Elsevier

Vaccine

Volume 29, Issue 46, 26 October 2011, Pages 8390-8396
Vaccine

Like mother, like daughter? Mother's history of cervical cancer screening and daughter's Human Papillomavirus vaccine uptake in Flanders (Belgium)

https://doi.org/10.1016/j.vaccine.2011.08.039Get rights and content

Abstract

Objective

We investigated whether and to what extent the uptake of the Human Papillomavirus (HPV) vaccine by girls aged 12–18 was related to the cervical cancer screening history of age-appropriate older female household members (assumed to be their mothers) in Flanders (Belgium).

Methods

We studied administrative records on 127,854 female members of the National Alliance of Christian Mutualities, which is the largest health insurance fund in Flanders. Reimbursement data for HPV vaccination of girls for the period 2007–2009 were linked with reimbursement data for cervical cancer screening of their mothers in the three preceding years. A multilevel logit model was used to study associations between both preventive behaviors. In the model we controlled for both the girl's and the mother's age, the province of residence and the socio-economic background of the family.

Results

A clear association between a mother's history of participation in cervical cancer screening and her daughter's HPV vaccination initiation was found. The conditional odds of HPV vaccination initiation were more than 4 times higher for girls whose mother had one Pap test than for girls whose mother had none (odds ratio [OR] = 4.5; 95% confidence interval [CI] = 3.5–5.9). For girls whose mother had three or more Pap tests, the conditional odds were 16 times higher than for girls whose mother did not have any pap tests ([OR] = 16.0; 95% [CI] = 12.1–21.2). The effect of screening (having received 1 pap smear as compared to none) was larger for girls living in neighborhoods with the lowest median income ([OR] = 6.0, 95% [CI] = 3.6–10.1).

Conclusion

In a situation where both cervical cancer screening and HPV vaccination are opportunistic, we found evidence that these preventive behaviors cluster within families.

Introduction

At present two preventive strategies exist in Flanders (the northern part of Belgium) for the prevention of cervical cancer: cytological screening (Papanicolaou (Pap) smear tests) on the one hand, and vaccination against Human Papillomavirus (henceforth: HPV vaccination) on the other. A relationship between a mother's cervical cancer screening and her daughter's HPV vaccination was described in the US, where the mother's testing history was associated with the daughter's likelihood for vaccination across ethnic and neighborhood socioeconomic strata (overall odds ratio = 1.42) [1].

The quadrivalent and the bivalent HPV vaccines (Gardasil® en Cervarix®) were licensed in Belgium in September 2006, and September 2007, respectively. During the first 2.5 years after their introduction on the Belgian market (from January 2007 to June 2009), no centralized vaccination policy was in place (only in September 2010 school-based vaccination was introduced for 11–12 year old girls in Flanders): HPV vaccination had to be initiated by the girl/woman, her general practitioner, pediatrician or her gynecologist. In the latter three cases, it could be initiated during a consultation for unrelated medical reasons. The vaccines were partly reimbursed by the national health insurance and by the sickness funds. The cost per dose for the vaccines was 124.16 euro. For certain age groups the national health insurance reimbursed 113.36 euro per dose, for other groups sickness funds reimbursed 50 euro per dose. Reimbursement rules varied over the period of analysis and were determined purely by the age of the girl [2].

The Flemish program for cervical cancer screening is based on the European guidelines. Hence, one Pap smear or liquid-based cytology sample every 3 years is recommended for women of 25–64 years of age. The implementation of the program is entrusted to the provinces that are instructed to make women and physicians aware of the screening policy. From 2004 to 2006, 4 out of 5 provinces undertook some form of activity with regard to cervical cancer screening, but to a large extent the screening was performed at the initiative of women or general practitioners / gynecologists [3], [4], [5]. The most recent available data on cervical cancer screening date from the year 2000, when in Flanders the screening coverage for women aged 25–64 was 57%. At the same time, substantial overuse of Pap smears was reported, the modal screening interval being 1 year [5].

In this article we investigate whether in Flanders an association exists between the uptake of the first dose of a HPV vaccine (HPV vaccination initiation) by girls aged 11–18 and the cervical screening behavior of age-appropriate older female household members (assumed to be their mothers). We also look whether HPV vaccination completion (having received a complete regimen of 3 doses) is related to the mother's screening behavior. By using multilevel analysis we explicitly model the clustering of vaccination behavior within families.

Section snippets

Sample

We analyse data from the National Alliance of Christian Mutualities (henceforth: NACM), the largest sickness fund in Flanders covering 53% of the Flemish population. All analyses were carried out at the NACM under supervision of a medical advisor.

We selected female members of the NACM aged 11–18 (years of birth 1989–1996) who were member of the NACM on December 31st 2006 and who were living in Flanders. Out of these girls, we selected those who continued membership of the NACM during the whole

Characteristics of the study population

In Table 1 we give an overview of the demographic characteristics of the girls included in and excluded from the study. Girls included in the study on average lived in neighborhoods with higher median income, and were less often eligible for preferential treatment compared to the girls that did not meet our inclusion criteria.

For the 127,854 girls used in the analysis 105,541 potential mothers were identified. Of these mothers, 33.06% (N = 34,888) had not received any Pap smears during 2004–2006,

Discussion

We found that HPV vaccination initiation by daughters was associated with cervical screening behavior of their mothers, which is in line with findings from the United States [1]. Moreover, the more frequently a mother received a Pap smear, the more likely her daughter was to initiate HPV vaccination. The association was stronger for girls living in neighborhoods with the lowest median incomes. A clear social gradient was found. The highest odds of vaccination initiation were seen in the

Acknowledgements

The authors wish to thank the Research Foundation Flanders (FWO) for financial support. They also thank Hervé Avalosse (NACM) for help with the acquisition, use and interpretation of the NACM data.

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