Table 1.
Characteristics of studies included in this narrative review on cultural barriers to HPV vaccination.
| # | Author(s), year | Country/region | Study design | Population | Sample | Key findings related to cultural barriers |
|---|---|---|---|---|---|---|
| A. Saudi Arabia and gulf cooperation council studies (n = 12) | ||||||
| 1 | Alghalyini et al., 2024 | Saudi Arabia | Cross-sectional survey | College students | N = 442 | 54.1% aware of HPV; only 10% vaccinated; 80.1% cited lack of education as primary barrier |
| 2 | AlShamlan et al., 2024 | Saudi Arabia | Cross-sectional survey | Female healthcare workers | N = 1,857 | 20% received HPV vaccine; 45% willing to vaccinate; lack of knowledge top hesitancy reason |
| 3 | Aldawood et al., 2023 | Saudi Arabia | Cross-sectional survey | Health college students | N = 405 | 49.9% aware of HPV vaccine; 5.2% vaccinated; 75.9% hesitancy in males vs. 43.9% in females |
| 4 | Hussain et al., 2016 | Saudi Arabia | Cross-sectional survey | Female patients aged 11–26 | N = 325 | 34.5% aware of HPV; Saudi nationals less aware (29.9%) than non-Saudis (48.8%) |
| 5 | Tobaiqy et al., 2023 | Saudi Arabia | Cross-sectional study | Parents at university hospital | N = 500 | 96.8% never heard of HPV vaccine; 94% unwilling to vaccinate; 85.2% cited lack of information |
| 6 | Sulaiman et al., 2023 | Saudi Arabia | Cross-sectional survey | Patients at King Saud Medical City | N = 384 | Significant link between education level and HPV knowledge; lower education = less awareness |
| 7 | Almatrafi et al., 2024 | Saudi Arabia | Interventional study | Secondary school girls | N = 148 | Post-education knowledge rose from 43.9 to 94.6% (p < 0.001); cultural stigma identified |
| 8 | Moshi et al., 2024 | Saudi Arabia | Mapping review | General population | Review | National uptake only 7.6%; 84.1% lacked cervical cancer screening knowledge |
| 9 | Mahmoud et al., 2024 | GCC countries | Comparative cross-sectional | Young adults aged 18–39 | N = 831 | UAE highest vaccination (18.9%), KSA only 4.6%; 53.6% cited lack of knowledge |
| 10 | Zakhour et al., 2023 | Lebanon | Cross-sectional KAP survey | Parents of children | N = 306 | 60% would not vaccinate; lack of physician recommendation top reason; gender bias present |
| 11 | Elbarazi et al., 2016 | United Arab Emirates | Content analysis | Newspaper coverage | Media 2006–2014 | Media coverage limited; taboo topics like promiscuity not addressed in coverage |
| 12 | Kisa and Kisa, 2024 | OIC countries | Scoping review | Multiple populations | 23 studies | Religious misconceptions drove hesitancy; 30% of Saudi opposition religiously motivated |
| B. Sub-Saharan Africa studies (n = 4) | ||||||
| 13 | Kutz et al., 2023 | Sub-Saharan Africa | Systematic review | Communities, parents, adolescents | 20 studies | Barriers: limited health systems, stigma, cost, misinformation; HPV prevalence 24% |
| 14 | Turiho et al., 2017 | Uganda | Qualitative study | Schoolgirls, parents, teachers | N = 105 | Rumors: vaccine causes infertility, is population control; religious group opposition |
| 15 | Binagwaho et al., 2012 | Rwanda | Program evaluation | Primary school girls | N = 93,888 | Achieved 93.23% three-dose coverage; school-based delivery with community outreach |
| 16 | Cooper et al., 2024 | Africa (multiple) | Research synthesis | Communities | Multiple studies | Social media can build vaccine confidence; community engagement and social science approaches effective |
| C. Asia-Pacific studies (n = 7) | ||||||
| 17 | Taghizadeh Asl et al., 2020 | Iran | Qualitative study | Married women aged 25–65 | N = 81 | Near-total HPV ignorance; cultural stigma around sexual organs; health deprioritization |
| 18 | Tay et al., 2015 | Singapore | Cross-sectional survey | Female nurses | N = 1,611 | 38.9% believed vaccine experimental; 76% believed cultural practices influenced health decisions |
| 19 | Wong et al., 2019 | China | Narrative review | General population | Review | Barriers: high cost, limited supply, preference for 9-valent vaccine; need school-based programs |
| 20 | Krokidi et al., 2023 | India | Literature review | People aged 9–29 | 7 studies | Health education effective; barriers: cost, awareness, STI stigma, patriarchal norms |
| 21 | Mehra et al., 2025 | India | Infodemiological study | Google Trends 2010–2024 | Search data | Significant increase in HPV vaccine searches after policy changes; regional variations |
| 22 | Njogu et al., 2024 | Kenya, India, Nigeria | Multi-country qualitative | Healthcare workers | Multiple sites | Effective HCW communication strategies; need culturally tailored messages |
| 23 | Islam et al., 2024 | India | Quantitative analysis | Children and families | Population data | Patriarchal norms negatively impact child wellbeing; gender-based barriers to healthcare |
| D. United States studies (n = 14) | ||||||
| 24 | Hirth J, 2019 | United States | Literature review | US population | Review | Significant disparities by race/ethnicity, geography, socioeconomic status |
| 25 | Rahman et al., 2015 | United States | Cross-sectional analysis | Young adults aged 18–26 | N = 3,727 | Southern women lowest initiation (30.4%) vs. Northeast (58.7%); male vaccination 6.3% |
| 26 | Xiong et al., 2024 | United States | Cross-sectional analysis | Male and female children | 5 states | Geographic-based socioeconomic factors significantly associated with HPV vaccination |
| 27 | DiClemente et al., 2015 | United States | Randomized clinical trial | African American females | N = 216 | Culturally-tailored media intervention improved compliance; perceived susceptibility key |
| 28 | Adegboyega et al., 2023 | United States | Cross-sectional survey | African Americans, African immigrants | N = 200 | Knowledge gaps identified; African immigrants had lower awareness; cultural beliefs influential |
| 29 | Harrington et al., 2021 | United States | Narrative review | Racial/ethnic minorities | 20 articles | High trust in doctors but low in pharma; mistrust associated with lower uptake |
| 30 | Morales-Campos et al., 2021 | United States | Qualitative study | Mexican American adults | 8 focus groups | Gendered perspectives: fathers linked risk to female promiscuity; cultural taboos present |
| 31 | Gilkey et al., 2016a | United States | Cross-sectional survey | Parents of adolescents | N = 1,495 | High-quality recommendations: 9-fold odds of initiation; only 36% received quality recommendation |
| 32 | Gilkey and McRee, 2016 | United States | Systematic review | Healthcare providers, patients | 101 studies | Providers less likely to recommend if uncomfortable discussing sex or perceived hesitancy |
| 33 | Gilkey et al., 2015 | United States | National survey | Physicians | N = 776 | Quality of physician communication varied; strong endorsement associated with higher uptake |
| 34 | Oh et al., 2021 | United States | Meta-analysis | Parents and adolescents | Multiple studies | Provider recommendation strongly associated with uptake; quality and timing matter |
| 35 | Sundstrom et al., 2021 | United States | Campaign evaluation | General public | Campaign data | HPV Vaccination NOW campaign effective at correcting misinformation online |
| 36 | Bruns et al., 2024 | United States | Cross-sectional survey | University community | N = 1,539 | Knowledge and trust significantly associated with vaccine confidence; education gaps identified |
| 37 | Brandt et al., 2016 | United States | Policy analysis | Policy makers | Policy review | Policy interventions effective; school-entry requirements and insurance mandates increase uptake |
| E. global and multi-country Studies (n = 14) | ||||||
| 38 | Bruni et al., 2016 | Global (64 countries) | Pooled analysis | Females in HPV programs | 47 million | Global coverage 1.4%; 33.6% in developed vs. 2.7% in less developed regions |
| 39 | Spayne and Hesketh, 2021 | Global (195 countries) | Cross-sectional analysis | Vaccine-eligible girls | 61 million | Global coverage 12.2%; fewer than half of countries reported data; LMICs face barriers |
| 40 | Hopkins and Wood, 2013 | Global | Cross-sectional analysis | Females targeted | Multiple countries | Vaccination lower in Asian/European countries; cultural attitudes impact uptake |
| 41 | Netfa et al., 2020 | Multi-country (Western) | Systematic review | Immigrant parents | 19 studies | 11/16 studies found no HPV vaccine knowledge; religious abstinence belief key barrier |
| 42 | Graci et al., 2024 | Global | Systematic review | Migrants and refugees | 34 studies | Adherence 34.5% among migrants, 0.6% refugees; 58.8% cited health literacy barrier |
| 43 | Grandahl and Neveus, 2021 | Global | Narrative review | Boys and young men | 103 articles | Five barriers: lack of knowledge, hesitancy, absent recommendations, cost, promiscuity myth |
| 44 | Ortiz et al., 2019 | Global | Systematic review | General population | 44 articles | Social media improved awareness but not uptake; negative content associated with lower rates |
| 45 | Escoffery et al., 2023 | Global | Systematic review | Adolescents, parents, HCPs | 79 articles | Most interventions informational; initiation ranged 5–99.2%; only 33.8% used theory |
| 46 | Jarrett et al., 2015 | Global | Systematic review | General population | Multiple studies | Dialogue-based interventions, reminders, education effective; multi-component approaches best |
| 47 | Kyei et al., 2024 | Global | Conceptual analysis | HPV hesitancy studies | 29 articles | False cultural beliefs primary antecedent (14/29 studies); perceived promiscuity key |
| 48 | Xu et al., 2024 | Low-resource settings | Narrative review | Adolescents in LMICs | Review | Sociocultural barriers: promiscuity concerns, religious beliefs, gender norms |
| 49 | Enria et al., 2024 | Global | Research synthesis | General population | Multiple studies | Political dimensions of misinformation; trust and vaccine confidence interlinked in digital age |
| 50 | Yim et al., 2024 | Global | Narrative review | Immunization programs | Review | Sustainable financing challenges for immunization programs; funding models vary globally |
| 51 | Brewer et al., 2017 | Global | Scientific review | Vaccination programs | Review | Presumptive announcements more effective than participatory approaches for vaccination |
| F. Vaccine science and general studies (n = 8) | ||||||
| 52 | Williamson AL, 2023 | Global | Scientific review | HPV vaccine development | Review | Recent developments in HPV vaccinology; different formulations may increase hesitancy |
| 53 | Clift and Rizzolo, 2014 | United States | Review article | General population | Review | Main factors: safety concerns, religious objections, science skepticism; autism myth persists |
| 54 | Bezbaruah et al., 2024 | Global | Book chapter | General population | Review | Common myths: vaccines cause disease, natural immunity superior, contain toxic materials |
| 55 | Hofstetter and Rosenthal, 2014 | United States | Review article | Adolescents and parents | Review | Healthcare professional communication critical for STI vaccine acceptance including HPV |
| 56 | Rathod et al., 2023 | Global | Comprehensive review | Women’s health | Review | HPV vaccination critical for cervical cancer prevention; need comprehensive strategies |
| 57 | Nielsen-Bohlman et al., 2004 | United States | IOM Report | General population | Report | Health literacy impacts health outcomes; cultural values influence treatment concordance |
| 58 | Vehmas E, 2021 | Global | Thesis/Review | General population | Review | Vaccination beliefs shaped by cultural aspects; need for culturally sensitive approaches |
| 59 | Salleh et al., 2025 | Global | Qualitative systematic review | Parents of daughters under 18 | Multiple qualitative studies | Cultural norms and values predominantly shaped parental vaccination decisions; fathers as decision-makers in patriarchal families created barriers; religious and ethnic factors influenced uptake |
FGDs, focus group discussions; GCC, Gulf Cooperation Council; HCPs, healthcare providers; HCWs, healthcare workers; HPV, human papillomavirus; IOM, Institute of Medicine; KAP, knowledge, attitudes, and practices; LMICs, low- and middle-income countries; OIC, Organization of Islamic Cooperation; SSA, sub-Saharan Africa; STI, sexually transmitted infection. This table includes all peer-reviewed studies cited in this narrative review. Studies are organized by geographic region. Total included: 59 studies comprising cross-sectional surveys (n = 20), systematic/literature reviews (n = 19), qualitative studies (n = 5), narrative reviews (n = 8), program evaluations (n = 1), randomized controlled trials (n = 1), policy analyses (n = 2), and other study designs (n = 3). Government and organizational websites (CDC, WHO, etc.) are not included in this table.