International prevalence and associated factors of parental vaccine hesitancy in human papillomavirus vaccination: A systematic review and meta-analysis.
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BACKGROUND: Human papillomavirus vaccination is a key strategy for preventing cervical cancer and other human papillomavirus-related diseases. Despite global efforts, vaccine hesitancy among parents remains a major barrier to achieving adequate immunization coverage in adolescents. OBJECTIVES: To estimate the international prevalence of parental human papillomavirus vaccine hesitancy and identify associated sociodemographic, psychological, and contextual factors. METHODS: Ten databases were searched from inception to March 19, 2025, with an updated search on July 15, 2025. Eligible studies included cross-sectional or cohort designs reporting parental hesitancy toward human papillomavirus vaccination. Two reviewers independently screened and selected studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute checklist. Pooled prevalence estimates and 95 % confidence intervals (CIs) were calculated using random-effects models due to substantial heterogeneity. Subgroup and meta-regression analyses were performed to explore moderators. Determinants of hesitancy were thematically synthesized and mapped to constructs of the Health Belief Model. RESULTS: Twenty-three studies involving 203,818 parents across 13 countries were included. The pooled global prevalence of parental human papillomavirus vaccine hesitancy was 39.6 % (95 % CI: 31.4 %-47.8 %). Subgroup and meta-regression analyses revealed significant moderators, including parental employment status, household income, country and continent, national income classification, year of publication, and measurement tools. Thematic synthesis identified key psychological determinants such as low perceived vaccine safety, limited benefits, low trust in healthcare providers, and susceptibility to misinformation. No significant publication bias was detected. CONCLUSIONS: Parental hesitancy toward human papillomavirus vaccination is a widespread issue with pronounced variation across socioeconomic and geographic contexts. Multilevel interventions are urgently needed to improve human papillomavirus vaccine acceptance, particularly those addressing safety concerns, provider trust, and structural access barriers. Standardizing measurement tools and expanding research in underrepresented regions, especially in Africa and Southeast Asia, are essential for informing global vaccination strategies. REGISTRATION: The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (Registration No. CRD420251030655).