Cross-country analysis on HPV vaccination behaviors among health workers and parents: a qualitative report from seven middle-income countries

Abstract

Purpose

This article presents a cross-country analysis of qualitative research reports on the barriers and drivers of HPV vaccination-related behavior among parents and health workers in seven middle-income countries using the COM-B theoretical framework. Four reports are from countries that had already introduced the HPV vaccine — Georgia, Moldova, Turkmenistan, and Uzbekistan, while the other three reports are from Kazakhstan, Kosovo, and Tajikistan which were preparing for HPV vaccine introduction in 2023 and 2024.

Results

The cross-country analysis revealed that health workers (HWs), especially specialists like gynecologists and oncologists, were viewed as trusted sources of vaccination information by both parents and HWs. However, HWs faced gaps in HPV vaccine knowledge and communication skills, and these gaps persisted in some form even after training was conducted in countries that had already introduced the HPV vaccine. In addition, these specialists were not always included when training sessions were conducted with family doctors and nurses in preparation for the vaccine's introduction. Parents also experience knowledge gaps, safety concerns, and lack of trust. Parents across countries shared concerns related to HPV vaccine safety and effectiveness and were often exposed to misconceptions or misinformation through media and social networks. This was compounded by the lack of a strong and confident recommendation from HWs and poor patient-provider communication.

Conclusions

The analyzed reports highlighted the need for tailored, multi-faceted interventions that account for locally specific issues, influencers, and target groups. Two prominent recommendations posited in the reports were: 1) engaging parents and addressing their concerns at the community level, and 2) ensuring HPV vaccine confidence through HW training and engagement, especially for specialists, and providing access to evidence-based information for HWs and others who influence vaccine acceptance.

Highlights

• •Health worker and parent barriers to HPV vaccination are similar.
• •Health workers lack knowledge and communication skills about the HPV vaccine.
• •Specialists also lack knowledge and are not always included in training about HPV vaccination.
• •Parents need HPV vaccine information to be shared with them by trusted health workers.
• •Health workers need repeated training to strengthen their own vaccine confidence which is needed for them to recommend HPV vaccination to parents.

1. Introduction

Human Papillomavirus (HPV) contributes to approximately 99.7 % of global cervical cancer cases [1]. Cervical cancer is the fourth leading cause of death for women worldwide, with over 90 % of deaths occurring in lower- and middle-income countries [2,3]. In 2020, 5.4 % (32,348) of women across Central and Eastern Europe were diagnosed with cervical cancer (14.5 cases per 100,000 women), three times higher than in Western Europe (1.7 %, 10,102 women, 7 cases per 100,000 women) [4]. Cervical cancer incidence rate among Central Asian women was 12.7 per 100,000, with the highest rate observed in Kazakhstan (15.7) and Kyrgyzstan (15.4) [5]. Six HPV vaccines are currently available and licensed for administration to individuals aged 9 and older, all of which are effective at preventing HPV infections [6]. Longitudinal studies show that introducing the HPV vaccine significantly reduces high-risk HPV types in populations, with up to an 83 % decrease among cohorts of adolescent girls 5–8 years after vaccination, with no long-term negative effects [[7], [8], [9]]. However, the global HPV vaccination coverage remains low, particularly in lower-middle income countries where only 7.6 % of target-aged girls are vaccinated compared to 42.4 % in high-income countries [10].

Currently, 125 countries include HPV vaccination in their national immunization programs, with 47 countries vaccinating both boys and girls [6]. Research in lower and middle income country settings shows that grade-based HPV vaccination introductions in schools are cost effective and improve vaccination uptake [[11], [12], [13]]. Training health workers and teachers, delivering educational outreach programs, implementing text or phone-call reminder systems, and conducting communication campaigns for parents, adolescents, and the public have been successful in improving HPV vaccination uptake [11,13], with interventions targeting multiple stakeholders being the most effective at addressing HPV vaccination uptake [14]. Global research shows that challenges to HPV vaccination uptake in countries where introduction was unsuccessful or terminated, stem from insufficient information provided to parents, poor crisis communication planning, lack of health worker training and buy-in, and the spread of media misinformation [[15], [16], [17], [18]].

This article presents a cross-country analysis of recent research on barriers and drivers of HPV vaccination-related behavior among parents and health workers (HWs) in Eastern Europe and Central Asia. Data were analyzed from seven WHO Regional Office for Europe (Regional Office) reports on HPV vaccination behavioral insights research. The insights research was conducted as technical support provided to middle income countries' national ministries of health (MOH) on HPV vaccine communication and intervention planning. Four reports are from Georgia, Moldova, Turkmenistan and Uzbekistan where the HPV vaccine had already been introduced and reported 20–99 % target-population coverage nationally, with challenges including a general decline in childhood vaccination uptake following the COVID-19 pandemic and population subgroup-specific HPV vaccine hesitancy [19]. The other three reports are from Kazakhstan, Kosovo,¹ and Tajikistan where preparations for HPV vaccine introduction in 2023 and 2024 were underway [20,21]. The reports analyzed reflected the Regional Office's technical support on improving and addressing coverage for HPV vaccine introduction as well as already introduced vaccines. As a framework for identifying behavioral factors impacting vaccine uptake, the COM-B framework was used in individual Regional Office reports and further permitted comparing factors across contexts where the HPV vaccine had already been introduced or were about to be introduced.

The analyzed reports presented insights research conducted with parents of target-aged children and relevant HWs (i.e. family doctors, nurses, pediatricians, gynecologists, immunologists or oncologists) via semi-structured focus group discussions (FGDs) and were analyzed using Rapid Assessment Procedure (RAP) methods [[22], [23], [24]]. The reports covered 1) barriers and drivers of HW behavior of recommending and delivering HPV vaccination, 2) parents' behavior of vaccinating their children against HPV, paying attention to social support for HPV vaccination, access to vaccination, and knowledge of childhood vaccination, HPV and HPV vaccination, and 3) suggestions on theory-based interventions to improve HPV vaccination uptake.

2. Methods

2.1. Study design

This is a secondary analysis of behavioral insights reports conducted by the Regional Office in seven countries across Central Asia and Eastern Europe. Table 1 presents an overview of HPV vaccination contexts and target groups of the behavioral insights research reports analyzed. All seven behavioral insights research studies were conducted between March and November 2023.

Table 1.

Overview of participants (health workers and parents) from seven behavioral insights studies.

	Georgia	Moldova	Turkmenistan	Uzbekistan	Kazakhstan	Kosovo	Tajikistan
HPV vaccination setting
Introduction status at time of research	Introduced in 2019	Introduced in 2017	Introduced in 2016	Introduced in 2019	Planned in September 2024	Planned in October 2023⁎	Planned in October 2024⁎
HPV vaccination target-group	Girls aged 10–12 years	Girls & boys aged 9–14 years	Girls & boys aged 9 years	Girls aged 9–14 years	Girls aged 11 years	Girls aged 12 years	Girls aged 10 years
Program delivery	PHC-based+	PHC-based	School- & PHC-based	School-based	School-based	School-based	School-based
Study design
Date of data collection	May–June 2023	September 2023	October 2023	August 2023	March 2023	August 2023	November 2023
Research participants
Health workers	Family doctors, nurses, pediatricians, gynecologists	Family doctors, medical assistants, pediatricians, immunologists, gynecologists, oncologists	Family doctors, nurses, pediatricians, gynecologists, and immunologists	School doctors and nurses	Family doctors and nurses	Family doctors, nurses, gynecologists, oncologists, pediatricians	Family doctors, nurses, gynecologists, pediatricians, immunologists
Total Focus Group Discussions	12	6	12	2	5	6	10
Total HWs	110	33	122	20	37	50	80
Parents	Mothers of vaccinated & unvaccinated girls	Mothers & fathers of unvaccinated boys and girls (general childhood and HPV vaccines)	Mothers & fathers of vaccinated & unvaccinated boys and girls (general childhood and HPV vaccines)	Mothers & fathers of unvaccinated girls	Mothers of unvaccinated girls	Mothers & fathers unvaccinated girls	Mothers & fathers of unvaccinated girls
Total Focus Group Discussions	3	2	8	4	5	4	5
Total parents	25	16	51	34	53	19	22

⁺PHC: Primary Health Care setting.

^⁎Kosovo and Tajikistan introductions were later postponed to February 2024 and October 2025, respectively.

2.2. Theoretical framework

The cross-country analysis presented in this study compiled findings structured around the Capability, Opportunity, and Motivation for Behavior Change (COM-B) framework modified for vaccination research [25]. This framework posits individuals' performance of health behaviors is influenced by three interrelated factors: capability, opportunity, and motivation. Capability covers individuals' knowledge, skills, and ability to perform a behavior. Opportunity is considered via two contextual subfactors of physical and social opportunity, respectively reflecting the availability of resources such as time, access, affordability, regulations, or social norms and values influencing possibilities to perform a behavior. Motivation encompasses individuals' internal processes, reflective or emotive, whereby a decision is made to perform a behavior [25]. Regional Office reports presented findings on barriers and drivers to HPV vaccination behaviors for similar target groups across countries by COM-B factor. This enabled a deductive approach to compare COM-B findings across contexts, allowing for the identification of cross-regional similarities and the consideration of for contextual differences.

2.3. Data availability and analysis

All seven WHO Regional Office behavioral insights reports were purposefully selected to include all Regional Office behavioral insights reports available. Each researcher had supported conducting insights research and drafting reports for at least three of the countries. This cross-country analysis was conducted by one researcher who reviewed all seven reports and compiled country-specific COM-B findings on HW behavior of recommending and administering the HPV vaccine and parents' behavior of vaccinating children against HPV.

Findings were compiled in Microsoft Excel, with separate sheets for each target group. For each target group, drivers and barriers were categorized according to the COM-B framework and data were included from all seven countries. One researcher developed a consolidated summary of cross-country findings by COM-B domain, and each team member reviewed the synthesized findings. As this study was based on finalized country reports, rather than raw qualitative excerpts, the Excel sheets contained summarized interpretations drawn from each report. Any differences in COM-B categorization among the country reports were discussed collectively by all researchers to reach an agreed upon categorization. All findings then were cross-checked against individual reports to ensure accuracy and consistency. Country names are not reported in this study to preserve confidentiality. However, the findings reflect common themes and differences identified across the seven Regional Office reports. Furthermore, in order to ensure consistency, the team followed structured application of the COM-B framework, engaged in team-based discussions to resolve any interpretation differences, and cross-checked findings against individual reports.

3. Results

Cross-country analysis findings on HW and parent behavior are presented below by COM-B factor and described in Table 2, with any notable differences highlighted between countries that already introduced HPV vaccine and those that were planning introduction.

Table 2.

Drivers and barriers to HPV vaccination among health workers and parents, organized by the COM-B factors.

COM-B factor	Health Workers (HWs)		Parents
	Drivers	Barriers	Drivers	Barriers
Capability	✓HWs expressed high confidence in their knowledge and communication skills. ✓HWs viewed themselves as trusted sources of information. ✓HWs in countries that introduced the HPV vaccine reported received training on HPV vaccine benefits, safety, and effectiveness.	✓Most HWs in countries preparing for HPV vaccine introduction lacked information on HPV, the HPV vaccine, its connection to cervical cancer, and on cervical cancer incidence and prevalence in their countries. ✓Across countries, specialist-doctors like gynecologists, oncologists, and pediatricians had not received any training on HPV vaccine, lacked knowledge and were not prepared to endorse HPV vaccination.		✓Parents had insufficient knowledge of HPV, the HPV vaccine, and cervical cancer risk or incidence in their country, even in countries that had introduced the HPV vaccine. ✓Some parents perceived the HPV vaccine as a “new” vaccine with unclear long-term safety and effectiveness and believed it could cause future infertility in vaccinated girls. ✓Fathers reported low knowledge of HPV vaccine and believed that cervical cancer is a women's issue, best discussed by mothers with daughters. ✓Parents across countries reported being unaware of or not knowing how to access official vaccination information, including where to get the HPV vaccine.
Opportunity (Physical)	✓HWs received institutional and government support for vaccination services, like procurement and training.	✓HWs in most countries reported having insufficient consultation time to inform parents, address questions, administer vaccines, and complete required documentation. ✓HWs in two countries that had introduced the HPV vaccine lacked informational materials (e.g. brochures). ✓HWs in three countries described resource barriers, including run-down, rural facilities and HW shortages to administer vaccination. ✓HWs in two countries reported facing a regulatory barrier where they are required to ensure high vaccination uptake. ✓HWs from one country reported the lack of a standardized vaccination consent or refusal form.		✓Some parents from two countries that had introduced the HPV vaccine mentioned that poor health facilities, road conditions, and limited transport options were barriers to visit clinics during official vaccination times. ✓In one country, some parents were reluctant to vaccinate their daughters due to low-quality services and a lack of heating in clinics. ✓In some countries, urban and young parents believed that health care services in private clinics were better than those in public clinics, and that private clinics had more experienced and knowledgeable health workers. ✓A few parents in three countries that had already introduced the HPV vaccine mentioned that they did not get brochures or remember the HPV vaccine campaigns that had been conducted. ✓In one country preparing to introduce the HPV vaccine, some parents mentioned that language barriers, especially among ethnic minority groups, could hinder access to official vaccination information.
Opportunity (Social)	✓HWs from two countries felt confident they would not be held accountable for AEFIs if they followed official vaccination protocols.	✓Most HWs from the other countries felt they would be blamed in the case of an AEFI, even if they followed official vaccination protocols. This lack of protection can influence HW confidence in recommending and administering vaccination. ✓HWs in two countries that had introduced the HPV vaccine mentioned misinformation on social media was negatively influencing parents.	✓Parents across countries trusted advice from their family doctors and nurses. ✓Parents also trusted the opinions of family members, friends, neighbors, relatives, and other parents they know. ✓Parents of unvaccinated children in one country that had introduced the HPV vaccine stated they would consent to vaccination if well-respected gynecologists gathered parents and gave a detailed presentation on HPV vaccination. ✓Parents in another country preparing to introduce the vaccine indicated that they would seek information on HPV vaccination from specialists.	✓Some parents opposed HPV vaccination due to prior negative experiences with HWs who dismissed side effects from earlier vaccines without clear explanations. ✓These parents stated that HWs dismissed their concerns, suggesting that side effects were not due to vaccination without providing a plausible explanation to address parental concerns. ✓Some parents in two countries that had introduced the HPV vaccine mentioned HWs, especially specialists, expressed mixed views, which contributed to parental doubt. ✓Across several countries, cervical cancer was seen as a taboo and rarely discussed in public or in mix-gendered settings.
Motivation	✓Across countries, HW confidence strongly influenced their willingness to recommend HPV vaccination. ✓HWs viewed themselves as instrumental in informing parents and communities about childhood vaccination. ✓When HWs felt they had received adequate training and information, they supported and recommended HPV vaccination. ✓HWs in one country that had already introduced the HPV vaccine stated that their specialist-colleagues (neurologists) recommend the HPV vaccine to parents, as neurologists described it to be a “gentle” vaccine with fewer side effects	✓Most HWs, especially from countries that were preparing for HPV vaccine introduction, wanted more training and information on the HPV vaccine. ✓Some HWs from one country that had already introduced the HPV vaccine and from two countries preparing to introduce it knew of colleagues who opposed vaccination. ✓These HWs indicated that they were aware of specialist colleagues, such as neurologists, who would verbally advice parents against specific childhood vaccines, like the pentavalent vaccine, or against vaccines in general. ✓HWs stated that specialist doctors' recommendation against vaccination may negatively influence parental trust in vaccines, including the HPV vaccine.	✓Parents expressed positive attitudes toward vaccination, motivated by a desire to protect their children from diseases, including from cervical cancer.	✓Most parents were concerned that the HPV vaccine was “new” and worried about serious side effects like infertility or disability, or that it may not be effective. ✓Some parents, particularly after the COVID-19 pandemic, viewed new vaccines as high-risk and were concerned about their safety. ✓Most urban parents reported low trust in health system and public agencies.

3.1. Health workers

3.1.1. Capability

Across countries, HWs in these studies were well-informed about general childhood vaccines, reported high confidence in their knowledge and communication skills, and considered themselves trusted sources of information. Most family doctors and nurses in countries where the HPV vaccine had been introduced, and some from the studies in countries preparing for introduction, were aware of HPV, the HPV vaccine, and cervical cancer incidence and mortality in their countries. HWs in countries that introduced the HPV vaccine had received training on HPV vaccine benefits, safety, and effectiveness.

However, knowledge gaps on the HPV vaccine and communication skills were still present across countries. Not surprisingly, most HWs included in research in those countries introducing the vaccine lacked information on HPV, the HPV vaccine, its connection to cervical cancer, and on cervical cancer incidence and prevalence in their countries. Many specialists like gynecologists, oncologists, and pediatricians across these countries were not prepared to endorse HPV vaccination because they were misinformed, lacked correct information, or were not confident in their ability to discuss and recommend HPV vaccination to parents. At the time the behavioral insights research was conducted, these HWs had not yet received any training on the HPV vaccine.

Even in those countries that had already introduced the vaccine and had conducted trainings as part of their preparation for HPV vaccine introduction, HWs in this research reported wanting more information on the HPV vaccine. Most said they would like to receive additional training from leading specialists in their countries they considered to be authorities on relevant topics, such as gynecologists and oncologists. Almost all HWs additionally wanted training on effective communication skills to facilitate discussions with parents about HPV vaccination.

3.1.2. Physical opportunity

HWs mentioned receiving institutional and governmental support for vaccination services, like procurement and training. In most countries, HWs reported that having insufficient consultation time to inform parents, address questions, administer vaccines, and complete required documentation as the significant barrier to vaccination. Relatedly, HWs in two countries where the HPV vaccine had been introduced said they lacked informational materials such as brochures to support them in these consultations and lessen their burden to explain everything about the vaccines. Resource barriers, like run-down and outdated rural facilities, and HW shortage to administer vaccination, were reported in three other countries. HWs in two countries reported facing a regulatory barrier where childhood vaccination is not mandatory even though HWs are required to ensure high vaccination uptake. HWs from one country reported the absence of a standardized vaccination consent or refusal form complicated vaccination consultations with parents.

3.1.3. Social opportunity

HWs from only two countries were confident that they would not be held responsible by authorities if there was an adverse event following immunization (AEFIs) when they had followed the official vaccination protocol. Most HWs from the other countries felt they would be blamed in the case of an AEFI. These HWs believed they would be held responsible for any AEFIs, even when following official vaccination protocols and even if the adverse event was coincidental and not caused by vaccination. This lack of protection can influence HW confidence in recommending and administering vaccination.

Some HWs in two countries that had introduced the HPV vaccine also mentioned information found on social media was negatively influencing parents. These HWs stated that local media and social media can spread misinformation about the HPV vaccine and some of them felt constantly scrutinized by the media, which they found stressful. These HWs recommended having more discussions and videos on the HPV vaccine on TV programs, social media, and the internet. A few HWs from one country preparing for introduction mentioned that they had heard of the HPV vaccine via social media as well.

3.1.4. Motivation

Across countries, HW confidence was a significant driver in recommending HPV vaccination. HWs generally saw themselves as instrumental in informing parents and communities about childhood vaccination. They said they trusted vaccine-related information from official sources like the government or international organizations. When HWs felt they had received adequate training and information, they supported and recommended HPV vaccination; however, for most HWs, this had not been the case, and more training and information on the HPV vaccine was requested, especially for those in countries planning HPV vaccine introduction. Overall, there was a clear relationship between HWs receiving training and information on HPV vaccine safety and effectiveness and their confidence and motivation to recommend HPV vaccination.

Some HWs from one country that had already introduced the HPV vaccine and from two countries preparing to introduce it reported knowing of colleagues who were generally opposed to vaccination. These HWs indicated that they were aware of specialist colleagues who would verbally instruct parents against specific childhood vaccines, like the pentavalent vaccine, or against vaccines in general. HWs from the other two countries also mentioned knowing gynecologists-colleagues who were against the HPV vaccine due to their worries about vaccine safety, which may in part persist due to a lack of knowledge and training on HPV vaccination. According to these HWs, specialist doctors' recommendation against vaccination may negatively influence parental trust in vaccines, including the HPV vaccine. However, in one country that had already introduced the HPV vaccine, HWs noted that some specialists they knew did recommended the HPV vaccine to parents, as these specialists perceived it to be a “gentle” vaccine with fewer side effects.

3.2. Parents

3.2.1. Capability

Parents generally exhibited or reported low and insufficient knowledge of HPV, the HPV vaccine, and cervical cancer risk or incidence in their country, even in countries that had introduced the HPV vaccine. Some parents perceived the HPV vaccine as a new vaccine with unclear long-term safety and effectiveness and believed it might cause future infertility in vaccinated girls. The knowledge gap was especially evident among fathers, some of whom were the decision-maker in the home but also believed that cervical cancer is a women's issue, and that only mothers should discuss it with daughters.

Parents across countries mentioned not being aware of or knowing how to access official vaccination information, including where to get the HPV vaccine. They mostly searched for information online, often accessing unofficial sources of health information. While parents acknowledged that social media and other online sources could spread misinformation, most were confident in their own ability to evaluate information sources. Parents wanted more information on HPV types, symptoms, transmission, and prognosis; the HPV vaccine's long-term effectiveness and safety evidence; statistical data from countries where it had been introduced; potential side effects; the consequences of vaccinating and not vaccinating; reasons for vaccinating at an early age; and why boys are vaccinated or not vaccinated in their country. Parents wanted to receive information from authoritative and confident specialists who could answer their questions.

3.2.2. Physical opportunity

Across countries, parents cited various barriers related to access to health facility or information. Some parents in rural areas in two countries that had introduced the HPV vaccine reported poor health facility and road conditions as well as limited transport options impeding access to clinics during official vaccination times as reasons for not vaccinating their children. In one country, some parents were reluctant to vaccinate their daughters due to low-quality services and a lack of heating in clinics. A few parents in three countries that had already introduced the HPV vaccine mentioned that they did not get brochures or remember the HPV vaccine campaigns that had been conducted.

In one country preparing to introduce the HPV vaccine, some parents mentioned that language barriers could hinder access to official vaccination information. Parents from ethnic minority groups might particularly experience language barriers, or even racial/ethnic discrimination in the provision of services.

3.2.3. Social opportunity

Parents across countries mentioned trusting their family doctor's and nurse's advice regarding vaccination and health decision-making. Parents also trusted the opinions of family members, friends, neighbors, relatives, and other parents they know. Some parents also wanted HPV vaccination advice from specialists such as gynecologists. Parents of unvaccinated children in one country that had introduced the HPV vaccine stated they would consent to vaccination if well-respected gynecologists gathered parents and gave a detailed presentation on HPV vaccination. Similarly, parents in another country preparing to introduce the vaccine indicated that they would seek information on HPV vaccination from specialists. For some parents, the responses of HWs to their children's previous experience of vaccination side effects had made them oppose HPV vaccination, which they saw as a new and risky vaccine. According to these parents, HWs dismissed their concerns, suggesting that side effects were not due to vaccination without providing a plausible explanation to address parental concerns.

Some social norms also negatively influenced parents' vaccination decisions. Across several countries, cervical cancer as a topic was considered taboo and could not be discussed openly in public or in mix-gendered settings. Some parents in two countries that had introduced the HPV vaccine mentioned HWs' mixed views on the HPV vaccine, especially specialists, led them to doubt the HPV vaccine.

3.2.4. Motivation

Overall, parents' desire to protect their children from diseases, including from cervical cancer, positively impacted their attitudes toward vaccination. Yet, most parents were concerned about the HPV vaccine being “new” and thus might have serious side effects like infertility or disability, or that it might not be effective. Some parents were especially worried about the safety of “new” vaccines following the COVID-19 pandemic, and some saw vaccination as a high-risk activity.

Apart from one country, urban parents particularly reported low trust in the health system and public agencies. They felt governments provided low-quality health services, including procurement and/or development of low-quality vaccines, and that public sector HWs were less experienced. This general distrust spilled over onto parents' attitude toward the HPV vaccine provided by the public health system.

4. Discussion

The purpose of this research was to present a cross-country analysis of recent qualitative research on barriers and drivers of HPV vaccination-related behavior among HWs and parents from seven middle-income countries located in Eastern Europe and Central Asia that have reported high cervical cancer incidence and mortality rates compared to high-income countries [5]. Four countries had already introduced the HPV vaccine and three countries were preparing for HPV vaccine introduction. To our knowledge, this is the first qualitative study that compared HPV vaccination behaviors across countries that had already introduced the HPV vaccine and that were planning to introduce it. Analyzing reports from these countries permitted observation of actors affecting HPV-vaccine related behaviors across contexts that can be instructive for other countries. Cross-country analysis of HW and parent HPV vaccination behavior insights presents several shared barriers across contexts. Findings point to the need for addressing interrelated barriers to HPV vaccination for both HWs and parents, in line with current evidence-based research on effective HPV vaccination interventions.

Across the seven countries, HWs were viewed as trusted sources of vaccination information, especially specialists like gynecologists or oncologists, whom both parents and HWs saw as credible sources of information on the HPV vaccine. However, capability findings showed such specialists were often not included when trainings were conducted with primary care doctors and nurses in preparation for the introduction. They were often not engaged in HPV vaccine advocacy, sometimes possessed incorrect information, and even at times actively dissuaded parents from vaccination. This lack of engagement among specialists creates not only a missed opportunity for HPV vaccine promotion efforts but a barrier to acceptance, as involved and informed gynecologists and oncologists can be strong advocates for the HPV vaccine among parents [26]. In our analysis, insights from only two countries with relatively high HPV vaccination coverage indicated the use of trained specialists in HW training ahead of introduction. Therefore, future training efforts on vaccine introduction should include not only primary care providers but also specialists in order to ensure that both groups of HWs are well informed and equipped to advocate for HPV vaccination.

This cross-country analysis showed most HWs lacked HPV vaccine knowledge and communication skills not only in countries where HPV vaccine had not yet been introduced but where HWs had received training prior to the introduction. Such findings echo research on the necessity of continuous HW training and up-to-date safety and effectiveness information to support HW confidence in recommending the HPV vaccine [[27], [28], [29], [30]]. In fact, in the analyzed reports, all HWs recommended strengthening their confidence through repeated trainings, tailored to the local context and aimed at raising HPV vaccine knowledge, strengthening confidence in vaccination, and using an evidence-based method to improve communication skills like active listening, targeted engagement, and explaining risks of disease versus vaccination [28]. Global research shows a HW recommendation is a significant predictor of HPV vaccine acceptance, especially when the HW uses a confident, presumptive approach to recommendation, like declaring a child is due for vaccination rather than asking the parent if they want to vaccinate their child [27,29,[31], [32], [33], [34], [35]].

Findings related to opportunity revealed that HWs in five out of seven countries felt they would be personally blamed in the case of AEFIs, even if they followed official vaccination protocols. This indicates that systems-level changes would be required to address this barrier. Some countries have addressed this issue through establishing vaccine-injury compensation schemes that do not attribute causality to one specific individual or organization, allowing HWs to administer vaccines without risk of personal blame [36].

HW barriers were also linked to parents' knowledge gaps, safety concerns, or mistrust. As in other contexts, parents across the seven countries shared concerns related to the HPV vaccine safety and effectiveness, which they often perceived as being new and unproven, lacking evidence, and potentially having dangerous side effects like infertility [[37], [38], [39], [40]]. Cross-country analysis findings echo studies showing such misconceptions or misinformation are spread through media and social networks [[41], [42], [43], [44]], and compounded by not receiving evidence-based information, not receiving a strong and confident recommendation from HWs, and poor patient-provider communication [37,45], even in countries where some parent outreach had been conducted during the HPV vaccine preparation for introduction. In some countries, urban and young parents reported low trust in health system and public agencies and wanted to receive health care services in private clinics. Other research in the region echoed this finding, suggesting overall low trust in government services among parents, including vaccination programs. [46,47] However, further research is needed with urban and young parents to explore their hesitancy to receive vaccination services from public health clinics.

In articulating the interconnectedness of HW and parent barriers, analyzed reports highlighted the need for tailored, multi-faceted interventions that account for locally specific issues, influencers, and target groups. This involved developing interventions that target specific groups that could potentially impact vaccination coverage. For example, fathers were often decision makers on children's vaccination but were not informed on the HPV vaccine, as they considered cervical cancer a women's issue irrelevant to them and not something to discuss with children. Additionally, parents in some communities may be excluded or unreached by vaccine promotion efforts due to structural marginalization requiring appropriate interventions addressing that community's particular context. For example, in one country where an ethnic minority had historically high mistrust of the public health system, extremely low vaccination uptake, and whose girls and women did not interact with outsiders, an intervention was suggested to build the capacity of health volunteers already embedded in and belonging to the community so they could go door-to-door to share HPV vaccine information. Following the door-to-door information campaign, mediated meetings with trusted health workers were held to vaccinate target-aged girls of consenting parents. This approach is in line with wider research on interventions to promote vaccine coverage that show such tailored interventions based on insights can ensure resources are efficiently spent to address the needs of unreached populations [48,49].

Two prominent recommendations posited in the reports were 1) engaging parents and addressing their concerns at the community level and 2) ensuring vaccine confidence through engagement and access to evidence-based information for HWs and others who influence parental vaccination decisions. However, despite these similar recommendations across countries, research findings illustrated context-specific barriers which informed the tailored design of the interventions. Community engagement efforts outlined in these reports suggested using targeted communication to address identified knowledge gaps and HPV misperceptions, emphasize the safety and effectiveness of the HPV vaccine, and provide parents with opportunities to voice their concerns, ask questions and receive information from trusted individuals and HWs like gynecologists and pediatricians. Reaching target groups was also emphasized to ensure information was not only provided in spaces like health facilities but in community settings such as reaching fathers where men gather like teahouses or religious gatherings. While HWs were widely regarded as the primary source of information, insights highlighted the necessity of including contextually relevant other influential persons within target communities to limit spread of misinformation and ensure that parents received a consistent message from all authoritative sources. Such interventions have been proven effective in improving HPV vaccination coverage across multiple contexts [50,51].

A second recommendation across reports focused on ensuring vaccine confidence among HWs through the consistent provision of official, evidence-based, and up-to-date information on the HPV vaccine and vaccination more generally that they could then share with parents. HW trainings were suggested as one approach, along with the development of print and electronic materials like brochures to serve as discussion aids for HWs. The reports also proposed interventions to promote access to relevant target groups through the training of health workers, embedding essential information for target populations throughout intervention components, and ensuring clear signposting to developed materials, websites, campaigns, and other informational products. Broader research supports this approach, stressing that it is not enough to simply develop materials, but it is important to ensure they systematically reach the right populations, including HWs and specialists, via the appropriate channels [49].

5. Conclusion

An analysis of behavioral insights research on improving HPV vaccine coverage from seven countries in the European region showed persisting similarities in the general barriers to HPV vaccination behaviors among HWs and parents. Barriers for HWs were mostly related to knowledge gaps, particularly among specialists not directly involved in vaccination but who can influence parental decisions, as well as challenges in effective communication with parents. Parents' acceptance of HPV vaccination was influenced by a lack of awareness and knowledge regarding HPV vaccination, limited access to official and evidence-based information, and factors like HW recommendations, social taboos, or myths surrounding the HPV vaccine. This analysis also highlighted the contextual differences of stakeholders, issues, and systems that necessitated continued interventions, even after a successful vaccine introduction, tailored to the context.

5.1. Strengths and limitations

This cross-country analysis is the first to analyze behavioral insights data on HPV vaccination across seven middle-income countries in the European region at both pre-and post HPV vaccine introduction stages using a theory-based approach. While findings might not be generalizable to other contexts, they reflect broader research literature on barriers affecting HW and parents' HPV vaccination behavior and how best to address them

Ethical approval and informed consent statements

Ethical approval was not required for this meta-analysis of pre-existing RAP sheets, which were generated in accordance with the Helsinki Declaration and WHO and national ethical approval.

CRediT authorship contribution statement

Gulaiim Almatkyzy: Writing – original draft, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Sahil Khan Warsi: Writing – review & editing, Validation, Project administration, Methodology, Investigation. Siff Malue Nielsen: Supervision, Resources, Methodology, Investigation, Funding acquisition. Brett J. Craig: Writing – review & editing, Validation, Supervision, Resources, Methodology, Investigation, Funding acquisition, Data curation, Conceptualization.

Funding source

The individual behavioral insight studies and the cross-country analysis were funded by the European Union and by Gavi, the Vaccine Alliance through the WHO Regional Office for Europe. The funders were not directly involved in the collection, analysis, and interpretation of data.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability statement

The existing RAP sheet analyzed during the current cross-country study is available from the corresponding author on reasonable request.