Determinants for HPV vaccine uptake in the Netherlands: A multilevel study
Introduction
Following advice from the Dutch Health Council in March 2008, the Minister of Health decided to introduce routine HPV vaccination in the National Immunisation Program (NIP) [1] in order to further reduce the incidence of and deaths due to cervical cancer in the Netherlands (8.44 cases and 2.41 deaths per 100,000 women yearly) [1]. The vaccine, targeting 12-year-old girls, will be implemented in the NIP in 2010. Prior to that, a catch-up campaign for girls born between January 1st 1993 and December 31st 1996 (between 13 and 16 years of age) was organized, starting in March 2009. The schedule of the used bivalent HPV16/18 vaccine consists of a first dose at baseline followed by two boosters at 1 and 6 months [2]. Delivery of the first two doses was scheduled before summer holidays. The third vaccination was given in September/October 2009. This campaign was coordinated by the National Institute for Public Health and the Environment (RIVM). The Community Health Services (CHS) were in charge of local implementation. Eligible girls received a personal invitation letter with an information leaflet. Vaccination was free of charge. They were invited to visit local (mass) vaccination sessions.
Introduction of HPV vaccine has previously been described as particularly challenging [3], [4] because of several new aspects compared to the regular vaccination programmes. In fact, tackling a sexually transmitted infection (STI), this vaccine is introduced for girls only and targets infection potentially leading to cancer. Furthermore, efficient secondary prevention by cervical smears is in place since 1976 in the Netherlands [5], [6]. Finally, due to the long duration between infection and the occurrence of cancer, the estimates of the long-term protection of the vaccine is based on extrapolation of shorter term effects, somehow less convincing for the public.
Scepticism of some Dutch scientists regarding HPV vaccine safety and efficacy and anti-vaccination lobbying divided the medical community by the time the catch-up campaign was implemented. The debate was widely relayed in the national media resulting in mixed messages and a feeling of confusion in the population.
Finally, the vaccination coverage for the first dose in the population targeted by the catch-up campaign was lower than the aimed 70%. Understanding reasons for the low vaccine uptake among Dutch girls is important to provide recommendations to the NIP and to determine which aspects further studies should focus on.
We performed a multilevel study using available data to investigate determinants for HPV vaccine uptake as well as successful measures of implementation.
Section snippets
Data collection
Data was gathered at different levels of aggregation as detailed in Table 1. Individual data could be extracted from the national vaccination register (Praeventis). In addition, detailed statistics on various background data are publicly available on the websites of Statistics Netherlands (www.cbs.nl) and the Dutch Institute for Social Research (SCP, www.scp.nl). At the municipal level, percentages of voters for two political parties (Reformed Political Party (SGP), with predominant orthodox
Results
The target population included 384,869 girls. The national coverage for the first dose of the HPV16/18 vaccine for this catch-up campaign was 49.9%.1 Large regional differences in vaccine uptake were observed, ranging from 31% to 61% per CHS region (see Fig. 1).
Descriptive results are presented for background information by level of aggregation
Discussion
To our knowledge, this study is the first evaluating determinants for HPV vaccine uptake nationwide. Using individual data on vaccination status available from the national vaccination register, this work provides answers to numerous previous studies predicting behaviours towards such a vaccination. Furthermore, our results represent an important basis for more in-depth studies addressing the reluctance of the population to vaccinate. This would be helpful in improving the success of future
Concluding remarks
Despite its inherent limitations, our multilevel study showed the complexity involved in the decision making process of the target population as to whether or not be vaccinated against HPV, as well as the influence of the media and professionals on this process. In-depth follow-up studies could give further insight into the reasons for reluctance to vaccinate.
In the short term, i.e. for the vaccination campaign of 12-year olds starting in 2010, organizing information meetings at schools and
Acknowledgments
We would like to thank the following persons:
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Petra Oomen for providing the individual data from the national vaccination registers (Praeventis).
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Maarten Mulder and Laurens Zwakhals for providing the demographical data and the map with regional vaccine uptake.
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All the CHS that completed the questionnaire on regional implementation aspects of the HPV vaccination campaign.
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Roel Coutinho, Marina Conyn-van Spaendonck and Marianne van der Sande for their advices.
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Wil Hilgersom (CHS Midden-Nederland) for
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