Barriers and facilitators of human papillomavirus vaccination uptake in India: A systematic review

INTRODUCTION

Human papillomavirus (HPV) is a major cause of dermatological disorders and malignancies, including cervical, anal, penile, vaginal, vulvar, and oropharyngeal cancers.^[1-3] It is the most common sexually transmitted infection, spreading through skin-to-skin or sexual contact.^[4,5] While many infections clear spontaneously, persistent HPV can lead to cancer.^[1]

Cervical cancer remains the leading cause of cancer-related deaths among women in low- and middle-income countries, despite being highly preventable.^[6] In 2022, India recorded 127,526 cases and 79,906 deaths, making it the second most common cancer among women.^[7,8] HPV vaccination significantly reduces cervical cancer risk, with immunization available for girls aged 9–26 in India, without requiring prior Pap or HPV screening.^[9]

Despite vaccine availability, uptake remains low due to economic constraints, sociocultural factors, and concerns over safety.^[10,11] The World Health Organization’s (WHO’s) 90/70/90 strategy aims to eliminate cervical cancer by vaccinating 90% of girls by 15, screening 70% of women by 35 and 45, and treating 90% of detected cases.^[12] This approach could prevent over 62 million cases globally.^[12] However, awareness and vaccination uptake remain alarmingly low.^[13]

Educational interventions improve vaccine acceptance, yet school-based programs often miss out-of-school girls.^[13-15] Expanding coverage to young men could further curb HPV transmission.^[16] However, misinformation, cultural beliefs, and hesitancy remain major obstacles.^[17-19]

Addressing barriers through education, community engagement, and public health initiatives is critical to increasing HPV vaccination coverage.^[13,20,21] This review examines facilitators and barriers to HPV vaccination in India, aligning with WHO’s goal of cervical cancer elimination by 2120.

MATERIALS AND METHODS

This systematic review follows the Integrated Methodology approach outlined in the Joanna Briggs Institute Reviewers’ Manual (2015), synthesizing quantitative and qualitative studies using a mixed-methods approach.^[22] The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used to ensure compliance with standardized reporting.^[23] Due to data heterogeneity, a meta-analysis was not performed.

Data extraction

Two independent reviewers screened titles and abstracts for eligibility. The Zotero citation manager was used to organize search results and remove duplicates.^[26] Full texts were assessed against the inclusion criteria, and key data were extracted into a standardized form, capturing author(s), year, study design, sample size, population characteristics, HPV vaccination uptake, facilitators, barriers, and effectiveness of educational interventions. The screening process followed the Moher model, shown in the PRISMA flow diagram [Figure 1].^[27]

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Figure 1:

Preferred Reporting Items for Systematic Reviews and Meta-analyses flowchart. For more information, visit: http://www.prisma-statement.org/. HPV: Human papilloma virus.

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RESULTS

This systematic review identified thirteen studies that met the inclusion criteria, focusing on HPV vaccination uptake, barriers, and awareness in India [Table 1]. The studies highlight significant gaps in knowledge and vaccination rates among parents, adolescents, and healthcare providers. Findings reveal various barriers and facilitators, providing insights into improving vaccine uptake and reducing cervical cancer burden.

DISCUSSION

The findings from this systematic review illuminate the multifaceted challenges surrounding HPV vaccination uptake in India, a country grappling with a significant cervical cancer burden. Despite the introduction of HPV vaccines as a preventive measure, coverage remains alarmingly low due to a combination of economic, sociocultural, and informational barriers. Awareness about HPV and its vaccine remains insufficient, even among critical groups such as healthcare providers and college students.^[18,28] This lack of knowledge underscores the need for targeted educational interventions. These interventions have proven effective in enhancing awareness and acceptance among diverse populations, particularly parents and young girls,^[14] but must be tailored to address the specific cultural contexts and needs of marginalized communities and out-of-school girls, who are often overlooked in traditional school-based programs.^[15] A study by Krokidi et al. further emphasizes significant knowledge gaps among college students in India, necessitating structured campaigns in academic settings to address misinformation and low awareness.^[13]

Economic barriers, including the high cost of vaccines and limited access to healthcare facilities, further impede vaccination efforts.^[10] The willingness of parents to vaccinate often does not translate into action due to financial constraints. This highlights the pressing need for policy interventions aimed at subsidizing costs or providing vaccines through public health initiatives.^[21] Such programs, if effectively implemented, could ensure equitable access to the HPV vaccine, particularly in rural and underserved areas. Furthermore, parental attitudes shaped by factors such as religion, age, and misconceptions about vaccine safety must be addressed through culturally sensitive messaging that emphasizes the vaccine’s efficacy and the importance of early vaccination.^[11] Madhivanan et al. identified parental preference to delay vaccination until daughters reach adolescence or adulthood, which reduces vaccine efficacy, further underscoring the importance of timely interventions.^[29]

The inclusion of young men in vaccination strategies also represents a promising avenue for reducing HPV transmission and cervical cancer risk.^[16] By fostering a more inclusive approach involving both genders, public health initiatives could enhance overall vaccination rates and contribute to broader community acceptance. However, this requires a shift in public perception to recognize HPV as a shared health concern rather than one specific to women.

Misinformation and cultural stigma remain significant barriers, perpetuating vaccine hesitancy.^[17] The spread of myths regarding vaccine safety and efficacy, often fueled by social media, underscores the importance of comprehensive communication strategies. Engaging community stakeholders, such as healthcare providers, educators, and local leaders, is crucial in dispelling myths and promoting accurate information about the HPV vaccine.^[30] Effective training of healthcare workers to advocate for vaccination can also play a pivotal role in countering misinformation and encouraging uptake.^[21]

In addition, systemic healthcare challenges, such as inadequate outreach mechanisms and gaps in school-based programs, were noted as barriers. For instance, current school-based initiatives often fail to reach out-of-school girls, highlighting the need for more inclusive delivery systems.^[15]

Addressing the barriers to HPV vaccination in India requires a coordinated, multifaceted strategy that integrates education, economic support, and community engagement. Efforts must prioritize equitable vaccination strategies by addressing economic and sociocultural barriers, such as vaccine cost, misinformation, and cultural stigma. Subsidized vaccine programs, community-based educational interventions, and targeted efforts for underserved populations, including out-of-school girls, are critical for improving coverage. Expanding vaccination to include men can further reduce transmission and increase herd immunity. Strengthening healthcare provider training and their active involvement can enhance vaccine acceptance while integrating HPV vaccination into national immunization programs and aligning with global initiatives like the WHO’s 90/70/90 strategy can accelerate cervical cancer elimination.^[12] Furthermore, expanding school-based programs to involve parents and community leaders can foster trust and sustainable vaccine uptake.

The findings are limited by heterogeneity across included studies, which precluded meta-analysis. Most studies focused on urban populations, potentially overlooking barriers unique to rural and tribal communities. In addition, reliance on self-reported data in several studies may introduce recall and social desirability biases.

Future studies should explore innovative delivery models for reaching marginalized populations, including mobile health units and digital campaigns. Longitudinal studies are needed to assess the long-term impact of educational interventions and policy changes. Research should also investigate the role of male vaccination in reducing HPV transmission and its broader societal acceptance.

CONCLUSION

This review highlights the need for comprehensive strategies to enhance HPV vaccination uptake in India. Economic challenges, cultural beliefs, and low awareness hinder progress, while educational interventions remain limited.

Expanding vaccination among young men and addressing through culturally tailored communication are crucial.

Policymakers must integrate HPV vaccination into public health programs and ensure affordability, particularly in rural areas.

A multifaceted approach – combining education, accessibility, and community involvement – is critical to increasing coverage and reducing cervical cancer burden. A coordinated, evidence-based national strategy aligned with global health frameworks is vital for sustainable progress.