Introduction

Human papillomavirus (HPV) infection remains the principal etiological factor in the development of cervical cancer, a disease largely attributable to persistent infection with high-risk genotypes, particularly HPV types 16 and 18. When these infections are not cleared, they may progress from precancerous lesions to invasive cancer over time [1]. In 2022, globally, this cancer ranked fourth among the most common cancers in women, with a total of 660,000 new cases reported and 350,000 deaths. Ninety-four percent of these deaths occurred in low- and middle-income countries [2,3]. HPV vaccination is the primary method for reducing the morbidity and mortality associated with this disease [4].

In the countries of the Eastern Mediterranean Region, age-standardized incidence rates are less than 10 per 100,000 women, with the exception of Somalia, where the age-standardized incidence rate is 25.4 per 100,000; Djibouti, where it is 13.4 per 100,000; and Afghanistan and Morocco, where it is 10.4 per 100,000 for each country [5,6].

In line with the World Health Organization’s framework for eliminating cervical cancer as a public health problem and Morocco’s national cancer prevention and control plan, it has been agreed to ensure that at least 90% of girls aged 11 years are vaccinated against HPV by 2030 [7,8].

In October 2022, a quadrivalent HPV vaccine was introduced into Morocco’s national immunization program. Vaccination is targeted at 11-year-old girls attending school and is administered in two doses at least six months apart (Gardasil) [9]. This strategy relied on the healthcare system’s capacity to integrate a new vaccine and drew on the successful experiences of several countries that had identified factors contributing to high-performing HPV vaccination programs.

However, the effectiveness of this strategy is highly dependent on parental acceptance of the vaccine. Yet, HPV vaccination—although effective, safe, and available—faces significant obstacles in many contexts, including parental refusal. The determinants of this refusal are numerous, including a lack of knowledge about the disease, a low perception of risk, fears related to the vaccine, institutional distrust, socioeconomic factors, and the absence of explicit recommendations from healthcare professionals [10–12].

In this context, it was important to identify, among the Moroccan population, the factors associated with parental refusal of HPV vaccination for their daughters in order to develop appropriate strategies. The objective of our study is therefore to estimate the prevalence of parental refusal of HPV vaccination and to identify the associated risk factors. The results of this study are essential to better guide public health policies and health strategies in order to improve HPV vaccination coverage and, ultimately, reduce the incidence of cervical cancer in women in Morocco and improve their sexual and reproductive health.

Methods

Results

1. Socioeconomic and demographic characteristics

A total of 1,444 participants were included in the study, and 415 (28.7%) refused to have their daughters vaccinated against HPV. The mean age of the participants was 37.7 ± 6.6 years, and 1,321 (91.5%) were married. Furthermore, 754 (52.2%) participants had a monthly household income of less than $299, 268 (18.6%) spent more than 30 minutes traveling to the health center, and 710 (49.2%) reported using public transportation to get there. Finally, 668 participants (46.2%) reported having little or no confidence in the healthcare system “Table 1”.

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. The socioeconomic and demographic characteristics of the parents, Morocco, 2025.

https://doi.org/10.1371/journal.pone.0348586.t001

2. Knowledge about cervical cancer and the human papillomavirus vaccine

Table 2 presents parents’ knowledge regarding cervical cancer and the HPV vaccine. Overall, 989 participants (68.5%) had never heard of HPV, while 487 (33.7%) reported no prior awareness of cervical cancer. Unsatisfactory general knowledge about cervical cancer was observed among 886 participants (61.4%). In addition, 828 participants (57.3%) demonstrated inadequate knowledge of risk factors, 1,021 (70.7%) of symptoms, 1,232 (85.3%) of complications, and 854 (59.1%) of preventive measures. Regarding the HPV vaccine, 1,201 participants (83.2%) were unaware of the recommended number of doses. Furthermore, 1,112 participants (77.0%) reported an insufficient perception of the level of information on the HPV vaccine disseminated by the media “Table 2”.

Download:

• PNG
  larger image
• TIFF
  original image

Table 2. General knowledge about cervical cancer and the human papillomavirus vaccine, parents, Morocco, 2025.

https://doi.org/10.1371/journal.pone.0348586.t002

3. Beliefs and fears about the human papillomavirus vaccine

Among the 1,444 participants, 939 (65.0%) believed that their daughters were unlikely to contract HPV. A total of 303 participants (21.0%) underestimated the severity of HPV infection, while 396 (27.4%) recognized the benefits of HPV vaccination. However, 846 participants (58.6%) feared potential side effects of the vaccine, and 461 (31.9%) worried that vaccination might encourage early sexual activity. Nearly half of the parents, 693 (48.0%), felt afraid to vaccinate their daughters, and 661 (45.8%) were concerned that they might later regret the decision “Table 3”.

Download:

• PNG
  larger image
• TIFF
  original image

Table 3. Parents’ beliefs and fears regarding the human papillomavirus vaccine, parents, Morocco, 2025.

https://doi.org/10.1371/journal.pone.0348586.t003

4. Environnemental influences

Table 4 presents the influence of environmental factors on the decision to vaccinate against HPV. 960 parents (66.5%) felt that the media had a negative influence on their vaccination decision, while 872 (60.4%) reported that societal norms also had a negative impact on their choice. Furthermore, 1007 participants (69.7%) reported having received no recommendation from a healthcare professional regarding HPV vaccination for their daughters “Table 4”.

Download:

• PNG
  larger image
• TIFF
  original image

Table 4. Influence of environmental factors on the decision to vaccinate against human papillomavirus, parents, Morocco, 2025.

https://doi.org/10.1371/journal.pone.0348586.t004

5. Bivariate analysis

Among the parents, 415 participants (28.7%) reported refusing the HPV vaccine for their daughters. In the bivariate analysis, a significance threshold of p ≤ 0.05 was applied, identifying 32 factors significantly associated with vaccine refusal. Sociodemographic factors included area of residence (p = 0.0005), being uncoupled (p = 0.045), the participant’s level of education (p = 0.001), the spouse’s level of education (p = 0.0003), and low monthly household income (p < 0.001). Access to healthcare, such as travel time to the health center (p = 0.0005) and reliance on transport (p = 0.005), was also associated with refusal. Participants with low trust in the healthcare system (p < 0.001), those who had never heard of HPV (p < 0.001) or cervical cancer (p < 0.001), and those who had prior contact with a person with cervical cancer (p = 0.01) were more likely to refuse vaccination. Insufficient knowledge about cervical cancer, including risk factors (p < 0.001), symptoms (p < 0.001), complications (p < 0.001), preventive measures (p < 0.001), and the number of HPV vaccine doses (p = 0.0013), was also significantly associated with refusal. Furthermore, participants who perceived media coverage about the HPV vaccine as unsatisfactory (p = 0.0001), who underestimated their daughters’ susceptibility to HPV (p < 0.001), who believed the infection was not severe (p < 0.001), or who doubted the vaccine’s effectiveness (p < 0.001) were more likely to refuse. Concerns about adverse effects (p < 0.001) and beliefs that vaccination could encourage sexual activity (p = 0.01) also contributed to refusal, as did fears of vaccinating their daughters (p < 0.001), fear of regretting vaccination (p < 0.004), and fear of regretting non-vaccination (p < 0.004). External influences, including the negative impact of media (p = 0.001) and societal norms (p < 0.001), further affected parents’ decisions. Finally, children not vaccinated according to the schedule (p < 0.001), previous failure to follow vaccination schedules (p = 0.01), lack of information from health professionals about vaccine availability (p < 0.001) and free provision (p < 0.001), as well as non-recommendation of the HPV vaccine by health professionals (p < 0.001), were all significantly associated with parental refusal “Table 5”.

Download:

• PNG
  larger image
• TIFF
  original image

Table 5. Multivariate analysis (odds ratio, P-value) of risk factors for refusal of human papillomavirus vaccination among parents of young girls, Morocco, 2025.

https://doi.org/10.1371/journal.pone.0348586.t005

Discussion

Vaccination against HPV represents a cornerstone strategy for the prevention of cervical cancer. Nevertheless, persistent parental refusal since the introduction of the vaccine into national immunization programs has limited its uptake and reduced its potential benefits for women’s sexual and reproductive health. In our study, 28.7% of parents reported refusing HPV vaccination for their daughters. This finding is consistent with rates reported in the scientific literature, which range from 20% to 44%. For example, refusal rates of 43.2% were reported in China in 2024 among 11,728 participants [18]; 34.5% in Saudi Arabia in 2023 among 534 participants [19]; 27.9% in Pakistan in 2021 among 610 participants [20]; 22.1% in Ivory Coast in 2024 among 181 participants [21]; and 20.1% in India in 2020 among 831 participants [22].

A lack of trust in the healthcare system is a risk factor associated with vaccine refusal. The spread of alarmist or anti-vaccine messages, often fueled by social media, exacerbates this loss of trust and reinforces refusal [23]. Contexts marked by fragile relationships between healthcare professionals and patients worsen this dynamic [24].

The lack of HPV vaccine recommendations from healthcare professionals is a risk factor associated with vaccine refusal. This finding aligns with the results of the scientific literature [25,26]. Indeed, in the United States, parents who did not receive an explicit recommendation were more likely to refuse the HPV vaccine. Kata et al. showed that the lack of professional guidance leaves an information gap that is quickly filled by misinformation on social media, thus exacerbating refusal [23].

The time required to reach a health center is a risk factor for vaccine refusal. In our study, parents living more than an hour from the health center were significantly more likely to refuse the HPV vaccine for their daughters. This finding can be explained by logistical constraints and the cost of travel, which reduce accessibility and lower the priority of vaccination [27]. Epidemiological studies conducted in low- and middle-income countries report that geographical remoteness and a lack of reliable transportation are consistently associated with vaccine refusal [28,29].

In our study, fear of vaccinating girls against HPV was a risk factor for vaccine refusal. Parents may link this fear to their perception of health risks, including moral and cultural concerns surrounding vaccination against a sexually transmitted infection [25].

High parental education levels are a risk factor associated with HPV vaccine refusal. Indeed, some more educated parents are more frequently exposed to conflicting information or critical messages about the vaccine, which can reinforce mistrust and lead to refusal [30]. These parents often have heightened critical thinking skills and actively seek alternative information, which may lead them to question the necessity or safety of the HPV vaccine [31].

Failure to adhere to the childhood vaccination schedule is a risk factor for HPV vaccine refusal. Parents who have not vaccinated their children according to the recommended schedule appear more likely to refuse further vaccinations, probably due to general vaccine hesitancy, lack of awareness, or the influence of personal and cultural beliefs [30]. A study in the United States showed that parents who delayed or refused childhood vaccinations were significantly more likely to refuse the HPV vaccine for their adolescents [26]. In the MENA region, studies conducted in Tunisia and Saudi Arabia also report that omission or non-adherence to the vaccination schedule is associated with lower HPV vaccine acceptance [32].

In our survey, a lack of knowledge of cervical cancer symptoms was a risk factor associated with refusal of the HPV vaccine. That could be explained by the tendency of these parents to underestimate the severity of and vulnerability to HPV infection, which reduces the perceived need for vaccination [25].

Not having heard of cervical cancer is a factor associated with refusing the HPV vaccine. Indeed, parents who have never heard of this disease often believe their daughters are not at risk, leading to a refusal of vaccination [25].

Low household income is a significant factor associated with refusal of the HPV vaccine, even though it is offered free of charge. Indeed, even without direct financial costs, vaccination can involve hidden costs—organizational or time-related—that disproportionately affect low-income families and contribute to refusal. Thus, despite the vaccine being free, the social, cognitive, and institutional dimensions linked to low income are decisive factors in HPV vaccination refusal.

A low perception of the severity of HPV infection is a risk factor associated with vaccine refusal. Indeed, when parents underestimate the potential severity of HPV, particularly its causal link to cervical cancer, they are less inclined to consider vaccination a necessary measure. This relationship is well documented by the Health Belief Model, according to which a low perception of severity directly reduces the intention to adopt preventive behavior [33]. Several studies have confirmed that parents who consider HPV a benign infection have higher rates of vaccine refusal because they do not perceive the urgency or importance of immunizing their children [34]. Furthermore, a lack of awareness of the link between HPV and cancer contributes to the trivialization of the infection, a phenomenon described in many contexts, particularly in the Middle East and North Africa [35].

An unsatisfactory perception of information provided by the media about the HPV vaccine is a risk factor associated with vaccine refusal. Indeed, when media messages are deemed insufficient, unclear, or lacking in credibility, parents more readily develop doubts about the vaccine’s efficacy and safety, thus reinforcing their refusal. Several studies show that the quality and clarity of media information play a central role in vaccine acceptance. A lack of clear communication increases mistrust and promotes exposure to unreliable sources disseminating anxiety-inducing or erroneous messages [36]. Research conducted in various settings has also demonstrated that parents who feel the media do not provide sufficient or consistent information are significantly more likely to refuse the HPV vaccine [37,38]. Because our measure aggregated all media sources, we cannot determine whether negative influence was driven primarily by social media misinformation or by traditional media underreporting. Future research should disaggregate these channels.

The lack of clear recommendations for the HPV vaccine from healthcare professionals constitutes a significant risk factor for HPV vaccine refusal. This may be explained by the central role of healthcare professionals as parents’ most trusted source of information regarding vaccination. Evidence from Gilkey et al. demonstrates that strong, clear, and timely recommendations markedly increase HPV vaccine acceptance, whereas weak or absent recommendations foster uncertainty, fear, and ultimately refusal [39].

The scientific literature shows that perceiving vaccine side effects as mild, expected, and non-dangerous promotes vaccine acceptance. Transparency about mild post-vaccination reactions strengthens parental confidence and reduces uncertainty [40]. Parents who perceive vaccine side effects as typical are less inclined to decline vaccination, indicating a pragmatic comprehension of vaccine safety. However, the finding that fear of adverse effects was more frequently reported among acceptors remains paradoxical and cannot be fully explained by knowledge alone. This may reflect a social desirability bias, whereby participants who accepted vaccination felt inclined to acknowledge potential risks without allowing these concerns to influence their decision. In contrast, those who refused vaccination may have minimized or dismissed these risks as a way to justify their choice.

Unexpectedly, a lack of knowledge regarding the recommended number of HPV vaccine doses emerged as a protective factor in our analysis. This result may seem counterintuitive, given that the literature generally associates low levels of knowledge with lower vaccine acceptance [41]. One possible explanation lies in the fact that vaccine acceptance depends not only on detailed factual knowledge but also on factors such as trust in healthcare professionals and general attitudes toward vaccination. Studies have indicated that a healthcare professional’s recommendation is one of the most influential determinants of adherence to HPV vaccination, regardless of specific knowledge level [39]. Thus, participants who were unfamiliar with the precise vaccination schedule might still adopt a favorable attitude by relying on medical recommendations.

Similarly, a lack of awareness regarding the availability of the HPV vaccine at health centers emerged as a protective factor against vaccine refusal. This seemingly paradoxical result contrasts with data from the literature suggesting that access to information and the perception of service availability generally promote vaccination adherence [25]. Several hypotheses can be put forward to explain this association. Indeed, vaccine acceptance often relies more on relational and contextual factors, particularly trust in healthcare professionals and the strength of their recommendation, than on logistical knowledge of services. It has been widely demonstrated that a healthcare professional’s recommendation is one of the most influential factors in the decision to receive HPV vaccination [39], which could explain why participants unaware of vaccine availability nevertheless remain willing to receive it when offered. Similarly, partial awareness of vaccine availability could lead to misinterpretations or concerns about actual accessibility (cost, continuity of supply, quality of services), potentially increasing vaccine hesitancy. Thus, it is not so much the information itself, but how it is understood and integrated, that could influence attitudes.

Limitations

Our study has various limitations, the most prominent of which is the cross-sectional design. While this method is often appreciated for its speed, simplicity, and cost-effectiveness, it does not allow us to establish a strong causal relationship between exposure variables and rejection of HPV vaccination because all data are collected at a single time point. Furthermore, household income data should be interpreted with caution, as they may have been influenced by prevarication bias, with some participants potentially underreporting or misreporting their income. Sexual activity status was based solely on parental self-reporting and may be subject to misclassification bias due to the sensitive nature of the topic. The influence of media on parental perception was assessed globally, encompassing both traditional media and social media, but the specific impact of each type of media was not distinguished.

Conclusion

Vaccination against HPV remains an essential strategy for preventing cervical cancer. However, persistent vaccine refusal limits its impact. In our study, numerous risk factors were identified, including low trust in the healthcare system, fear related to vaccination, lack of knowledge of cervical cancer symptoms, reduced perception of the infection’s severity, failure to adhere to the previous vaccination schedule, low household income, and the absence of explicit recommendations from healthcare professionals. These findings highlight the need for targeted public health interventions to raise awareness about HPV and its vaccination, with particular emphasis on empowering healthcare professionals to actively provide clear guidance to parents. Communication strategies should be developed in a targeted and practical manner, including mandatory training for healthcare professionals and information sessions at health centers, community gathering places (e.g., women’s associations, mosques), and schools, tailored to the recommended vaccination ages and parents’ educational levels. Conversely, some protective factors, such as the perception of mild side effects, lack of knowledge about the exact number of doses required, and a lack of information on vaccine availability at the health center, were associated with vaccine acceptance by enabling parents to make a more autonomous and pragmatic decision. These results highlight the need for comprehensive strategies that include clear communication, culturally sensitive awareness campaigns, and active involvement of healthcare professionals. Promoting trust, addressing misconceptions, and supporting families in their decisions are essential to increasing HPV vaccine acceptance and safeguarding the sexual and reproductive health of women.

Supporting information