Key messages
• Many complex factors may influence caregivers’ and adolescents’ views and actions about human papillomavirus (HPV) vaccination for adolescents. We divided them into 8 themes relating to individual knowledge and perceptions, family and social relationships, and the wider contexts in which caregivers and adolescents live.
• Healthcare planners and policy-makers could use the themes to help them understand specific contexts in which people are making decisions about HPV vaccination. This may help them design more relevant and effective ways to promote vaccination acceptance and uptake.
What is human papillomavirus (HPV), and why vaccinate against it?
HPV is the leading cause of cervical cancer in women and also causes genital warts and several types of cancers in people of all genders. Vaccinating adolescents (young people aged from 9 to 19 years) is one of the most effective ways to prevent these illnesses.
Why is it important to understand what affects caregivers’ and adolescents’ decisions around HPV vaccination?
To be successful, HPV vaccination programmes depend on high levels of vaccination uptake. However, worldwide, many adolescents do not receive HPV vaccination. There are several reasons for this. Vaccines might be unavailable or adolescents may experience difficulties accessing vaccination services, for instance, because of poor-quality health services, distance from a health facility, or lack of money. Some caregivers and adolescents may not accept HPV vaccination.
What did we want to find out?
We wanted to know what factors influence caregivers’ and adolescents’ views and actions around HPV vaccination. We were interested in factors that may ‘enhance’ or ‘reduce’ acceptance of HPV vaccination.
What did we do?
We searched for studies that explored caregivers’ or adolescents’ views, experiences, and actions related to HPV vaccination for adolescents, in all countries where HPV vaccination is provided. Study participants had to be adolescents or caregivers who were responsible for deciding whether an adolescent should be vaccinated.
What did we find?
We found 206 relevant studies and analysed the results from 71 of them. Studies took place all over the world, and included urban and rural locations, as well as people living in high-, middle-, and low-income countries and communities.
Main results
We found that many complex factors may influence what caregivers and adolescents think about HPV vaccination and what actions they take. We divided these into 8 themes.
1. A lack of medical knowledge
2. Beliefs and ideas about the risks and benefits of HPV vaccination
3. Views or experiences of other vaccines and vaccination programmes
4. The roles adolescents and their primary caregivers play in decision-making
5. The views and actions about HPV vaccination of other family members or other members of their social community, such as peers, traditional or religious leaders, and the media
6. Wider social or cultural beliefs about adolescence, sexuality, gender, parenting and health
7. Trust or mistrust in the institutions or people associated with vaccination, such as teachers and schools, the pharmaceutical industry, the government, and healthcare professionals
8. Access to, and experiences of, HPV vaccination programmes and services, such as how convenient they are, the cost of the vaccine, or barriers related to language.
What are the limitations of the evidence?
Our confidence in the evidence is mainly moderate to high. However, the methods or findings of some studies were not very clear, and some focused on one type of setting or country, so were potentially not relevant for other settings or countries. All the included studies were published in English or French, so we may have missed findings published in other languages.
How up to date is this evidence?
The evidence is up-to-date to February 2023.
Our review reveals that caregivers’ and adolescents’ HPV vaccination views and practices are not only influenced by issues related to individual knowledge and perceptions of the vaccine, but also an array of more complex, contextual factors and meanings: social, political, economic, structural, and moral. Successful development of interventions to promote the acceptance and uptake of HPV vaccination for adolescents requires an understanding of the context-specific factors that influence HPV vaccination views and practices in the target setting. Through this, more tailored and in turn more relevant, acceptable, and effective responses could be developed. The eight overarching themes that emerged from our review could serve as a basis for gaining this understanding.
Human papillomavirus (HPV) vaccination in adolescents provides a powerful tool for preventing cervical cancer in women and other HPV-associated diseases in people of all genders. HPV vaccines have been progressively introduced in many countries. However, worldwide, many adolescents do not receive HPV vaccination, for various reasons. The HPV vaccine might be costly or unavailable, healthcare systems might lack capacity for its delivery, or adolescent health might not be prioritised. Some caregivers and adolescents may not accept available HPV vaccines and vaccination services.
We currently lack a comprehensive understanding of the factors that influence HPV vaccination views and practices, and why some caregivers and adolescents may be less accepting of the vaccine. Qualitative research can contribute to this understanding and help inform policy and practice, including the development of more relevant, acceptable and effective interventions to promote public acceptance and uptake of HPV vaccination in adolescents.
This qualitative evidence synthesis supplements a Cochrane review of the effectiveness of interventions to improve uptake of adolescent vaccination, including HPV vaccination.
The objectives of the review are to identify, appraise, and synthesise qualitative studies that explore caregivers’ or adolescents’ views, experiences, practices, intentions, decision-making, acceptance, hesitancy, or nonacceptance of HPV vaccination; to gain an understanding of the factors that influence caregiver and adolescent views and practices regarding HPV vaccination for adolescents; and to explore how the findings of this review can enhance our understanding of the related Cochrane intervention review.
We searched MEDLINE, Embase, CINAHL, PsycInfo, and Scopus for eligible studies (February 2023). We updated this search in October 2024, but these results have not yet been fully incorporated.
We included studies that utilised qualitative methods for data collection and analysis; focused on caregivers’ or adolescents’ views, practices, acceptance, hesitancy, or refusal of HPV vaccination for adolescents aged 9 to 19 years of age; and were from any setting globally where HPV vaccination is provided.
We used a prespecified sampling frame to capture a sample of eligible studies that were from a range of geographical and income-level settings, were conceptually rich in relation to the review's phenomenon of interest, and included HPV vaccination for diverse genders. We extracted contextual and methodological data from each sampled study. We used a thematic synthesis approach to analyse the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We integrated the findings of this review with those from the related Cochrane review of intervention effectiveness (by Abdullahi and colleagues), by mapping whether the trial interventions reflected or targeted the factors identified by this review as influencing caregivers’ or adolescents’ views and practices regarding HPV vaccination.
We included 206 studies in the review and sampled 71 of these for our synthesis. Of these, 35 studies were conducted in high-income countries, 26 studies in middle-income countries, 8 studies in low-income countries, and 2 studies in multiple-income settings. Studies came from all six World Health Organization (WHO) regions and included urban and rural settings. We downgraded our confidence in several findings, mainly due to concerns about how the studies were conducted (methodological limitations), concerns about perspectives lacking from some types of participants or in some settings (relevance), or because of variability in the data or insufficient evidence to support all aspects of a review finding (coherence).
Many complex factors were found to influence caregivers’ and adolescents’ HPV vaccination views and practices, which we categorised into eight overarching themes: 1) A lack of biomedical knowledge; 2) Perceptions of a range of interrelated risks and benefits (or lack thereof) associated with HPV vaccination; 3) Routine responses to vaccination generally or more specific views or experiences of other vaccines and vaccination programmes; 4) Complex nuclear familial decision-making dynamics; 5) Extended familial and social relations and networks, particularly extended family members, peers, traditional or religious leaders, and the media; 6) Interrelated socio-cultural beliefs and practices regarding adolescence, sexuality, gender, parenting and health; 7) Trust or distrust in the institutions, systems or experts associated with vaccination, most particularly teachers and the school, the pharmaceutical industry, government, science and biomedicine, and healthcare professionals; and 8) Access to, and experiences of, HPV vaccination programmes and delivery services, such as the convenience (or lack thereof) of HPV vaccination services, the cost of the vaccine, language barriers, the feminisation of HPV vaccination programmes and procedural aspects of school-based vaccination delivery.
We did not identify any major differences in the occurrence of these overarching themes between subgroups. However, for various subthemes certain differences emerged in relation to place, gender and socio-economic status, and between caregivers and adolescents.
The interventions tested in the related Cochrane review of intervention effectiveness most commonly targeted caregivers' and adolescents’ lack of biomedical knowledge and their perceptions of the risks and benefits of HPV vaccination, with the other influencing factors identified by our review being underrepresented.