Like mother, like daughter? Mother's history of cervical cancer screening and daughter's Human Papillomavirus vaccine uptake in Flanders (Belgium)
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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2013, VaccineCitation Excerpt :Though HPV vaccination protects against only 70% of CC, it may be important that these girls at particular risk of not being screened in adulthood are vaccinated against HPV in adolescence. Two other groups (American and Belgian) found a very strong link between HPV vaccination (initiation and completion) and mothers’ PPS status [15–17]. Our link was more moderate.
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