Determinants of HPV Vaccination Among Women in the United States: A Multilevel Socio-Ecological Analysis

Background: Cervical cancer remains a major public health concern in the United States despite being largely preventable through human papillomavirus (HPV) vaccination. Although HPV vaccines are highly effective and have led to substantial declines in HPV infections and precancerous lesions, national coverage continues to fall short of targets, with persistent disparities across socioeconomic, racial/ethnic, and insurance groups.

Objectives: To identify multilevel barriers to HPV vaccination (individual, interpersonal, and policy levels) among U.S. women, examining variation by education, race/ethnicity, income, and insurance coverage, and assessing how these factors collectively contribute to inequities in HPV vaccine uptake.

Methodology: This study applied the Socio-Ecological Model (SEM) to examine determinants of HPV vaccination using 2020–2023 Behavioral Risk Factor Surveillance System (BRFSS) data. Differences in vaccine uptake were assessed across individual-level (education), interpersonal/community-level (race and ethnicity), and structural-level (income and insurance) factors. Due to substantial missingness in the HPV vaccination module, analyses used unweighted valid responses, which may limit population generalizability.

Results: Analytic samples ranged from 5,557 to 6,435 women with complete HPV vaccination data. Clear disparities were evident across all determinants. Vaccination prevalence increased with higher income and educational attainment, while uninsured women had the lowest coverage. Racial and ethnic inequities were also observed: Hispanic and Black women reported lower vaccination rates compared with White and Asian women. These patterns reflect the combined influence of socioeconomic disadvantage, limited healthcare access, and systemic inequities on HPV vaccination uptake.

Conclusion: Findings underscore the need for multilevel strategies-such as expanded insurance coverage, culturally tailored education, and strengthened provider recommendations-to improve vaccination equity. Addressing individual, interpersonal, and structural barriers is essential to reducing the long-term burden of HPV-associated cancers and advancing cervical cancer prevention nationwide.