Social capital interventions for human papillomavirus (HPV) immunization and cervical cancer screening: A rapid review

Background Social capital can be used as a conceptual framework to include social context as a predictor of human papillomavirus (HPV) vaccination and cervical cancer screening behaviours. However, the effectiveness of interventions that use social capital as a mechanism to improve uptake of immunization and screening remains elusive. Objective To synthesize empirical evidence on the impact of social capital interventions on HPV immunization and cervical cancer screening and describe key characteristics of such interventions. Methods Using a rapid review methodology, a search of literature published between 2012 and 2022 was conducted in four databases. Two researchers assessed the studies according to inclusion criteria in a three-step screening process. Studies were assessed for quality and data concerning social capital and equity components and intervention impact were extracted and analyzed using narrative synthesis. Results Seven studies met the inclusion criteria. Studies found improved knowledge, beliefs and intentions regarding HPV immunization and cervical cancer screening. None of the studies improved uptake of immunization; however, three studies found post-intervention improvements in uptake of cervical cancer screening. All studies either tailored their interventions to meet the needs of specific groups or described results for specific disadvantaged groups. Conclusion Limited evidence suggests that interventions that consider and reflect local context through social capital may be more likely to increase the uptake of HPV immunization and cervical cancer screening. However, further research must be done to bridge the gap in translating improvements in knowledge and intention into HPV immunization and cervical cancer screening behaviours.


Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection in North America, affecting most sexually active people at least once in their lifetime, if not immunized (1).Persistent HPV infection can cause cancers of the cervix, as well as the vulva, vagina, penis, anus, mouth and throat (2,3).While cervical cancer incidence has slowly declined, it remains the third most common cancer among people with a cervix aged 35-44 years (4).Due to social and structural determinants, OVERVIEW inequities in HPV infection rates and incidence of cervical cancer are also experienced by Indigenous people, immigrants, sexual and gender minorities and residents in rural and remote communities (1,5).Therefore, slowing the spread of HPV infection and eliminating the incidence of cervical cancer through evidence-based, equitable interventions to improve prevention remains a pressing public health concern.
Morbidity and mortality of cervical cancer can be reduced or eliminated through primary and secondary prevention against HPV.In Canada, publicly funded vaccination programs in school, community and healthcare settings (6) have proven to be a highly effective primary prevention strategy for HPV infection and high-risk precancerous cervical lesions (1).Secondary prevention through publicly funded cervical cancer screening programs (e.g., Pap smears and self-sampling test kits) can also detect cell changes to be treated before they progress to cervical cancer (4).The provincial and territorial final dose uptake rate for HPV vaccination in schools ranges from 57% to 91% (7), while adherence to recommended cervical cancer screening guidelines across the country also ranges, from 63% to 71% (4).
Human papillomavirus immunization and cervical cancer screening behaviours are complex and influenced by numerous factors, including lack of information, vaccine hesitancy and gaps in access and financial coverage (6,8).Social capital has been used as a conceptual framework to broaden the lens beyond conventional predictors of immunization and screening behaviours to include social context.Within public health, social capital most often refers to the resources available to people through their social networks (e.g., families, workplaces) (9).Indicators of social capital fall into two dimensions: cognitive social capital (subjective perception of level of trust, sharing and reciprocity) and structural social capital (observable extent of social participation) (9).Social capital is further understood through three functions: bonding social capital (resources accessed within groups that have similar socioeconomic and demographic characteristics), bridging social capital (resources that may be accessed across groups with different characteristics) and linking social capital (networks of trust connecting groups with differences in power) (9).Social capital interventions represent activities aimed at improving health through changes in an individual's or group's capacity to mobilize social capital (9), including social norms, social cohesion, community networks, connectedness, belonging and reciprocity.For instance, social capital may help provide underserved individuals with information, financial assistance or transportation to access immunization programs.Such interventions may enhance individual uptake of cancer prevention behaviours, thereby reducing cancer incidence and mitigating cancer-related inequities (8).However, there is limited knowledge concerning social capital as a mechanism to improve uptake of HPV immunization and cervical cancer screening.This paper aimed to synthesize empirical evidence on the impact of social capital interventions on HPV immunization and cervical cancer screening and describe key characteristics of such interventions.

Methods
Evidence concerning social capital and HPV-related cancer prevention was required for the development of a provincialbased intervention to reduce HPV-related cancers in Alberta.Accordingly, a rapid review methodology (10,11) was chosen for evidence-based, rapid decision-making.The research question was: What is the empirical evidence of the impact of social capital interventions on uptake of HPV immunization and/or cervical cancer screening (secondary prevention) to prevent HPVassociated cancers?
The search strategy was developed by a librarian in collaboration with content experts, from May 6 to June 22, 2022.The search strategy included testing, language, development, peer review, translations and deduping.The search was conducted in Ovid Medline, Ovid PsycINFO, Ovid Embase and EBSCOhost CINAHL on June 22, 2022 (the search protocol, including full search strategies, is available upon request).Studies were included if they were peer-reviewed intervention studies, systematic reviews, or meta-analyses published in English between 2012 and 2022 (see Appendix, Table A1 for inclusion and exclusion criteria).
Following a three-step screening process, two researchers began by independently conducting title-abstract screening for the same set of 10% of the studies.A third researcher helped resolve discrepancies.When an inter-rater agreement of 100% was reached, the database was split into two.The same two researchers completed the primary screening separately using half of the database each.This process was repeated for full text screening.Finally, the references of included studies were screened for potential inclusion.No protocol outlining all methodological steps in our rapid review was developed a priori or registered in an open-source platform.
One researcher extracted data (e.g., participants' characteristics, study limitations) from the studies using Microsoft Excel and a second researcher verified the data (available upon request).Through group discussion, social capital was categorized by dimensions and functions.The PROGRESS-Plus (12) characteristics from Cochrane Equity were used to organize findings by social factors influencing health inequities.Quality appraisal was performed independently by two researchers for 10% of studies using the Quality Assessment Tool for Quantitative Studies (13).After achieving an inter-rater agreement of 100%, the two researchers completed the remaining quality appraisals.They discussed their independent scoring with each other to determine the final rating (see Appendix, Table A2).The 2020 PRISMA checklist (14) was used as a reporting guideline for our rapid review findings.

OVERVIEW
Due to heterogeneity of the data from the included studies, a meta-analysis could not be conducted.Rather, the evidence was synthesized narratively and thematically according to the social dimensions and functions of the interventions and social factors considered.The analysis focused on the characteristics of social capital interventions and their impact on HPV immunization and cervical cancer screening (e.g., uptake, knowledge, intentions).

Overview
The search produced 2,873 studies.Through primary screening, 103 studies met the inclusion criteria.In the secondary screening, 97 studies were excluded.In the reference list screening process, one study met the inclusion criteria.This review included seven studies (15-21) (Figure 1).

Key characteristics
Table 1 summarizes the key characteristics of the included studies.Most studies were conducted in the United States (15,(17)(18)(19)(20). Six were quasi-experimental studies (15)(16)(17)(18)20,21) and one was a randomized control trial (19).All seven studies had an educational component.Six studies incorporated culture into the educational component by utilizing co-ethnic health professionals or lay health educators who came from the same ethnic groups and/or spoke the same language as the participants (15,(17)(18)(19)(20)(21).All seven studies included a cognitive dimension of social capital and two studies had a structural dimension of social capital (19,21).All studies had a bonding and bridging function of social capital and five had a linking component (16,17,(19)(20)(21).Six studies had a "weak" quality rating score (15,(17)(18)(19)(20)(21) and one received a "moderate" rating (16) (Appendix, Table A2).Overall, the evidence was weak due to data collection methods, withdrawal reporting and limitations of blinding.

Impact on human papillomavirus immunization
Only two studies reported the impact of social capital on HPV immunization (15,19) (Table 2).Factors associated with uptake included: HPV immunization-related knowledge; perceptions about one's susceptibility to HPV; understanding the risks of HPV-related diseases and benefits of the immunization; intentions to be vaccinated for HPV; and immunization behaviours.One culturally appropriate, community-based education program delivered by co-ethnic health professionals resulted in significant improvement in mothers' knowledge, beliefs and intentions to immunize their own children (15).However, there were no statistically significant differences in HPV immunization uptake among children within a six-month time frame.A narrative intervention also resulted in higher levels of intention to immunize among girls, but no differences in actual HPV immunization uptake (19).Due to the combination of multiple components (e.g., social capital and education) in the intervention, the effects of each component on the outcomes were not described.Despite improving knowledge, beliefs and intentions around HPV immunization, both studies reported the ineffectiveness of educational and narrative interventions in improving HPV immunization uptake in girls and their mothers (15,19).

Impact on cervical cancer screening
Five studies found mixed results regarding the impact of social capital on cervical cancer screening (16)(17)(18)20,21) (Table 3).One study on Pap smear testing found no significant differences in subjective norms and perceived behavioural control between the groups receiving and not receiving an educational intervention (16).However, these factors increased significantly among the participants within the education intervention groups, according to pre-post analysis.Two other studies found that the group format of the educational sessions contributed to higher overall scores in emotional, instrumental, reciprocal and perceived social support (17,18).One study in local community and faithbased settings examined the knowledge, attitudes and uptake of HPV self-sampling tests that were provided by bilingual health educators (18).All participants completed the HPV selfsample test, with most participants reporting that they were "comfortable/very comfortable" with self-sampling.Cognitive: • Social norms and influences were measured using survey items.
• Focus group findings deepened the understanding of social influences (social, cultural, religious factors).These findings on contextual factors informed the development of the intervention.
Bridging and bonding: • The intervention was designed to be sensitive, language and culturally appropriate and audiencecentric to appeal to the East African community.
• Within 6 months of the intervention, only 2% (n=2) of the 96 mothers with children who had no HPV vaccination records received the HPV vaccine.
• Post-intervention, 86.4% (n=95/110) of mothers reported that they were more likely to talk with their children's doctors about the HPV vaccine than pre-intervention (p<0.0001).Linking: • Trusted community health leaders utilized their social networks to aid in study recruitment. Bridging: • Participants, community health leaders and actors within the storytelling narrative were all part of the Khmer community.While these groups share similar characteristics or identities, they are part of different networks. Bonding: • Dyads of mothers and daughters were recruited because mothers are the primary health decision-makers for their daughters.
• Within one month, daughters from the intervention group reported higher intentions to receive HPV immunization than their control group counterparts.However, there was no difference in actual vaccination initiation between both groups.
• Storytellers shared how they were personally influenced by their social networks and norms from friends, mothers and healthcare providers to receive the HPV vaccination.
• Social network norms were effective in motivating the vaccination intentions of participants through a positive emotional reaction.
Note: No statistical data was provided.
Abbreviations: CI, confidence interval; HPV, human papillomavirus; RR, relative risk Linking: • Lay health educators were considered "practical supports", as individuals who can share health information with others.
Bridging and bonding: • Lay health educators (or promotoras de salud) were language-matched and networked in their communities.
• No significant differences in cervical cancer screening between the SSG and IND groups (p=0.315).
• No significant differences in maintenance of cervical cancer screening (p=0.971).Cognitive:

OVERVIEW
• Promotores de salud offered social support, a sense of belonging and trust. Linking: • Promotores de salud lived in the communities and provided health services and education as trusted members of the community.They acted as cultural brokers between the communities and the healthcare system.
Bridging and bonding: • The intervention was delivered to a group of participants that identified as Latina and were part of a culturally similar group.

Structural and cognitive:
• The development of the intervention was informed by perceived barriers related to religion, culture, spouses' disapproval and feelings of embarrassment.
• Religious leaders, traditional leaders and husbands helped promote the Pap smear services through speeches at health education sessions.

Bridging and bonding:
• People were assigned to groups based on similar sociodemographic characteristics, beliefs, values and behaviours.
• Sensitization and educational sessions were targeted toward husbands to reduce spouses' disapproval.
• Change in knowledge was statistically significant in the intervention group (mean=0.0,SD=0.

OVERVIEW
Groups receiving educational interventions reported outcomes that included increased knowledge related to cervical cancer and screening procedures, improved understanding of perceived susceptibility to HPV (i.e., the belief that one is likely to get HPV or HPV-related disease), severity of cervical cancer (i.e., risk and seriousness of HPV, HPV-related disease and associated complications to one's life), benefits of cervical cancer screening (i.e., reduction of risk and severity of getting HPV and HPV-related disease), increased intentions for cervical cancer screening uptake and greater uptake of the Pap smear test (e.g., administered by a physician or HPV self-sampling test) (16,18,20,21).Among the four studies that included uptake measures (12-14,17), three reported increased cervical cancer screening uptake (16,18,21).One study found no significant differences in cervical cancer screening uptake between the cohort receiving education sessions in groups to promote social capital and the cohort receiving the session individually with no social capital component (17).However, it also found that cervical cancer screening increased in both group and individual education sessions.

Equity considerations
Table 4 presents equity-related findings on HPV immunization and cervical cancer.The studies either tailored their interventions to meet the needs of specific groups or described results for specific disadvantaged groups (e.g., immigrants) considering, for example, education level and gender and/or sex.

Discussion
To our knowledge, this is the first review of social capital interventions in public health regarding HPV immunization and cervical cancer screening.Despite interest in the use of social capital to improve cancer outcomes (8,22,23), only seven papers met this review's inclusion criteria.Concerning primary prevention, education interventions containing social capital dimensions and/or functions were found to increase HPV immunization knowledge, attitudes and intentions.They successfully addressed concerns, fears and doubts for providing accurate information, building a trustworthy relationship between participants and researchers or providers and meeting participants' life circumstances and sociocultural needs.However, they seemed to have failed in bridging the intention-uptake gap in HPV immunization.This finding speaks to the recognition that knowledge is only one of the multiple determinants of vaccine decision-making, as some vaccine-hesitant people delay or refuse vaccination after educational interventions (24).Pairing social capital interventions with a vaccine offer or immunization appointment scheduling at the end of the intervention may effectively increase uptake.For those with limited access to the healthcare system, school-based health outreach and partnerships with communities should be part of the strategy to build multisectoral delivery platforms for vaccination and to promote uptake following educational intervention (25).
Regarding secondary prevention, this review found that interventions improved several outcomes including knowledge on cervical cancer and screening procedures; understanding of perceived susceptibility to and severity of HPV infection and cervical cancer; benefits and intentions of cervical cancer screening; and emotional, instrumental, reciprocal and perceived social support.Among the four studies analyzing the uptake of cervical cancer screening, three found increased uptake.These three studies used the health belief model in the design of their interventions, which seeks to change an individual's beliefs, knowledge and perceived benefits and risks to positively influence their health behaviours (26)

OVERVIEW
rates among males generally and that HPV-related cancer rates are predicted to rise among populations who do not have a cervix (29).This may be due to the prior focus of HPV vaccine promotions to prevent cervical cancer, which continues to act as a barrier for uptake of the newer nonavalent HPV vaccine that protects against oropharyngeal, anogenital and cervical cancer-causing strains of HPV.The LGBTQ2S+ community is more likely to experience an HPV infection and less likely to receive an HPV vaccine than heterosexual groups (30)(31)(32).Social support may support HPV vaccine uptake among LGBTQ2S+ people (33).
As HPV infects both biological males and females and can lead to cancer in any person irrespective of their gender identity or • Findings were mixed regarding the influence of fathers and husbands on women receiving cervical cancer screening and children's decisions to receive HPV Immunization.One study indicated that Somali fathers had less influence than mothers on their decisions to immunize their children (Chu et al., 2021).In some countries, husbands may need to consent before women are able to undergo cervical cancer screening.Thus, providing education sessions for husbands was recommended to reduce disapproval of screening (Olubodun et al., 2022).• Overall, the reported preference to have a female sample collector for cervical cancer screening may indicate an opportunity to engage female physicians and nurses while reducing patients' shyness and shame (Olubodun et al., 2022).

OVERVIEW
sexual orientation, future research should expand the evidence base concerning interventions utilizing social capital targeting LGBTQ2S+ populations and biological males.

Limitations
The strengths of this rapid review include the use of a systematic methodology for screening and data extraction and analysis, assessment of methodological quality and consideration of social factors.However, data synthesis was limited to a small sample of studies, which may reflect the heterogeneity of study designs and measures.As the included studies focused on interventions across the world, the generalizability, transferability and applicability of the review findings are context-dependent and the unique circumstances of each region and population should be considered.This creates opportunity for future research and implementation work focusing on the unique knowledge and awareness needs of each population, such that HPV immunization and cervical cancer screening is promoted as an autonomous, yet supported, culturally appropriate decision among disadvantaged populations.

Conclusion
This rapid review examined the evidence concerning the characteristics and impact of interventions utilizing social capital on HPV immunization and cervical cancer screening.It found limited and mixed results regarding the use of social capital as a mechanism to improve uptake of HPV immunization and cervical cancer screening.However, evidence suggests that interventions that consider and reflect the local context may increase the uptake of HPV immunization and cervical cancer screening.

Figure 1 :
Figure 1: PRISMA chart of rapid review screening process

Table 2 :
Characteristics of the social capital interventions and their impacts on human papillomavirus immunization

Table 3 :
Characteristics of the social capital interventions and their impacts on cervical cancer screening Page 264 CCDR • July/August 2024 • Vol.50 No.7/8

Table 3 :
Characteristics of the social capital interventions and their impacts on cervical cancer screening (continued) . This finding may indicate the value of using a theoretical health behaviour change model alongside dimensions of social capital to guide cervical cancer screening interventions.While our findings do not allow us to infer how much contribution social capital made on cervical cancer screening uptake, they indicate that social capital plays a role and should be a component in screening interventions.Further research should consider the influences of other factors on participation in cervical cancer screening (e.g., limited access to sexual and reproductive healthcare programs).

Table 4 :
Summary of equity considerations in the included studies Knowledge, attitudes, intentions and behaviours related to HPV immunization and cervical cancer screening were improved by creating an enabling environment in low-income countries facing poor access to health services, long hospital wait times, lower education levels, lack of basic amenities (e.g., latrines and safe running water) and higher prevalence of risky sexual behaviours (Khani Jeihooni et al., 2021; Olubodun et al., 2022).• The majority of population groups studied received a high school education or less, which had implications on how the educational components of the intervention were designed (e.g., delivered verbally through lay health advisors, promoters, mixed marketing approach, PowerPoint) (Chu et al., 2021; Khani Jeihooni et al., 2021; Larkey et al., 2012; Lee et al., 2018; Ma et al., 2022; McDonough et al., 2016; Olubodun et al., 2022).• Given the majority of the population groups were from low-income households or lived in poverty (Chu et al., 2021; Khani Jeihooni et al., 2021; Larkey et al., 2012; Ma et al., 2022; McDonough et al., 2016; Olubodun et al., 2022), provision of free Pap tests or referrals reduced cost barriers (especially for those who were uninsured) to receiving cervical cancer screening (McDonough et al., 2016; Olubodun et al., 2022).Language • Given language negatively affected knowledge and confidence in HPV-related decision-making, interventions provided multiple translated versions of their materials for their target population (Chu et al., 2021; Larkey et al., 2012; Lee et al., 2018; Ma et al., 2022; McDonough et al., 2016; Olubodun et al., 2022).• Participants preferred community classes delivered in the community's native language, which facilitated community dialogue and reduced mistrust of immunization and healthcare (Chu et al., 2021).Racial and ethnic minority groups in the United States have lower uptake of HPV immunization and cervical cancer screening due to limited awareness and lack of knowledge; language barriers; physical barriers (e.g., transportation and time to get to clinics); misperceptions about efficacy and safety regarding HPV immunization; mistrust of healthcare or immunization; lack of strong healthcare provider recommendations; healthcare costs (e.g., lack of insurance); and cultural beliefs, norms (e.g., restrictions around pork products) and stigma (e.g., association between getting the HPV vaccine and increasing sexual behaviours) (Chu et al., 2021; Larkey et al., 2012; Ma et al., 2022).• Culturally appropriate interventions resulted in significant improvement in mothers' confidence, knowledge, beliefs and intentions to immunize their own children (Chu et al., 2021).• Several studies utilized focus groups, stakeholder feedback and consultations with community leaders to inform their research design to create culturally relevant, community-based and audience-sensitive and specific content (Chu et al., 2021; Larkey et al., 2012; Lee et al., 2018; Ma et al., 2022; McDonough et al., 2016).• Inviting community members and organizations to support HPV immunization initiatives (e.g., sharing the HPV immunization program with their communities) had a positive effect on participant recruitment among racial and ethnic groups (Chu et al., 2021; Ma et al., 2022).• Storytelling narratives effectively increased HPV immunization intentions (Lee et al., 2018).• Delivery of an immunization information by co-ethnic research assistants was found to be successful in promoting behaviour changes in target populations (Chu et al., 2021).• Trusted community members (e.g., lay health advisors, patient navigators) were found to have the ability to broker the relationships between healthcare providers and target population groups and act on their established social networks to diffuse information into the communities (Larkey et al., 2012; McDonough et al., 2016).Barriers for women to seek a Pap test included the painful nature of the test; shame attributed to getting tested; inadequate knowledge; cultural and religious beliefs; and psychosocial causes (e.g., subjective norms, social pressures, embarrassment) (Khani Jeihooni et al., 2021).• Women who had adequate knowledge of cervical cancer were more likely to recognize the risks, severity, susceptibility and benefits of cervical cancer screening (Khani Jeihooni et al., 2021).• Subjective norms, such as support of family members and healthcare staff cooperation, impacted the intention and behaviour of women to seek cervical cancer screening (Khani Jeihooni et al., 2021).
• HPV immunization target populations were predominantly specified as girls and women (Chu et al., 2021; Khani Jeihooni et al., 2021; Larkey et al., 2012; Lee et al., 2018; Ma et al., 2022; McDonough et al., 2016; Olubodun et al., 2022).• Given the strength of evidence from experiments and quasi-experiments, more research using those design studies are needed to understand the impacts of social capital interventions on HPV immunization and cervical cancer screening.Health researchers examining those programs should consider designing interventions that include social capital components that, for instance, enhance participants' trust of health practitioners and engage with religious leaders.Public health agencies should consider the promising results of culturally appropriate and tailored interventions containing components of social capital for creating positive change in HPV-related knowledge, attitudes, intentions and behaviours toward HPV immunization and cervical cancer screening.Further research must translate these psychological changes into HPV immunization and cervical cancer screening behaviours.