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

ABSTRACT

Human Papillomavirus (HPV) is a highly contagious sexually transmitted infection that leads to preventable cancers of the mouth, throat, cervix, and genitalia. Despite the wide availability of HPV Vaccine (HPVV) in Canada, its uptake remains suboptimal. This review aims to identify factors (barriers and facilitators) in HPV vaccine uptake across English Canada at three levels (provider, system, and patient). We explored academic and gray literature to examine factors involved in HPVV uptake and synthesized results based on interpretive content analysis. The review identified the following factors of prime significance in the uptake of the HPV vaccine (a) at the provider level, ‘acceptability’ of the HPV vaccine, and ‘appropriateness’ of an intervention (b) at the patient level, the ‘ability to perceive’ and ‘knowledge sufficiency’ (c) at the system level, ‘attitudes’ of different players in vaccine programming, planning and delivery. Further research is needed to conduct population health intervention research in this area.

KEYWORDS:

• Human Papilloma Virus (HPV)
• HPV immunization
• papillomavirus infection
• preventable cancer
• sexually transmitted infections
• viral wart

Introduction

The verb “eradicate” has never been used in the context of cancer before, and to “eradicate” Human Papillomavirus (HPV) related cancers (cervical, oral, and genital), preventive strategies should target optimal uptake of HPV immunization in all jurisdictions of Canada.¹ Canada has been a success story in implementing a publicly funded school-based HPV immunization program.¹ Canada’s earlier achievements are challenged by the negative influence of the rapidly prevailing anti-vaccine activism, hence reversing the earlier gains.² Therefore, despite a widespread effort to gain optimal uptake of publicly funded Human Papilloma Virus Vaccine (HPVV) programs throughout Canada, the uptake of HPVV remains suboptimal in some Canadian jurisdictions.³ The COVID-19 pandemic has further affected cancer control efforts across the spectrum.⁴ International efforts highlighted that the diagnoses of cancers were reduced by 40% between March 9 and May 17, 2020.⁵ Moreover, the program interruptions will notably impact future cancer survival.⁴ Information on the determinants of HPVV uptake is vital for health policymakers to develop strategies that enhance the uptake of widely available HPVV and meet the target the Government of Canada has set of reaching 90% HPVV coverage among Canadian adolescents by 2025.⁶

Human papillomavirus is the most common viral infection of the reproductive tract and is the leading cause (more than 95%) of cervical cancer.⁷ All sexually active women and men contract at least one of its types at some point in life.⁸ According to the Canadian Cancer Society, HPV is more common than any other sexually transmitted infection combined.⁹ Most will never know if they have been infected because HPV often does not cause any symptoms, making it hard to know exactly when or how the virus was spread.⁹ Lung cancer has a high incidence but low survival; therefore, its prevalence is lower because fewer survivors remain in the population over time.⁴ In contrast, cervical cancer falls into the top 10 cancer types for the 25-year prevalence due to its high survival and the younger average age at diagnosis.⁴ The projections by the Oncosims model indicate that increasing HPVV uptake to 90% from 67% would result in a 23% reduction in cervical cancer incidence rates, which in turn causes a 23% decline in the average annual cervical cancer mortality rate.⁶ Vaccination against HPV is a cornerstone in preventing HPV-related infections and cancers developed as a sequela.¹⁰

Despite this widespread effort, HPVV uptake has remained suboptimal in certain Canadian jurisdictions.³ The rate of cervical cancer among Canadian women has not declined since 2005.¹¹ The suboptimal uptake of HPVV with a status quo of cervical cancer incidence rate is partly because HPV immunization’s impact on cancer prevention has not been realized adequately¹ by vaccine providers and vaccine receivers.¹² This is further challenged by the presence of a significant portion of women who remained under-screened or unscreened for detection of cancerous changes via pap smear¹³ The disease’s infectious nature, its widespread transmission, and the consequent development of cancer of a preventable origin have become common knowledge among scientists and public health professionals. Further exploration of determinants of HPVV uptake (barriers and facilitators) is required to situate contextually appropriate policies around enhancing its uptake. It should be realized that HPV is the most common Sexually Transmitted Infection (STI) that causes cancers of preventable nature. Thus, primary prevention of HPV by vaccination should be a high priority in Canada’s cancer prevention efforts. Clearly, a thorough examination of determinants of HPVV uptake across English Canada is an important topic, although literature on this topic is sparse.

This review brings together literature that articulates barriers and facilitators in HPVV uptake by meaningfully integrating determinants of vaccine uptake on both the demand and supply sides to balance the health-care equation and ultimately lead to enhanced HPVV utilization (refer to Figure −2: Analytical Framework). Extrapolating on Engel’s biopsychosocial concept model,¹⁴ we classify the identified barriers and facilitators at three levels: provider, patient, and system level to illuminate the factors adherent to HPVV uptake distinctively on either side of the health-care equation (the supply vs demand side).¹⁵ Using several 10 A’s themes from Levesque’s conceptual framework,¹⁶ the provider-level determinants (of vaccine uptake) include appropriateness, affordability, availability, acceptability, and approachability.¹⁶ The patient-level determinants include the ability to engage, ability to pay, ability to reach, ability to seek, and ability to perceive. The system-level determinants include ubiquitous Provision,¹⁷ catch-up Programs,¹⁸ supply-Chain maintenance, cost, and vaccine Attitudes.¹⁹ We connect the identified factors with a set of vaccine uptake determinants²⁰ to uncover high-resolution quality improvement investment targets for under-immunized population groups.

Methods

A systematic approach was implemented to review studies of barriers and facilitators affecting HPVV uptake across English Canada.

Search strategy

We undertook an extensive and systematic review of the literature using the following electronic databases: Medline, PubMed, SCOPUS, and Web of Sciences. We developed and conducted searches in consultation with an academic librarian using various combinations of keywords and Medical Subject Heading (MeSH) terms using the search strategy worksheet by the University of Ottawa.²¹

Broadly, the selection criteria for studies included any study that identifies barriers and facilitators in HPVV uptake involving individuals eligible for and receiving the HPV vaccine. We assessed the studies for the following outcomes: 1) If the study discussed factors around decreased uptake of HPVV (barriers) and/or 2) If the study examined factors around increased uptake of vaccine (facilitators and interventions).

We conducted a search after creating the search syntaxes. Search syntaxes individual to each database and a master list of keywords prepared and utilized for academic literature search are included in the appendix. We searched the gray literature in two steps. A general search utilizing Google Scholar was followed by a specific search using websites of relevance and interest: Urban Public Health Network (UPHN) and Ontario Public Health Libraries Association (OPHLA). We used keywords for gray literature after shortlisting from the master list of keywords prepared for the academic literature search (refer to search strategy sheet).

Eligibility criteria

Studies eligible for inclusion were on the topic of HPVV; human subjects, wholly or partially targeting Canadian populations; published in English; during 2010–2019 (inclusive); and highlighted, addressed, studied, and discussed barriers and/or facilitators around the uptake of HPVV. This review included empirical studies that used any study design, any immunization program types, or study settings (i.e. community-based, publicly funded, health care based, school-based, hybrid), any serological HPV vaccine type (i.e. quadrivalent, non-valent, bivalent, etc.), all factors affecting (increase or decrease) HPV vaccine uptake and/or completion of all the HPV vaccine doses, at all levels (i.e. policy, individual, community, organizational, interpersonal, institutional, intrapersonal, etc.), and from multiple perspectives (i.e., key stakeholders, community members, parents, teachers, professionals involved in the program, young females, and males, school goers, health care, and policy practitioners, different Canadian subpopulations, i.e., refugee, immigrant, indigenous, etc.). All studies meeting inclusion criteria were included for level-1 screening.

Level-1 screening

This phase involved abstract and title screening. References identified through academic and gray literature searches were exported and assessed for level-1 screening by employing a screening tool software: DistillerSR. Studies qualified by level-1 screening were promoted to level-2 for a full-text screen.

Level 2 eligibility

This phase involved a full-text screen, also called the eligibility check. All qualified studies from level 1 were obtained in full-text form and were subjected to a full-length reading to ensure they fulfilled the eligibility criteria. DistillerSR facilitated this phase.

We carried out level-1 screening and level-2 eligibility checks. The PRISMA flow diagram (Figure 1) displays the process of its execution. Before data extraction, a senior colleague, and an expert in the field of immunization sought studies that required a second assessor agreement or a second opinion on inclusion. Utilizing the master list of keywords and MESH terminologies and with the help of a sociologist, the selection of various keywords for level-1 and level-2 screening was made after incorporating those in DistillerSR.

Figure 1. PRISMA flow diagram.

Data abstraction

Data on specific characteristics from the included studies were abstracted using Microsoft Excel (Microsoft Corporation, Version 2014). We extracted data on the following: the year of publication and data collection, study purpose, design/method(s), settings, location, population attributes, factors around the HPV vaccine uptake and/or completion (barriers/facilitators), and limitations unique to each included study.

Procedure of analysis

This review uses preexisting theoretical constructs deductively, then reaffirms the various theoretical constructs, with inductive aspects following the content analysis approach. Closely following the guidelines, we carried out interpretive content analysis by creating and assigning codes and building categories to the emerging themes from the text of the included studies.²²

Based on the research questions (barriers and facilitators in HPVV uptake), we selected the context to be analyzed based on the included studies. This step was followed by choosing the text called “text-selection” to be analyzed based on the medium (research studies and provincial reports)^23,26 criteria of inclusion and selected parameters (i.e., date range, study location, study design, etc.). We then define the units and categories of analysis based on the analytical framework (Figure 2). We prepared the analytical framework utilizing the following sources: Levesque’s conceptual framework,¹⁶ Engel’s biopsychosocial concept model,¹⁴ the system-level determinants^17–19and determinants of vaccine uptake²⁰ that integrate HPVV uptake factors at three levels.

Figure 2. Analytical framework.

The units and categories were coded based on the selected text’s presence and frequency of themes (including words, phrases, and characteristics). Using the pre-identified themes at three levels (patient, provider, and system), the themes that emerged in the selected text were bolded as depicted in Table 4. Following the coding rules, we similarly furthered text coding and carried out several iterations before obtaining the final set of codes. We then matched the final set of codes against the vaccine determinants at all three levels (provider, patient, and system) and synthesized results based on prominent themes based on the frequency of a particular theme(s) for barriers and facilitators in HPVV uptake. Finally, we reiterated the review’s main findings and elaborated on each, discussing the limitations of this work and implications based on the review’s findings.

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.

Results

This review identified 9,234 references through academic literature via database searches. A Grey literature search identified additional ten references by manually searching through UPHN and OPHLA websites. After application of filters based on inclusion and exclusion criteria and carrying out the first round of deduplication, the number of identified references (N = 9,234) was reduced to 165 (refer to Figure 1: PRISMA flow diagram). The studies identified were then subjected to level-1 screening and to the second round of deduplication, which excluded additional 100 references, leaving 63 for the full-text screen. A level-2 eligibility check assessed 63 references based on a full-text screen, which excluded 30 more, leaving a total of 33 references (Figure 1: PRISMA flow diagram).

The reasons for the exclusion of the references from the academic literature search record included: non-Canadian studies (N = 4), insufficient Canadian focus (N = 7), not directly relevant to the review focus area (N = 6), no specific mention of factors around HPVV uptake (N = 7), and outcome other than a factor for HPVV acceptance, uptake, and/or completion (N = 6). For references from a gray literature search, the main reasons for exclusion included being outside the study period (N = 1) and the study being too broad in scope (N = 1). Figure 1: The PRISMA flow diagram depicts references flow through various levels of searches and screenings in this review, accompanied by a display of reasons for exclusion. In total, 33 references (studies) qualified for inclusion. An account of all the included studies is given in Table 1.

Overview of searched literature

The results of this review are reported in two parts.

First, a tabulated display (Table 2) of descriptive statistics of the literature is provided across Canadian jurisdictions based on the date of study publication (2010–14, 2015–19), study settings (school-based, community-based, hybrid), and study design/method (survey [quantitative], qualitative, cohort, cross-sectional, mixed-method, community-driven, review and reports).

Similarly, a tabulated display (Table 3) of descriptive statistics on the various participant groups identified in this review and variations captured across the respective subgroups is provided and that included: 1) vaccine receivers (school/university goers, young girls and boys age > 9, parents of kids in grade > 4, newcomers, Canadian population), and vaccine providers (physicians, pharmacists, public health professionals, others), 2) HPV vaccine status (uptake, completion, catch-up, and hybrid), and 3) factors around HPV immunization at various levels (personal, system, and hybrid).

Overall, Table 2 shows that more studies were conducted during the years 2015–19 than in 2010–14, mostly followed hybrid study settings (a combination of school and community based) and used a survey method. Table 3 depicts that the most prominent subgroup of vaccine receivers were school/university goers, and for vaccine providers, these were physicians and others (such as nurses, etc.). Concerning HPVV status, a significant portion of the studies examined uptake rates and/or factors as opposed to vaccine completion or catch-up rates and/or factors. Interestingly, more studies reported personal factors (referred to as patient-level factors in this review) followed by system-level factors and a combination of system and personal factors.

Second, results are reported based on interpretive content analysis that alludes to the most significant barriers and facilitators in the uptake of HPVV at three levels (provider, system, and patient), drawing from the concept of the health-care equation based on the analytical framework (Figure 2).

Reporting significant factors in HPVV uptake – patient level

Barriers:

The ability to perceive stood out as a prominent theme among the themes drawn from various coding categories, i.e., ability to seek, ability to pay, ability to perceive, ability to engage, and ability to reach. Within the identified theme (i.e., ability to perceive), knowledge insufficiency around HPVV was the main barrier to its optimal uptake.

Facilitators:

Interestingly, ability to perceive was again found as the most prominent theme among the themes drawn from various coding categories. Within this theme (i.e., ability to perceive), knowledge sufficiency around HPVV remained the central factor in facilitating HPVV uptake.

Reporting significant factors in HPVV uptake - provider level

Barriers:

Content analysis revealed acceptability as the most prominent theme among the themes drawn from various coding categories, i.e., appropriateness, availability, approachability, and affordability. Overall, most studies^{27–29–31,32} identified the acceptability of the HPV vaccine as the main barrier to its uptake from a provider’s perspective. Acceptability represented issues with HPVV recommendation practices due to several interrelated factors that retard HPVV uptake.

Facilitators:

Appropriateness was determined as the central theme among the themes drawn from various coding categories for facilitators from a provider’s perspective. ‘Appropriateness’ mainly reflected tailored interventions.

Reporting significant factors in HPVV uptake – system level

Barriers:

Attitude was identified as the most prominent system-level barrier to HPVV from other coding categories, i.e., cost, provision, catch-up programs, and supply chain maintenance.³¹

Facilitators:

It was worth noting that attitudes again stood out as the main factor that carried the potential to serve as an influential facilitator in optimizing HPVV at the system level when components of attitudes, as discussed in the discussion section, were addressed adequately (please refer to Table 4).

Discussion

In this section, we first discuss how studies compare based on barriers and facilitators and then reiterate key findings, highlighting how they can be used to enhance HPVV uptake. This is followed by a discussion of limitations and future research.

Patient level barriers and facilitators

Concerning patient-level barriers, Fernandes et al. reported that a lack of knowledge about vaccines, their potential efficacy, side effects, and even uncertainty about vaccination cost play a significant role in HPVV uptake.³⁵ Literature^36,42 reaffirmed that knowledge about HPV immunization is critical as a vast majority of parents expressed concerns about HPVV safety⁴⁸ and wished to delay the HPV vaccine for their daughters due to not having enough information to make an informed decision.

Furthermore, Dube³ reinforced that the knowledge, attitudes, and beliefs of the different players involved in the HPV vaccination system also play their role in HPVV uptake. Grace²⁹ highlighted that lack of knowledge was an influential factor around HPVV uptake as the participants had misconceptions or beliefs that HPV was predominantly or exclusively a risk for females. The same study²⁹ also highlighted that the participants lacked knowledge about the vaccine’s availability, which indicates insufficient knowledge about HPVV.

Low literacy around the HPV vaccine has led to various misconceptions and misperceptions. Stanley reported that the most significant barrier around HPVV was adult participants’ concerns about being over the recommended age.⁴³ Also, most adult participants perceived that their own risk of HPV was low.⁴⁵ Moreover, parents refuse HPVV for their daughters perceiving they are not sexually active, so vaccination is unnecessary.⁴⁶

Finally, Scott and colleagues³⁰ revealed that families’ lack of knowledge about the vaccine, attitudes not informed by evidence-based science, and their perception of lack of data on HPVV efficacy⁴³ are all factors contributing to misperception secondary to knowledge insufficiency.

Concerning patient-level facilitators, Dube⁵¹ identified the self-estimated sufficiency of knowledge on HPVV, its perceived efficacy, and acceptability by vaccine providers and the public as important facilitators around HPVV uptake. Rambout reported that the perceived benefits of HPVV among vaccine receivers were an influential factor in its uptake.⁴⁷

Similarly, Krawczyk⁴⁶ reaffirmed that parental acceptance was influenced mainly by the perceived benefits of HPVV, e.g., health protection, HPV-related cancer, and infection prevention. Along similar lines, Stanley asserted that knowledge about the importance of personal protection from HPV disease was the most common motivating factor in getting the HPVV⁴³ for oneself and in deciding for their children.

Teachers’ education on HPVV and their knowledge and understanding about the relevance of HPVV were recognized as factors of prime importance^36,52 as they help public health staff to distribute vaccine information material, consent forms, and set up HPV vaccine clinics in the schools. Furthermore, parents’ lack of literacy⁴⁸ around HPVV posed significant challenges to trusting the healthcare system and the school vaccine programs.⁴⁶ A study⁴⁹ determining the difference in vaccine uptake between the two service delivery models (in-school and community) also examined whether socioeconomic status (SES) was a contributing factor. The study⁴⁹ highlighted that girls with lower socioeconomic status were differently disadvantaged by not having access to an “in-school” vaccination. Thus, improving the overall knowledge levels around HPVV might combat factors around contextual, social norms⁴⁷ and cultural sensitivity.³⁶

Provider level barriers and facilitators

Concerning provider-level barriers, Ferrer²⁷ and Isenor³³ highlighted health-care professional recommendations and provisions as significant. Grace²⁸ illuminated that health-care professional recommendation practices are limited in their perspectives on the prevention and therapeutic benefits of vaccinating specific subpopulations such as older GBM (Gay, Bisexual, and Men who have sex with men). Grace²⁸ also highlighted cost/insurance coverage, especially for some older patients, as an overarching factor that leads to inconsistent recommendation practices.

Markowitz³¹ expressed that uncertainty around two HPV vaccine types, the extent of catch-up vaccine programs, and the role of manufacturers and interest groups in promoting the HPV vaccine served as overarching factors in HPV vaccine recommendation practices and provisions. Moreover, Wilson³² asserted that difficulties receiving agreement from local school boards to set up HPVV clinics and refusals from some Catholic schools contribute to the non-acceptability of HPVV by the school administration. Shapiro³⁸ identified that certain subgroups prefer receiving HPVV outside the school setting due to reasons, such as fear of needles and peer pressure.

Grace²⁹ reaffirmed that HPV literacy levels serve as a substantial obstacle to its provision and acceptance, and the long-standing gendered association with HPVV²⁹ further complicates this. Changing communication modes around HPVV uptake has also served as a significant barrier to accepting HPVV.³⁴

Concerning provider-level facilitators, Mrklas³⁹ suggested that interventions tailored to address specific barriers to HPVV, especially relevant to contextual differences, play a vital role in increasing its uptake. The same study highlighted that tailored interventions also lessen hesitancy issues around HPV uptake. Rubens and colleagues³⁶ encouraged targeted health promotions to enhance HPVV uptake. Janeczek⁴⁰ reaffirmed that interventions designed to address specific barriers unique to regional context are imperative at all levels, including vaccine receivers, health-care providers, and social marketing. Janeczek⁴⁰ also provided an example of a ‘tailored intervention’ appropriate to specific contexts in which school-based clinics were deemed more effective for administering HPVV.

Dube and colleagues⁵⁴ reported primary schools as an effective and appropriate means to obtain higher HPV immunization coverage since HPVV is preferable before the commencement of sexual activity. Wilson³² advocated for Grade 8 students to be able to request HPV immunization without parental consent if they were judged capable of providing informed consent.

Bird’s³⁷ review provided important information that could be utilized to infer gaps in the HPV delivery and administration system. Bird³⁷ reported that HPV vaccine uptake in females (57.2%) was higher than in males (47.0%) when given through school-based programs (69.6%) compared to community-based (18.66%). Furthermore, to develop a suitable intervention, Henderson³⁴ suggested establishing and strengthening community inter-generational relationships to combat trust issues in the health system. Finally, the Canadian Immunization Committee (CIC) report⁴¹ called for consideration of new and unresolved research priorities and evaluation of indicators (i.e., adequate measures to prioritize the assessments of new and ongoing HPV immunization programs) to devise locally and nationally driven policies and interventions⁴¹

System level barriers and facilitators

Attitude was the most significant factor at the system level. Attitudes reflect three main components⁵³. The affective component reflects a person’s feelings/emotions about the HPVV. A study⁵¹ reported physicians’ intention to recommend HPVV was perceived as acceptability by both vaccine providers (working at system level in vaccine program planning and roll-out) and vaccine receivers^45,28,3. Moreover, Physicians’ self-estimated sufficiency of knowledge on HPVV and perceived efficacy of HPVV were also reported as barriers to HPVV.⁵¹

The behavioral component reflects people’s attitudes and influences their behavior. From the studies discussed above, it was clear that multiple factors at all three levels (patient, provider, and system level) play a role in shaping people’s attitudes and their behavior; hence, the associated factors served as important barriers to HPVV. Some of those factors included social group values and norms³ and fear of side effects^46,48 which might be the reasons for the parental refusal,⁴⁴ especially among those parents who had a previous history of refusing mandatory or optional vaccines.^44,50 Pre-informed behaviors could also contribute to difficulty in receiving agreements from local school boards to hold HPVV clinics in schools.³²

The cognitive component reflects people’s belief/knowledge about HPV infection and the HPV vaccine. Studies reported people’s beliefs that HPV was either predominantly or exclusively a risk factor for females'²⁹ concerns about being over the recommended age⁴³ doubts about vaccine safety benefits³¹ uncertainty around the vaccine types, and the role of manufacturers and interest group in its promotion,³¹ all of these factors are significant barriers to optimal HPVV uptake.

The key findings from this review are as follows: (a) interrelated factors (i.e. acceptability to provide HPV vaccine recommendations and appropriateness of tailored interventions) play a role in HPV vaccine uptake at the provider level, (b) the ability to perceive (knowledge sufficiency and knowledge insufficiency) was identified as the main factor at the patient level, and (c) attitudes toward HPV vaccine (a combination of feelings/emotions, belief, behavior, and knowledge) stood out as the main factor at the system level.

Drawing on the literature reviewed, this analysis revealed that in providing HPV vaccine programming, planning, delivery, and administration services, there is no one-size-fits-all strategy that could effectively enhance HPV vaccine uptake. A combination of factors should be considered. For instance, factors that hinder the ‘acceptability’ of the HPV vaccine should be addressed to design appropriately tailored interventions that suit the context of local population subgroups to obtain optimal HPVV uptake. The identified barriers that impede providers’ abilities to make recommendations and provisions should be addressed through proper staffing, regular training of front-line providers to refine provider’s perceptions about HPV vaccine prevention and therapeutic benefits, education on the use of different communication modes to address questions and concerns around gendered association around HPV vaccine, the vaccine types, cost and insurance plan, and catch-up programs. Strategies should be in place to train providers on practicing culturally appropriate modes of communication and service delivery for different population subgroups.

Analysis of the identified literature also showed that raising awareness of HPV infection and its prevention is the strongest factor for enhancing rates of HPVV uptake. Multicomponent educational strategies should be devised, followed, and maintained in a phased manner. Educational campaigns, workshops, and advertisements on social media platforms are possible avenues for increasing awareness of this highly contagious sexually transmitted infection. Social media can be used, as it was for COVID-19, to create awareness about HPVV among the public. The literature shows that social media can serve as an excellent platform for public health intervention in raising awareness around COVID-19 infection and vaccines and addressing vaccine hesitancy.⁵⁵ Social media can be crucial not only in disseminating health information but can also tackle infodemics and misinformation.⁵⁶

The findings also reveal the attitudes of different stakeholders working at the system level in planning, programming, roll out, and delivery of HPV vaccines should be appropriately addressed. System-level workers range from medical health officers to physicians, immunization specialists, managers, and more; therefore, multifaceted strategies are required that address knowledge, attitudes, behaviors, and beliefs of system-level workers to facilitate HPV vaccine provision.³⁸ Strategies could include regularly holding educational workshops, refresher courses, and feedback sessions for continuous improvement. Quality improvement surveys and audits that collect high-resolution information and investment targets should be launched and regularly operated to enhance HPV uptake by under-immunized populations.

There are limitations to this review. One of the major limitations is that it was not undertaken following a specific type of review procedures, such as systematic review, scoping review, etc. The review, however, follows an organized approach detailed throughout methods and results. We also did not carry out a quality assessment of the studies included in the review using a quality appraisal tool or checklist. Only one coder undertook coding, which precluded comparison of coding, category formation, and labeling during the analysis process. The review was limited in its scope to only English Canada; therefore, it did not include French manuscripts. Also, more than half of the included studies targeted one-time uptake of the HPV vaccine to determine vaccine status, and none embarked upon all dose series completion and/or a catch-up vaccine status. As a consequence of these limitations, the review might have missed some factors important to HPVV uptake among subpopulations who encounter unique challenges with vaccine catch-up programs or would otherwise remain unable to complete all vaccination doses against HPV infection.

There is scope for future research to explore and address factors associated with HPV vaccine uptake at all levels, i.e., provider recommendation, patient acceptance, and potent delivery by the health-care system. Improved understanding of the system-, provider-, and patient-level factors of HPVV in different jurisdictions of Canada will help target high-resolution investment targets and guide the classification of the identified barriers and facilitators according to the province-specific requirements around the country. Increased HPV vaccine uptake will help procure herd immunity against HPV, which is important to meet the target that the Government of Canada has set of reaching 90% HPVV coverage among Canadian adolescents by 2025.⁶ Reducing the occurrence of HPV-related cancers will take Canada toward the fulfillment of an essential step toward the WHO goals of a global strategy in eliminating preventable cancer.⁵⁷

With a better understanding of the underlying determinants of inconsistent and sub-optimal HPV vaccination coverage, policymakers, and health-care professionals can devise effective and locally tailored interventions. This review’s findings should be used to guide future research, especially those plans to carry out population health intervention research in this topic area. There remains an urgent need to further elucidate the determinants of HPVV uptake as well as actively use knowledge already generated to formulate strategies that enhance its uptake in all jurisdictions of Canada. The existence and availability of safe and effective vaccines like the HPV vaccine in even a developed country like Canada have limited impact when their utility is not appropriately realized.

Consent for publication

I consent to publish the data and images enclosed with this submission.

Acknowledgments

Drs. Sandro Galea, Shahid Ahmed, Thilina Bandara, and Charles Plante.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Funding support was received from the Canadian Partnership Against Cancer.

Appendix.

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