The HPV vaccination is influenced by several key factors including vaccine awareness, knowledge, willingness to vaccinate, vaccine accessibility, affordability, and the coverage, quality, and implementation of vaccination services. Research has identified significant supportive and inhibitory factors related to vaccine acceptance and behavior. At the individual level, factors such as vaccine-related knowledge, perceived susceptibility of HPV and severity of cervical cancer, awareness and attitudes towards vaccine efficacy and safety, lower vaccine prices, and higher willingness to pay are all conducive to vaccine uptake. At the socio-cultural level, stakeholders such as parents, friends, healthcare providers, school teachers, and community opinion leaders often influence vaccination decision-making. Negative attitudes within interpersonal social networks, biases towards sexual behavior, and misinformation propagated within the communities act as barriers to vaccine uptake. The impact of religious beliefs on vaccine acceptance varies in different research and warrants further investigation.

From the health system prospects, several significant barriers impede the accessibility and implementation of vaccination services, such as Insufficient infrastructure, limited healthcare workforce capacity, deficiencies in healthcare workers’ knowledge, and the absence of incentive mechanisms to promote vaccine recommendations. While school-based vaccination programs have shown effectiveness in some areas, they may not fully cover vulnerable populations in regions with high dropout rates from school. To support vaccine promotion, political commitment, and inter-sectoral collaboration are essential. Additionally, HPV vaccination initiatives may encounter competition from other public health programs for financial and resource allocation. Support from International organizations facilitates the vaccine introduction and accessibility in low-income countries. However, it may also present challenges regarding the long-term sustainability of vaccination projects.

Individual Factors

At the individual level, factors influencing HPV vaccine uptake include the extent to which the target population and their caregivers understand HPV vaccines and cervical cancer, are aware of HPV susceptibility, comprehend vaccine effectiveness and safety, are concerned about adverse reactions, and consider vaccine costs and affordability.

Vaccine-Related Knowledge

Studies from various countries confirm that awareness and understanding of HPV vaccines and their role in preventing cervical cancer significantly impact HPV vaccine decision-making [1-5]. Parents’ knowledge and attitudes towards HPV vaccines play a crucial role in the vaccination decision-making for adolescents. A systematic review in Southeast Asia found that adolescents whose parents had higher socio-economic status, education levels, and greater knowledge of HPV vaccines were more likely to receive the HPV vaccine. Studies in several European countries also found that insufficient knowledge about HPV vaccines and the low quality and quantity of information available were major barriers to parents’ decision-making related to HPV vaccination [1].

Perceived Susceptibility of HPV and Severity of Cervical Cancer

Research indicates that women’s perception of susceptibility to HPV and cervical cancer is related to their willingness and demand for HPV vaccination [4, 5]. Women who perceive a potential risk of HPV infection or cervical cancer are more willing to get vaccinated compared to those with little perceived susceptibility. Additionally, knowledge of the severity of cervical cancer has the potential to help women make supportive decisions about HPV vaccination.

Perceived Vaccine Efficacy and Safety

Studies from various countries highlight concerns about the efficacy and safety of vaccines as significant barriers to vaccine uptake [5]. Some studies found that women’s intention to receive the HPV vaccine increases if they are confident in its efficacy in combating cervical cancer. Conversely, mothers who doubt the vaccine’s efficacy are less likely to accept the vaccination for their daughters [5].

Vaccine Price and Willingness to Pay

Research in multiple countries across Europe and Southeast Asia has identified vaccine cost as a crucial factor influencing vaccine uptake [1, 3]. For example, a study in Thailand found that two-thirds of participants were unwilling to get vaccinated due to the high vaccine cost, while 85% would be willing if the vaccine were free [6]. Similar findings were reported in Vietnam, where free vaccines were identified as a key factor in parents’ decision-making regarding their children’s vaccination [3, 7]. In European countries such as Germany, Greece, Ireland, and Sweden, 47% of respondents considered vaccine cost the primary concern influencing their decision to vaccinate against HPV. However, a survey in Shandong, China, found that less than 4% of respondents considered vaccine cost a major obstacle to vaccination [8].

Research also indicates variations in willingness to pay for the HPV vaccine. For instance, a study in India found that respondents from rural areas were more willing to pay than those from urban areas [9]. In Thailand, mothers were found to be more willing to pay than fathers [10]. Additionally, a study in Sweden revealed that parents of girls were more willing to pay than parents of boys [11].

Sociocultural Factors

Regarding the sociocultural barriers to implementing HPV vaccines, it is important to consider the key decision influencers among vaccine recipients, social norms, values, and the impact of social advocacy on individual health behavior and decision-making.

Decision Influencers

Studies have identified various parties influencing vaccine uptake, including the vaccine recipient’s family members (primarily parents or other caregivers), friends, parents’ friends, healthcare professionals, schoolteachers, and community opinion leaders [3, 5]. Healthcare professionals, school nurses, and family doctors often have a positive influence on HPV vaccine uptake, while advice against vaccination from family members, friends, and parents of other children tends to have a negative impact [1].

Sexual Behavior-related Stigmatization

Stigmatization related to sexual behavior would significantly influence HPV vaccine uptake. Studies found that parental concerns about their children’s future (in)fertility, increased and/or earlier sexual activity after the vaccination, and the safety of the vaccine are major barriers to vaccine uptake and vaccination willingness [2]. However, several studies from LMICs report successful mitigation of concerns regarding vaccinating adolescents against an STI and other potential stigmatization following sufficient communication about vaccine benefits during the roll-out of HPV vaccines in the communities [2].

Religious Beliefs

Some studies in the Southeast Asian Region have found that religious beliefs are among the factors influencing parental willingness and behaviors regarding HPV vaccination for adolescents [3]. In Indonesia, 11.3% of parents consider religion as a supportive factor in their vaccination decision-making [12], while Muslim families in Malaysia may view HPV vaccination as contradictory to their faith [13]. Some parents with religious beliefs may perceive their children as unlikely to engage in premarital sexual activity, thus considering the risk of HPV infection low and seeing no need for HPV vaccination.

Misinformation and Community Advocacy

A systematic review covering multiple European countries indicated that misinformation, rumors, distrust in medical authorities, and skepticism toward doctors and medical technology are primary barriers to HPV vaccine decision-making [1]. People are often misled by unofficial misinformation, leading to skepticism and misunderstanding about the value and safety of the vaccine. Studies have pointed to the need for effective community outreach and advocacy before the introduction of the HPV vaccine, and without evidence-based advocacy, vaccination is often subject to misinformation from other unofficial sources, leading to skepticism and misconceptions about the value of vaccination. Dispelling people’s misunderstanding about vaccines caused by exposure to misinformation often takes more time and effort [2].

Healthcare System Factors

The healthcare system plays a pivotal role in vaccine accessibility and vaccination implementation. Infrastructure, health human resources, healthcare providers’ knowledge and attitudes, and vaccine delivery methods are factors closely associated with vaccine coverage.

Infrastructure and Health Human Resources

In resource-constrained areas, infrastructure challenges are common in terms of the logistical issues (transporting staff and vaccines) and cold storage of vaccines. These areas are also lack of human resources and the capacity of staff to deliver vaccines. Studies have identified insufficient infrastructure and human resources as significant challenges hindering the implementation and expansion of vaccination programs in low- to middle-income countries [2]. Research also indicates that, compared to vaccinations conducted in healthcare facilities, HPV vaccination programs in many regions are carried out in non-medical settings such as schools, requiring more time and resources to mobilize personnel and materials to implement the program[2].

Healthcare Providers’ Knowledge and Attitudes

Studies have noted that disparities in HPV vaccine recommendations by healthcare professionals can affect vaccination rates [14,15]. Pediatricians and other Healthcare providers’ higher level of knowledge and lower level of concern about the vaccine are associated with higher levels of recommendation [16, 17]. It has also been noted that lower knowledge of HPV and HPV vaccines among primary care physicians, obstetricians, and gynecologists [18], the perception of no obligation to recommend by healthcare providers [17], and difficulty in discussing sexual topics [17] are some of the barriers that prevent healthcare providers from recommending the HPV vaccine.

Vaccine Delivery Methods

Vaccine delivery methods affect the accessibility and coverage of vaccines. In some countries, vaccinations are scheduled at specific times and locations, limiting access to immunization among certain population groups. While school-based immunization programs in many high-income countries effectively enhance vaccination efficiency and coverage, studies in regions such as India, Peru, Uganda, and Tanzania have identified dropping out of school as a significant factor preventing some girls from receiving HPV vaccines. Besides, the absence of non-school-based vaccination programs deprives out-of-school girls and mobile children of vaccination opportunities [2]. Therefore, in Uganda, Rwanda, and Vietnam, a combination of school-based and community-based vaccination approaches has been adopted for HPV vaccination programs, expanding accessibility to vaccination services for school-going and out-of-school children [2].

Political Factors

Vaccine-related policies and political commitments often influence the implementation process, quality, and sustainability of the immunization program.

Political Commitment:

Research highlights the lack of political commitment to promote new medical technologies and health interventions as a significant challenge in implementing HPV vaccination projects [2, 14]. The introduction of new health technologies or interventions typically requires decision-makers to have a comprehensive understanding of their effectiveness, cost-effectiveness, and long-term impacts. International organizations, vaccine suppliers, and other institutions influence the government’s political commitment.

Inter-Sectoral Collaboration:

For countries that have included the HPV vaccine in their national immunization programs, HPV vaccination rates are high. Policy decision-making and implementation of HPV vaccine immunization projects often involve multiple government departments such as the Ministry of Health, Ministry of Education, Ministry of Finance, professional associations, and global partners [15]. A well-established mechanism for inter-sectoral collaboration is essential to drive the implementation of HPV vaccine immunization projects.

Global Partners and Development Aid:

Some low—and middle-income countries expand vaccine accessibility and coverage through donations from international organizations or charitable institutions. International organizations like Gavi and WHO encourage introducing HPV vaccines in low-income countries, initiating pilot projects, or integrating HPV vaccines into national immunization plans. However, certain studies indicate that HPV vaccine immunization projects conducted through donations often face sustainability-related challenges. The demonstration projects may easily fail or lack long-term sustainability if there is no sustained financing and implementation plan and a lack of incentives for local healthcare workers [2].

Competition from Other Projects:

In resource-constrained countries where cervical cancer is not the primary health challenge, HPV vaccine immunization often competes with other vaccination projects [16].

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Content Reviewer: Kelly Hunter, Menglu Jiang

Page Editor: Jiaqi Zu

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