Analysis of the characteristics of parents' reasons for refusing HPV vaccination for their daughters: a cross-sectional study.
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BACKGROUND: Parental decision-making is pivotal to the uptake of the human papillomavirus (HPV) vaccine among girls aged 9-14 years. However, the characteristics that distinguish parents who are willing versus unwilling to vaccinate-particularly those who are unwilling-remain insufficiently characterized. This study aimed to examine the underlying reasons and attributes associated with parental willingness and unwillingness, thereby providing evidence on the classification and heterogeneity of HPV vaccine hesitancy. METHODS: In May 2024, we conducted a cross-sectional questionnaire survey using convenience sampling among 1,331 parents of girls aged 9-14 years from seven schools in Shanghai, China. The survey collected sociodemographic characteristics, willingness to vaccinate daughters against HPV and the underlying reasons, and parental knowledge literacy regarding cervical cancer, HPV, HPV vaccination, and cervical cancer screening. Two-step cluster analysis was used to classify parents based on their stated reasons for willingness or unwillingness to vaccinate. We then examined associations between parental characteristics and cluster membership. RESULTS: Among 1,076 parents of unvaccinated girls aged 9-14 years, 18.12% reported unwillingness to vaccinate. Cluster analysis identified three distinct refusal clusters, labeled as the Moderate and Hesitant type (low knowledge literacy and limited understanding of HPV-related risks), the Trust-Critical type (high knowledge literacy but low institutional trust), and the Social-Norm Sensitive type (high educational attainment and susceptibility to peer and societal influences). Significant between-cluster differences were observed in educational attainment, number of children, and knowledge literacy, indicating that vaccine refusal is structurally diverse rather than uniform. CONCLUSIONS: HPV vaccine refusal among Chinese parents is heterogeneous and appears to be shaped by cognitive, emotional, and social factors. Tailored interventions are therefore warranted. Segmented strategies that address cluster-specific drivers may reduce vaccine hesitancy more effectively than uniform public health messaging.