BACKGROUND: Human papillomavirus (HPV) related cancers, particularly cervical cancer, remain a major public health challenge in low- and lower-middle-income countries (LLMICs), which bear a disproportionate share of global HPV-attributable mortality. Despite the availability of safe and effective vaccines for nearly two decades, vaccination coverage remains low in LLMICs. Several barriers ranging from health misinformation to systemic delivery challenges have hindered efforts to scale up vaccination programs in these settings.
OBJECTIVES: This systematic review aims to identify and synthesize the behavioral and structural factors influencing HPV vaccine uptake among adolescents in LLMICs. Guided by a multi-level behavioral health framework, findings were categorized across: individual, interpersonal, and structural domains.
METHODS: A comprehensive search of seven databases identified 639 records, of which 34 empirical studies met inclusion criteria. Eligible studies focused on HPV vaccination uptake among adolescents in World Bank-defined LLMICs and were assessed for thematic relevance. Data extraction emphasized barriers and facilitators to uptake.
RESULTS: Individual-level barriers included limited awareness, misconceptions about HPV and the vaccine, and fear of side effects. Interpersonal dynamics—particularly parental consent, gendered norms, and community endorsement—shaped adolescent vaccine decision-making. Structural barriers included vaccine stock-outs, weak delivery infrastructure, and limited reach among out-of-school youth. School-based delivery models, trusted healthcare workers, and community sensitization emerged as key facilitators.
CONCLUSIONS: Improving HPV vaccine coverage in LLMICs requires coordinated, multi-level interventions that simultaneously address behavioral and structural determinants. Findings highlight the critical role of community engagement, flexible delivery models, and long-term sustainability planning to ensure effective implementation. These insights have direct implications for national immunization policy, health system strengthening, and achievement of global cervical cancer elimination targets in resource-limited settings. Tailoring implementation to the contextual realities of LLMICs will be essential to advancing equity in HPV-related cancer prevention.
Factors affecting human papillomavirus vaccination: A review of individual, interpersonal, and structural factors affecting vaccine uptake among adolescents
Vaccine, 81, 128563. doi: 10.1016/j.vaccine.2026.128563.