Dalla Lana School of Public Health

Having conversations with Canadians about why they do — or do not — get vaccinated

April 19/2024

How U of T researcher Gilla Shapiro is using a new approach to understand what drives HPV vaccine uptake in Canada.

Ishani Nath 

Gilla Shapiro wants to have a conversation with you about HPV vaccines.

Specifically, the U of T researcher is leading a new research program to understand why some people choose to get — or not get — vaccinated against human papillomavirus, or HPV, and what motivators and barriers factor into those decisions.

“HPV is related to nearly 4,000 new cancer cases each year in Canada, many of which can be prevented by the HPV vaccine,” explains Shapiro, a member of the Centre for Vaccine Preventable Diseases (CVPD) at the Dalla Lana School of Public Health and a psychologist at the Princess Margaret Cancer Centre.

HPV vaccines are offered for free as part of school-based vaccinations programs across the country to students in grades 4 to 7. Uptake is well below targets, despite vaccination being an essential component of Canada’s goal to eliminate cervical cancer by 2040.

Shapiro hopes to get a better sense of what leads people to have their children vaccinated against HPV by surveying and interviewing parents and caregivers of children eligible for HPV vaccinations across Canada.

“The point of this research program is to develop tools to help us better understand the drivers of HPV vaccination in parents — so understanding what influences people to get their children vaccinated or not to get vaccinated,” says Shapiro. To do that, Shapiro and other researchers around the globe are looking at the multiple factors that can influence vaccine decision making — a particularly timely topic as public health experts push communities around the globe to catch up on routine childhood immunizations missed during the pandemic.

For National Immunization Awareness Week, the CVPD spoke with Shapiro to learn more about her research on HPV vaccination and the potential impact of her work on how we support Canadians thinking about vaccination.

This interview has been edited and condensed for clarity.

Public health leaders have recently expressed concern about low vaccine rates for several preventable diseases in Canada. Why did you want to specifically look at the drivers for the HPV vaccine?

There are two main reasons why I think looking at HPV is really important. One is because HPV vaccination is one of the available measures we have to prevent a growing number of cancers. HPV can cause cervical, anogenital and oropharyngeal cancers. In addition, oropharyngeal cancers are on the rise in high income countries like Canada.

The other reason is if you look at other school-based vaccines, the HPV vaccine is the lowest in terms of coverage rates. I want to know why that is. What has contributed to that? And what can be done about it to support parents and children making this decision?

How do you figure out what factors influence whether someone will get an HPV vaccine?

We’re using something called the BeSD, the Behavioural and Social Drivers of vaccination tool developed by the World Health Organization (WHO). The ‘tool’ includes a survey and interview guide that help us understand many influences from confidence in vaccines to practical factors, like how one accesses the vaccine, whether the vaccine is affordable, and someone’s experiences when getting the vaccine. All these different factors really impact whether someone will get the vaccine or not, and this may be different for each individual.

How is this approach different from previous research?

Most previous research has examined what people think and what they feel about vaccination. But one of the areas that has not been looked at to the same extent is practical factors, like the relationship between vaccine access and affordability and whether people get the vaccine or not. We know that even if someone has a very positive attitude towards the vaccine, but it’s hard to get to it, or they don’t get the time off work, or they miss the day of school when the nurse was vaccinating, that presents barriers to getting vaccinated. So those are important areas to measure as well. That’s what this BeSD tool is hoping to do — not only look at attitudes and confidence, those thinking and feeling components, but also look at social processes, motivation, and practical factors that have been less examined in the past.

This year marks 50 years of the World Health Organization (WHO)’s Expanded Programme on Immunization (EPI), initially aimed to protect against six key childhood illnesses (tuberculosis, diphtheria, tetanus, pertussis, polio, measles) but has expanded to 13 vaccines including HPV. Your research focuses on Canada but is part of a larger effort to research and address the behavioural and social drivers of vaccination around the world. What will that achieve?

The goal of our project is to help the WHO develop a standardized tool to understand vaccine uptake in many cultural contexts around the world. We are specifically surveying the Canadian population as part of that effort. We’re part of a team of researchers around the world who are all testing the BeSD HPV tool in other countries. In this way, the same surveys can be asked in high-, low- and middle-income countries, and can also be asked in the same country over time, so we can track these drivers and better understand the impact of our programmes and interventions.

How do you create a standard questionnaire that is still accessible for diverse groups and settings?

The questions have been developed with culturally and linguistically diverse groups in mind. So we have tried to address different key issues, like vaccine accessibility, in a way that would apply to many languages, countries and cultural settings. There are specific guidelines that have been developed for the WHO’s original BeSD tools (and I expect will be developed for the BeSD HPV tools as well), about, for example, how translation should be done, or if certain questions don’t work in different contexts, how to address this.

What is the potential impact of this research?

This is the first time BeSD is being conducted in Canada. Doing this research will help us better understand what gaps exist here in Canada and what groups might need more targeted campaigns or resources to inform their decisions around HPV immunization. These are not questions we’ve asked before, so we stand to learn a lot.