONMENT OR “RURAL AND URBAN” OR GAP* OR MARGINALIZATION OR MARGINALIZED OR WORST-OFF OR CULTURE* OR CULTURAL* OR RELIGION* OR ’HEALTH CARE ACCESSIBILTY“OR ’HEALTHCARE ACCESSIBILITY” OR “HEALTH SERVICES AVAILABILITY” OR “HEALTH CARE AVAILABILITY” OR “HEALTHCARE AVAILABILITY” OR “HEALTH SERVICES AVAILABILITY” OR “DELIVERY OF HEALTH SERVICES” OR “HEALTH CARE DELIVERY” OR “HEALTHCARE DELIVERY” OR ’RIGHT TO HEALTH“OR “UNIVERSAL HEALTH CARE” OR “UNIVERSAL HEALTHCARE” OR “INSURANCE” OR “HEALTH PROVISION”) AND TOPIC: (“DEVELOPED COUNTRIES” OR “INDUSTRIALIZED COUNTRIES” OR “DEVELOPED WORLD” OR “INDUSTRIALIZED WORLD” OR “CANADA” OR “USA” OR “NORTH AMERICA” OR “SCANDINAVIAN COUNTRIES” OR SCANDINAVIAN* OR “GREAT BRITAIN” OR EUROPE OR AUSTRALIA OR NETHER LAND OR NEW ZEALAND OR UK OR “THE UK” OR “THE USA” OR SWEDEN OR NORWAY OR GERMANY OR FRANCE OR “UNITED STATES OF AMERICA” OR “UNITED KINGDOM” OR “NEW ZEALAND” OR “PAN EUROPEAN”) Refined by: LANGUAGES: (ENGLISH) AND Open Access: (All Open Access) AND DOCUMENT TYPES: (ARTICLE OR REVIEW) AND COUNTRIES/REGIONS: (CANADA) Timespan: 2010–2020. Indexes: ESCI.	23

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