Theoretical foundations of the study

At the conceptual level, the BeSD framework is inherently aligned with the TPB. The TPB is the best-known socio-cognitive model used in psycho-social research to predict health-related behaviors and intentions [19]. Evidence from recent research also supports the use of TPB, which is widely employed to understand COVID-19 vaccination behavior [20].

Behavioral and social drivers of vaccine uptake in the cultural and geographic context in Pakistan’s can be explained in conjunction with the theory of planned behavior. Despite extensive research on the behavioral drivers of vaccination, the theory of behavior change has been applied only to a limited extent in the Pakistani context. Existing theories have not been adapted to inform an in-depth exploration of the behavioral and social drivers of vaccine uptake in Pakistan. In the absence of an existing theory to explain the social drivers of vaccination uptake, researchers have been unable to identify and focus efforts on developing measures of the social locus of control that underlie latent demand for vaccination.

BeSD domains align closely with TPB’s constructs: Thinking and Feeling correspond to Attitudes, Social Processes to Subjective Norms, and Practical Issues to Perceived Behavioral Control, while Motivation reflects Intention formation, the central construct in TPB. This integration provides robust evidence for understanding why individuals intend or fail to engage in preventive behavior, and for explaining the phenomena underlying hesitancy.

According to the Theory of Planned Activity, Attitudes towards behavior are influenced by underlying assumptions about the beliefs and values assigned to expected results. The BeSD framework reflects this construct through the Thinking and Feeling domain, which assesses perceived vaccine safety, disease risk and confidence in vaccine safety and efficacy. However, in the context of Pakistan, the culturally mediated attitudes influence the Thinking and Feeling domain of BeSD; these attitudes are inadequately captured by this domain, as they are treated as individual cognitive appraisals. The theory-driven adaptation amplifies the attitudinal domain by implicitly incorporating cultural nuances that reflect how HPV vaccination uptake is determined collectively as a cultural process influenced by gendered, patriarchal and hierarchical authorities rather than personally appraised individual decision.

In TPB, the perceived social pressure from significant others refers to Subjective Norms, which corresponds to Social Processes in the BeSD framework. This domain captures the influence of family norms, peer influence on approval, and disapproval of vaccination. However, in the context of Pakistan, the sociocultural influence extends beyond perceived approval and operates through deeply rooted cultural influences that function through gendered, patriarchal and hierarchical dynamics influencing the power dynamics for vaccine decision making. Vaccine uptake is strongly influenced by voices that hold moral legitimacy and regulate compliance and social sanctions.

Within TPB, Perceived Behavioral Control refers to the ease or difficulty of performing a behavior. The BeSD framework operates through a closely related construct, namely Practical Issues, which captures logistical barriers. However, in the context of Pakistan, structural access is deeply entangled with gendered mobility restrictions, limited female autonomy, economic dependencies, permission from male guardians, and even the gender of the vaccinator also influences vaccine decision-making.

The adaptation of the WHO Behavior Social Drivers’ framework in this study is theoretically aligned with the TPB, which postulates that health-related decision making is determined by behavior intentions which are shaped by Subjective Norms, Attitudes, and Perceived Behavior Control. Therefore, Cultural Integration serves as a cross-cutting analytical domain that shapes attitude (Thinking & Feeling), regulates social processes and norms (Social Processes) and logistic issues (Practical Issues) that limit translation of motivation into vaccine uptake.

Cultural Integration clarifies what is otherwise under-specified and implicit, instead of just replicating the existing BeSD domain. It provides clear, actionable insights to provide evidence-based strategies for culturally sensitive interventions to enhance uptake of the HPV vaccine in Pakistan’s sociocultural context, where cultural legitimacy is a prerequisite for vaccine acceptance. Therefore, Cultural Integration serves as a unique meta-level construct that captures the cultural, moral, and religious conditions that shape attitudes/Thinking and Feeling, subjective norms/Social Processes, and perceived behaviors/Practical Issues that influence Motivation.

Study design and setting

The study employed descriptive qualitative design and was conducted from the end of February 2025 to August 2025 in District Rawalpindi and Islamabad Capital Territory in Northern Punjab and District Bahawalpur in Southern Punjab. On February 24th, 2025, the Ethical Review Board (ERB) of Health Services Academy granted ethical approval under IRB approval number (00015/HAS/PhD 2022). The study was conducted after taking informed written consent and in accordance with the policies and procedures established by the Graduate Research Management Council (GRMC) of Health Services Academy HSA Research and Ethical Committee and it adhered to the ethical guidelines outlined in the World Medical Association’s Declaration of Helsinki as revised in 2013 [21]. Detailed steps of the whole methodology are shown in Fig 1.

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Fig 1. Methodological framework for a culturally adapted HPV vaccine acceptance study in Pakistan (Step 1: study design & setting, Step 2: sampling & recruitment, Step 3: data collection Tools, Step 4: analysis & validation, Step 5: final outcome).

https://doi.org/10.1371/journal.pone.0350162.g001

Selection and description of participants

The purposive sampling technique was employed, considering that the study focuses on understanding the social and behavioral drivers using the WHO BeSD framework. This technique allows the purposeful selection of all relevant stakeholders, enabling in-depth exploration of factors influencing vaccine uptake and informing culturally relevant strategies for vaccine rollout. Study participants were recruited from District Rawalpindi and the Islamabad Capital Territory, in Northern Punjab, and from District Bahawalpur, in Southern Punjab. Prior to data collection, the participants were briefed on the study’s goals and objectives, and rapport was established. Data was collected after taking informed written consent. Participants who provided consent were recruited for the study. Participants included were adolescent girls (9–14 years), Parents/guardians of adolescent girls, Healthcare providers (vaccination staff, gynecologist, pediatrician, nurses, physicians), community workers (LHWs, LHSs & LHVs), teachers and school administrators, community leaders, and religious scholars from the Ministry of Religious Affairs. The districts were selected with a specific purpose to demonstrate differences in culture and health services in Punjab. Islamabad is the Capital Territory, and Rawalpindi comprises towns and urban areas with greater level of exposure to vaccination programs health services. Bahawalpur is a rural, more conservative place with its cultural regulations and more difficult accessibility to services. The reason behind this decision is to determine how the behavior of people, society and culture contributes to HPV vaccination in different environments, but not merely to obtain a statistically representative sample.

The selection of stakeholders was not random, as they are the ones who make HPV vaccination decisions and deliver it. The inclusion of diverse segments of society provided the option to obtain information on family, community, and health systems, which directly influence decisions about implementation and acceptance of the vaccine. Maximum variation sampling, rich contextual description, and stakeholder involvement in geographic, socioeconomic, and institutional settings were used to address transferability. These characteristics enable readers to determine the relevance of the findings in other LMICs and socio-culturally similar settings.

During the data collection period, HPV vaccination was not included in Pakistan’s national immunization program; therefore, none of the study participants (adolescent girls, parents, and community members) had been vaccinated against HPV. Thus, participants’ views are based on expected acceptance, conditional acceptance, or reluctance toward a new vaccine, instead of the experience related to the previous uptake.

Data collection tool

Data were collected using semi-structured interview guides based on the WHO BeSD qualitative interview guides [10]. Original BeSD qualitative interview guides were used for data collection after adaptation. There are 4 qualitative interview guides for caregivers, health workers, community influencers, and program managers (attached as S1 File). The caregivers (parents/guardians) guide explored Thinking and Feeling (perceived safety, fertility concerns, trust), Social Processes (family and community influence), Motivation (intention to vaccinate, response to mandates), and Practical Issues (access, cost, service preferences), with further probes to elicit culturally mediated decision-making and paternal authority. The healthcare provider discussed Social Processes (provider-community trust), Motivation (perceived responsibility to recommend HPV vaccination), and Practical Issues (delivery feasibility, staffing, outreach), and reflections on cultural and gender-related barriers experienced in practice. The community influencer and program manager guide (teachers, religious leaders, policymakers) stressed Social Processes and Motivation at the community and system levels, which include normative influence, legitimacy of vaccination, and implementation constraints, and also obtaining views on the widespread cultural norms influencing vaccine acceptance.

The core constructs of the BeSD framework were retained across all guides, and probes were tailored to stakeholder roles and local sensitivities to enable a systematic, yet flexible exploration of behavioral, social, and cultural motivations related to HPV vaccination. Interview guides were adapted to the local context following these steps:

1. Familiarization with original BeSD

The first step is to familiarize oneself with the original BeSD tools. This step involves detailed reviews conducted by a team of experts comprising researchers, Public Health experts, social sciences experts, behavioral scientists, anthropologists, and psychologists. During this stage, the following steps were involved.

• Each probe, item, and prompt was thoroughly examined for its conceptual intent.
• Potential areas of cultural disparity, like sensitive topics and terminology, were highlighted for modification.

2. Contextual needs assessment

Before making modifications, a desk review of the literature was conducted to identify potential barriers and facilitators to the HPV vaccine in the context of religious, sociocultural, gendered, and complex hierarchical dynamics.

This process helped to identify topics requiring modification in terms of rephrasing and contextual probing to enhance cultural relevance. Input from anthropologists, social scientists, and public health specialists familiar with the sociocultural and religious dynamics of the Pakistani setting guided the adaptation.

Data collection and measurements

Data were collected through four focus group discussions and 45 in-depth interviews, each lasting 30–45 minutes, until data saturation was achieved. Interviews and Focus Group Discussions were conducted by KN, SM, and MN in the workplace. Participants were approached through personal contacts, emails, and phone calls. All interviews and focus group discussions were conducted face-to-face, except for three interviews with health system stakeholders, which were conducted virtually via Zoom. All interviews were conducted after informed consent was taken. There were no refusals or drop-outs. Anonymity and confidentiality were maintained throughout the process.

Focus group discussions (FGDs)

• Number and composition: A total of four focus group discussion sessions were conducted. The first session was with mothers, the second with adolescent girls, the third with schoolteachers and staff, and the fourth session with program managers
• Purpose: FGDs were conducted to unfold shared norms, beliefs, identify behavioral and social factors, and examine culturally embedded perceptions influencing the vaccine uptake.
• Moderation: Each session was moderated by a trained facilitator with experience in qualitative research, well-versed in the local dialect, and fluent in Urdu. A scribe took detailed field notes, maintained group dynamics, and documented non-verbal cues. Each focus group session included 8–10 participants.

In-depth interviews (IDIs)

• Number and participants: A total of 45 IDIs were conducted with diverse participants, including adolescent girls, their parents, LHWs, LHVs, and LHSs, healthcare providers, doctors, nurses, immunization staff, vaccinators, representatives from GAVI, WHO, and UNICEF, religious leaders, teachers, and school staff.
• Purpose: IDIs allowed probing of socio-culturally sensitive issues, exploration of personal beliefs, gendered norms, patriarchal influences, and in-depth understanding of culturally embedded facilitators and barriers to vaccination.

Data analysis

We applied Braun and Clarke’s six-step thematic analysis using both inductive and deductive coding approaches in NVivo [22]. Deductive codes were aligned to the BeSD framework; inductive coding identified new constructs, leading to an additional “Cultural Integration” domain.

Using Braun and Clarke’s six-step thematic analysis approach, transcripts were independently coded by researchers KN, SM, and MN. A preliminary coding scheme was established through team discussions. The measure of coder agreement was the presence of regular debriefing meetings, during which codes and emergent themes were compared. Differences were resolved by consensus, with reference to the initial transcripts to ensure conformity with the participants’ meanings.

For translation, verbatim English interviews were transcribed into Urdu, and then bilingual researchers translated the material back into English. To provide an accurate and conceptually equivalent back-check, a second bilingual team member was used, who read and discussed the chosen transcripts with any discrepancies identified and resolved as a group. This allowed us to retain semantic as well as contextual meaning.

All interviews were audio-taped and recorded. Field Notes were also taken during and after the interviews and the focus group discussion. During analysis, an additional theme emerged inductively from participants’ narratives, capturing the community norms, patriarchal influence, gendered norms, social values, and religious beliefs.

The complete de-identified interview transcripts and coding tree have been uploaded as S2 and S3 Files.

Thematic analysis

At the beginning, four domains of the WHO BeSD, namely Thinking and Feeling, Social Processes, Motivation, and Practical Issues, were considered as a priori analytic scaffolds. In the first coding stage, all transcripts were initially looked at deductively to find out whether participants’ narratives could be meaningfully and conceptually placed within the established BeSD constructs and aligned with the corresponding TPB constructs. Coding decisions were determined by the theoretical purpose of each domain, not just by superficial thematic similarity. The use of this methodology made it clear that new findings are analyzed against the background of the original logic of behavior of the respective theoretical construct (e.g., cognition, social influence, intention, or access), and it avoided premature domain fragmentation.

Participant descriptions that could not be accommodated conceptually within any of the four domains, without disturbing their sense or overloading the definition of the domain, were designated to be inductively analyzed. This analytical field of study ensured that the original domains were not eroded by unjustified broadening.

After completing all deductive coding, the research team conducted a cross-domain analytical review to identify patterns in the data that explain domain insufficiency. For example, themes that did not logically fit into attitudes (Thinking and Feeling), subjective norms (Social Processes), intention (Motivation), or perceived behavioral control (Practical Issues) were considered conceptually non-aligned. Constructs that co-influenced beliefs, motivation, and behavior, reflecting an organizing role, but not falling under a single domain role, were believed to be cross-domain influence. The element based on long-standing sociocultural structures (such as patriarchy, religious authority, gender norms) but not on personal perceptions or situational constraints was counted as structural embeddedness. Themes that met the three criteria above were analyzed separately by contextual modifier within the existing domains.

Conceptual framework

Item mapping and construct derivation

For each domain, the generation of new items and their mapping into relevant constructs were performed in the following steps:

Cultural integration as an emergent cross-cutting domain

Using the above criteria, a consistent group of items was identified that runs throughout the stakeholder groups, such as a) household decision-making authority, which is patriarchal b) moral framing and religious legitimacy of vaccination, c) cultural silence on sexuality and reproductive health, and d) gendered standards of communication, consent, and service provision.

Analytically, this construct served as a fundamental determinant, acting as a bridge explaining how the four original BeSD domains integrate with the TPB construct in the Pakistani setting. For instance, cultural norms not only regulated social processes but also defined how individuals could engage socially. They did not merely affect motivation; they also described whether the motivation was socially allowed. In line with this, enlisting these constructs within the already established domains would have made their systemic contribution and explanatory value less clear.

Therefore, a separate domain, “Cultural Integration,” was introduced. It was thus not meant as an addition but rather as a structural extension required to maintain theoretical consistency while remaining contextually valid.

During the last stage of synthesis, all domains, both original and emergent, were mutually cross-referenced with participant quotations, derived constructs and suggested survey items. This step ensured conceptual consistency of the WHO BeSD framework with TPB, definite analytic demarcations between domains, and availability of raw qualitative data to the framework elements. The resulting BeSD-HPV model is therefore a culturally specific adaptation which retains the integrity of the original BeSD model but empirically generalizes it to incorporate sociocultural determinants that are fundamentally located in Pakistan and other such situations.

The coding tree is attached as a S3 File.

Integrative framework adaptation

By mapping qualitative findings onto TPB constructs and BeSD domains, the cultural adaptation process ensured conceptual coherence between empirical data and theory. In instances where culturally embedded determinants such as social authority and subjective norms were not fully captured by the original BeSD framework, behavior is shaped by collective, patriarchal, social, and religious norms. Fig 2 shows the conceptual framework for qualitative exploration and cultural adaptation

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Fig 2. Conceptual framework for the qualitative exploration and cultural adaptation of the BeSD-HPV tool.

The figure illustrates five phases: tool adaptation and expert review; purposive recruitment; qualitative data collection (FGDs and IDIs); thematic analysis and mapping to WHO BeSD domains; and linguistic adaptation. The process yielded a culturally adapted BeSD-HPV tool with five domains, including Cultural Integration.

https://doi.org/10.1371/journal.pone.0350162.g002

The final 70-item tool was developed through item mapping, construct derivation, and rationale; the corresponding Urdu item is attached as S4 File.

Theoretical and methodological implications

Aligning TPB with BeSD during adaptation enhances the theoretical validity of the adapted framework by establishing that cultural determinants correspond to deeply ingrained behavioral phenomena. This integration positions the adapted BeSD framework not only as a descriptive tool but also as a theoretically grounded model for developing culturally responsive HPV vaccination interventions in Pakistan and comparable sociocultural settings.

The construction of the culturally adapted BeSD-HPV framework was not developed through a superficial exploration or de novo structure-building method, but through a theory-preserving, step-by-step analytic synthesis method. The analytic procedure was also designed to maintain the conceptual soundness of the original WHO BeSD framework and to empirically test its suitability in the Pakistani sociocultural environment.

5. Finalization and documentation

The final adapted preliminary version of BeSD HPV comprised:

• Items aligned to construct mapping to Original WHO BeSD domains in alignment with TPB’s construct (Thinking and Feeling (Attitudes), Social Processes (Subjective Norms), Motivation (Intention), Practical Issues (Perceived Behavior Control)
• New Items aligned to construct mapping to the newly added domain “Cultural Integration

To ensure transparency and reproducibility, all adaptation decisions, rationale, and justifications were documented.

Supplementary Tables (S1–S5 Tables) mapped each survey item within each BeSD domain, which were then systematically mapped to specific constructs based on subthemes that emerged during thematic analysis. Detailed item mapping for each domain is provided in Supplementary Tables (S1–S5 Tables).

Each construct is then aligned with the survey item, linking it to key quotes from participants and providing a detailed rationale. Finally, linguistic adaptation is ensured by translating it into Urdu with the help of a bilingual language expert. able cell colors are aligned with WHO color coding and indicative of the respective domains (Thinking and Feeling, Social Processes, Motivation, Practical Issues, and emergent new theme, Cultural Integration. Fig 3 illustrates the theoretical basis for aligning BeSD domains with TPB constructs.

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Fig 3. Cultural adaptation process aligning BeSD domains with the Theory of Planned Behavior (TPB).

This framework illustrates how TPB constructs correspond to BeSD domains: Attitude aligns with Thinking and Feeling; Subjective Norms with Social Processes; Perceived Behavioral Control with Practical Issues; and Intention with Motivation. Cultural Integration functions as a cross-cutting domain shaping all components.

https://doi.org/10.1371/journal.pone.0350162.g003

To make the study results rigorous and credible, the research team was actively involved in the process of reflexivity and used the Four-Dimensions Criteria of credibility, transferability, dependability, and confirmability developed by Lincoln and Guba [23].

Credibility was facilitated through FGDs, intensive interviews, and data triangulation. The deep insight was possible with the use of both IDIs and FGDs. During interviews, member checking was an informal process used to verify participants’ statements and clarify their meanings. Moreover, the interviewers were trained in the qualitative approach and practiced cultural sensitivity to foster an atmosphere of openness and trust.

The transferability was supported by the intentional selection of a diverse sample that consisted of participants with different educational backgrounds, socioeconomic statuses, and geographic locations. The participants’ responses and the settings within local health services were also described in detail and in context, which would allow readers and future researchers to assess the generalizability of the findings to other settings.

The question of dependability was addressed through an open, logical approach to data collection and analysis. Thematic refinement included an audit trail tracked through elements such as interview guides, transcription protocols, coding structures, and decision logs. To maintain analytic consistency, the research team held debriefing sessions to discuss new trends and address inconsistencies.

The confirmability was ensured by being in a reflexive position throughout the study. The authors prepared subjective reflections and subjective memorandums, which they recorded in order to bracket their own assumptions and minimize bias. Peer debriefing and team discussions also helped to suggest an impartial interpretation. The research ensured a strong relationship between the data and its interpretation by grounding the themes in rich, participant-derived quotations, and the results correlated with the BeSD framework. Collectively, these strategies enhanced the study’s methodological rigor and reinforced the authenticity, reliability, and applicability of the findings on HPV vaccine hesitancy and acceptance within the Pakistani context. This study was reported in accordance with the COREQ (Consolidated Criteria for Reporting Qualitative Research) reporting guidelines [24].

Strengths and limitations

The study draws strength from the inclusion of diverse stakeholder perspectives including adolescents, parents, healthcare providers, teachers, and community and religious leaders, ensuring a holistic understanding of HPV vaccine uptake. The use of the WHO BeSD framework further enhances methodological rigor and aligns the study with global standards, while the integration of cultural constructs adds contextual relevance and practical applicability of the findings.

The present study has several limitations that must be acknowledged. Firstly, HPV vaccination status was not considered in sampling or analysis because, at the start of the study, HPV vaccination was not included in the Pakistani government’s vaccination schedule. Secondly, the potential for social desirability bias during interviews, particularly when addressing sensitive cultural and religious issues. It is quite possible that respondents may have provided answers acceptable within society rather than expressing their full reservations. Thirdly, as the study was conducted in only two districts of Punjab Province, the perceptions captured may not fully represent the views of participants from other provinces of Pakistan, which have different sociocultural and ethnic backgrounds and health-system environments. Fourthly, the present study relied on purposive sampling, which is appropriate for in-depth qualitative investigation and offers an opportunity to include essential stakeholders, but it limits representativeness and does not allow generalization of the results to the broader population.

Despite these shortcomings, the research provides valuable, context-based insights that are invaluable for culturally adapting the BeSD framework and for informing HPV vaccine introduction efforts in similar settings.