Barriers and Enablers of HPV Vaccination Among Caregivers of School-Age Girls in Resource-Limited Regions of Western Sichuan, China: A Mixed-Methods Study

Qiwen Zhang^1,2Lu Zhang²Zubo Huang³Yue Zeng³Yueshan Wang²Jie-Ru Peng²Yan Kou⁴Wei Huang⁴Gang Zhu⁵Wencheng Long²Yao Dong²Chunxia Yang^2*

• ¹Sichuan University, Chengdu, China
• ²Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, China
• ³Sub-health department, Sichuan Integrative Medicine Hospital, Chengdu, China
• ⁴Songpan County Center for Disease Control and Prevention, Songpan, China
• ⁵Mianning County Maternal and Child Health Hospital, Mianning, China

Background The HPV infection rate in Sichuan exceeds the national average. The provincial government has initiated vaccination programs, with a particular focus on impoverished areas such as the Ganzi, Aba, and Liangshan prefectures, where both the HPV disease burden is elevated and vaccination uptake remains suboptimal. This study aimed to investigate HPV vaccination among adolescent girls in these prefectures, evaluate caregivers' knowledge and attitudes, identify factors influencing their willingness to vaccinate their daughters, and examine existing policies to provide evidence-based recommendations for improving vaccination strategies. Methods A cross-sectional study was conducted in Ganzi, Aba, and Liangshan prefectures from September 2023 to May 2024, integrating both quantitative and qualitative methods. At least 2,034 caregivers and 75 participants should be recruited for the quantitative and qualitative studies, respectively. Questionnaires were used to assess caregivers' willingness to vaccinate girls under the age of 15. Quantitative analyses included Chi-square tests, Mann-Whitney U tests, and logistic regression analyses. Additionally, focus group discussions and face-to-face interviews with vaccination personnel and caregivers explored vaccination coverage and barriers, with qualitative data analyzed via thematic framework analysis. Results A total of 2,397 caregivers completed valid questionnaires, with 59.28% having heard of HPV and 69.63% being aware of the HPV vaccine. Although 92.12% expressed willingness to vaccinate their girls against HPV, the actual vaccination rate was only 6.59%. Reluctance to vaccinate was primarily due to a lack of knowledge about the vaccine (30.69%), concern about potential side effects (28.04%), and uncertainty about the vaccine's effectiveness (18.5%). Regression analysis showed that caregivers who were mothers, willing to pay for HPV vaccination, personally willing to receive the HPV vaccine, and had never refused a vaccine were more likely to vaccinate girls against HPV (all P <0.05). Qualitative findings further identified economic constraints, insufficient vaccine supply, and limited public awareness as major barriers to HPV vaccination. Conclusion Caregivers hold positive attitudes towards HPV vaccination, but the coverage rate among girls remains low in Ganzi, Aba, and Liangshan prefectures. Ensuring vaccine supply, reducing costs, improving caregivers' knowledge, and increasing vaccination accessibility could significantly enhance vaccination rates in resource-limited regions of western China.