Factors associated with HPV vaccine hesitancy: A nationally representative cross-sectional study

HPV related tumors continue to be a global leading cause of cancer mainly due to cervical cancer (CC) burden. In Brazil, CC is the third most common cancer and the fourth highest cancer mortality rate among women. HPV vaccine mass immunization represents the current most promising intervention for CC prevention. It was first implemented in the Brazilian public health system in 2014, however, despite a history of excellent coverage for other vaccines, HPV vaccine uptake is below the necessary threshold for CC elimination. Identifying the factors that influence HPV vaccine hesitancy is an essential step to further develop strategies to improve vaccination coverage.

The aim of this study is to provide insights into whether or not Brazilians are resistant to HPV vaccination and to determine the factors and variables that influence this decision.

This is a population-based cross-sectional study which used quantitative methodology through personal interviews. A total of 2010 interviews were planned to result in error margins of 2 percentage points, more or less considering a 95 % confidence level, encompassing all five Brazilian regions. Cities of different sizes and complexities were included in the sample, as capitals and cities in both metropolitan and rural areas. The research was carried out with the Brazilian population aged 16 and over, interviewees were approached at points of population flow.

Between June 12th and 16th 2023, a total of 2010 personal interviews were done, with participants from all five Brazilian regions. The prevalence of vaccine resistance was 5.97 % (95 % confidence interval [CI], 4.93-7.23) among those interviewed. A multivariate analysis demonstrated greater resistance to the vaccine among men (prevalence ratios (PR): 1.58; 95 %CI 1.06-2.34; p: 0.023) and residents in the South region of the country (PR: 1.77; 95 %CI, 1.06-2.94; p: 0.028). The three main reasons for refusing the vaccine reported by the participants were: lack of knowledge about the HPV vaccine; difficulty in accessing the vaccine; and lack of vaccine prescription by health professionals. Safety was the main reason not to vaccinate, cited by 10 %.

Despite HPV vaccine availability in Brazil at the public health system, vaccination coverage remains below the target for both genders. However, according to this analysis, there is a low rate of HPV vaccination hesitancy in the country, being lack of knowledge, difficulty in accessing the vaccine and lack of vaccine prescription by health professionals the main obstacles to adequate adherence. The COVID-19 pandemic doesn't seem to have affected HPV vaccination resistance in the country. Proper strategies for vaccine implementation, including school-based programs, patient-provider communication and education, and integrated monitoring and evaluation strategies are needed, otherwise HPV vaccine programs run the risk of repeating the problems associated with Pap programs in Low- and Middle-Income Countries (LMICs): an efficient, life-saving tool underutilized for cancer prevention.