Global evidence highlights social roots of HPV vaccine hesitancy on World Cervical Cancer Day
Decisions about the HPV vaccine among adolescents and their families are influenced by a web of social, cultural and trust-related factors, beyond simple awareness or access, a Cochrane review finds.
Published in April this year, the qualitative Cochrane review identified eight overarching themes that shape how caregivers and adolescents view and engage with HPV vaccination programmes. For World Cervical Cancer Elimination Day, the team behind the review have written a new blog to help public health professionals navigate these complexities.
Human papillomavirus (HPV) is a family of common viruses, including the viruses that cause genital warts and several types of cancers in people of all genders. Cervical cancer, the fourth most common cancer in women worldwide, is the most common cancer associated with HPV infection. Vaccination in young people provides a powerful tool for preventing cervical cancer and other HPV‐associated diseases.
Despite being progressively introduced in many countries, HPV vaccination has been suboptimal in several settings worldwide. Since vaccination programmes depend on high levels of coverage to succeed, understanding why some young people and their caregivers hesitate or refuse vaccination is crucial.
Eight key themes influencing HPV vaccination decisions This review aimed to build a comprehensive understanding of the multifactorial factors that influence caregivers’ and adolescents’ views and practices regarding HPV vaccination, and why some may be less accepting of it.
The review included 206 studies, of which 71 studies were included in the analysis. Studies came from all six World Health Organization (WHO) regions and included urban and rural settings.
The review found that many complex factors – social, political, economic, structural, and moral – may influence the ways in which caregivers and young people perceive the HPV
vaccination. These were grouped into eight overarching themes:
Limited medical knowledge about HPV and vaccination.
Perceptions of risks and benefits, including safety concerns and moral beliefs about sexuality.
General attitudes toward vaccination, shaped by past experiences with other vaccines.
Family decision-making dynamics between caregivers and adolescents.
Social and community influences, including peers, extended family, religious, or traditional leaders, and the media.
Cultural beliefs and norms around adolescence, gender, parenting, and sexuality.
Trust or distrust in institutions such as schools, government, science, and healthcare systems.
Practical barriers to accessing HPV vaccination, including cost, language, and convenience.
These factors intertwine across different contexts and income levels, highlighting that vaccine hesitancy is rarely a matter of misinformation alone. Instead, it reflects deeper
social, political, and moral contexts within which health decisions are made.
“It is frequently assumed that when people decide against vaccination it is because they lack knowledge or awareness,” said Dr Sara Cooper, lead author of the review from Cochrane South Africa. “Yet the findings from our review suggest a more complex relationship between knowledge about HPV vaccination and acceptance of it.”
Taking action beyond education and awareness-raising
The authors stress that understanding parents’ and adolescents’ concerns about HPV vaccination, and the wider social norms and values these may form part of, is important.
Allowing these concerns to be voiced and listening to them with empathy can help build trust and strengthen confidence in vaccination programmes.
“To accelerate progress toward cervical cancer elimination, we must go beyond awareness campaigns. Building trust, understanding local moral frameworks, and ensuring equitable access are crucial for improving HPV vaccination uptake worldwide,” said Professor Charles Shey Wiysonge, senior author of the review from Cochrane South Africa.
By targeting these influences, policymakers and healthcare professionals may be able to strengthen confidence in HPV vaccination in ways that are more relevant, acceptable and ultimately effective.
How can public health professionals overcome vaccine hesitation? Cochrane review team shares their latest findings
This article was written by Dr’s Sara Cooper and Ebrahim Samodien at Cochrane South Africa (CSA), based at the South African Medical Research Council. CSA is part of the global, independent Cochrane network of researchers, professionals, patients, carers and people interested in health.
Vaccination against human papillomavirus (HPV) is one of the most effective tools for preventing cervical cancer in women and other HPV-associated diseases in people of all genders. Yet many people worldwide remain reluctant to take the vaccine.
To understand the reasons for this, we conducted a Cochrane qualitative evidence synthesis of the factors that influence caregivers’ and adolescents’ views and practices around HPV vaccination.
Our findings suggest that when people express their position on HPV vaccination, they are not merely stating a health preference – they are often also expressing their identity, personal and communal values, and negotiating their place within the wider society. Here we summarize key findings and highlight potential implications for consideration.
Knowledge isn’t everything
It is frequently assumed that when people decide against vaccination it is because they lack knowledge or awareness. Yet the findings from our review suggest a more complex relationship between knowledge about HPV vaccination and acceptance of it. Many parents and adolescents who were hesitant about the HPV vaccine had very sophisticated understandings, whilst others who accepted it knew very little. In some instances, a lack of biomedical knowledge about the vaccine was ironically a strong motivator to receive it, for example where people believed it prevents pregnancy or protects against HIV/AIDS.
Social norms and moral judgements matter
Our review demonstrates multiple contexts, processes and meanings that may shape HPV vaccination. These include social, political, economic, ideological, moral as well as biological factors. Parents’ and adolescents’ views and practices around the vaccine were influenced by wider sociocultural beliefs about adolescence, sexuality, gender, parenting and health. In many communities, HPV-related infections are linked to ideas of “immoral” sexual behavior, such as promiscuity. This stigma can make the vaccine feel unnecessary, or even shameful.
HPV vaccination views were also shaped by complex decision-making dynamics between adolescents and their primary caregivers, and the gender roles that exist within nuclear families. The vaccine decisions and opinions of extended family, friends and members of their communities also frequently had an impact.
Trust in healthcare systems is key
An important factor is the level of trust placed in the institutions and individuals responsible for delivering vaccination programmes. In many settings, vaccine decisions were shaped by broader political and historical issues, particularly when there is a legacy of mistrust in government, schools or public health authorities. Additionally, negative experiences with vaccination programmes or services may also play a critical role. For example, if someone has previously struggled to access a vaccine due to stock issues, high costs or poor communication, they may be reluctant to try again.
Taking positive, targeted action
Promoting HPV vaccination isn’t just about education and raising awareness. Multi-faceted strategies must address social and cultural barriers shaping HPV vaccination decisions. These factors vary across place, time and population. Thus, understanding and targeting the context-specific drivers of HPV vaccination is essential.
Consider what exactly you want to achieve through an intervention or programme. Do you want to raise awareness and enhance compliance, or is the aim to build science literacy so people can make informed decisions? These different goals might give rise to different types of interventions and potential outcomes, which are not necessarily as straightforward as increasing HPV vaccination acceptance.
Compassion, empathy and community co-creation
Understanding caregivers’ and adolescents’ concerns about HPV vaccination, and the wider social norms and values these may form part of, is important. This may require allowing people to voice their concerns, and genuinely and empathically listening to them, rather than dismissing or necessarily trying to correct. Incorporating broader trust-building measures that focus on dialogue, relationships, transparency and community engagement and ownership is also essential. It could be useful to understand which individuals or institutions are potentially trusted or distrusted, and why. Involving trusted community figures in the design or implementation of programmes can help to bring communities on board and overcome barriers.
There is no single ‘magic bullet’ to overcoming vaccine hesitancy. If you start by pinpointing the structural and service-level issues that may be hindering the quality and accessibility of HPV vaccination, you can then consider how these might be addressed. By targeting these deeper influences, policymakers and healthcare professionals may be able to strengthen confidence in HPV vaccination in ways that are more relevant, acceptable and ultimately effective.
