Global evidence highlights social roots of HPV vaccine hesitancy

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:

1. Limited medical knowledge about HPV and vaccination.
2. Perceptions of risks and benefits, including safety concerns and moral beliefs about sexuality.
3. General attitudes toward vaccination, shaped by past experiences with other vaccines.
4. Family decision-making dynamics between caregivers and adolescents.
5. Social and community influences, including peers, extended family, religious, or traditional leaders, and the media.
6. Cultural beliefs and norms around adolescence, gender, parenting, and sexuality.
7. Trust or distrust in institutions such as schools, government, science, and healthcare systems.
8. 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 caregivers’ 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.