Willingness Outpaces Action: Parental HPV Vaccine Beliefs Across the Middle East

A systematic review of 33 studies covering 18,170 parents across the Middle East has found a striking disconnect between what parents say and what they do when it comes to protecting their children against human papillomavirus, the virus responsible for the vast majority of cervical cancer cases. Across the region, between 58 and 94.6 percent of surveyed parents expressed willingness or intention to vaccinate their children, yet where actual uptake was documented, the figures collapsed dramatically. In the United Arab Emirates, only 9.8 percent of mothers reported that their daughters had actually received the vaccine, and in one Turkish sample of 1,000 parents, just two children had been vaccinated. The review, published in Frontiers in Public Health and led by Ahmad Abuzoor and Md. Shafiqur Rahman Jabin of the University of Bradford with Cor Jonker, is the first to synthesize evidence specifically from parents living within Middle Eastern countries rather than from diaspora communities, and it organizes its findings through the health belief model, a long-standing psychological framework for understanding why people adopt or reject preventive health behaviors.

The research team followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching PubMed/MEDLINE, Web of Science, CINAHL, and Google Scholar for studies published between January 2006, when the first HPV vaccine was licensed, and May 2025. From 381 reports identified through electronic databases and six more through snowballing, the reviewers screened 330 studies after removing duplicates, excluded 249 on title and abstract review, and assessed 81 full-text articles against strict inclusion criteria requiring that participants be parents or guardians of children under 18 residing in one of 17 Middle Eastern countries. Thirty-three studies survived: 32 quantitative cross-sectional surveys and a single qualitative study using focus groups and semi-structured interviews. Two independent reviewers appraised methodological quality using the Joanna Briggs Institute checklist for cross-sectional research and the Critical Appraisal Skills Programme checklist for the qualitative study, and no study was excluded on quality grounds. The protocol was registered with PROSPERO under registration number CRD42025645551.

The public health stakes are considerable. HPV is the most common sexually transmitted infection in women worldwide and the leading cause of cervical and anogenital cancers. Roughly 80 percent of sexually active individuals become infected at some point, and while most infections are asymptomatic and resolve within a year, the two most prevalent strains, HPV 16 and 18, account for nearly 70 percent of HPV-related cancers. Approved vaccine formulations include bivalent products protecting against two strains, quadrivalent vaccines covering four strains that together account for about 90 percent of cervical cancer cases, and one nonavalent vaccine protecting against nine. Vaccination before the first sexual activity remains the gold standard for primary prevention. Yet within the Middle East, only two countries, the United Arab Emirates and Saudi Arabia, have effectively introduced the HPV vaccine through national immunization programs, a policy divide that shapes much of the review’s findings.

Knowledge deficits emerged as the most pervasive pattern. In one Saudi study of 500 parents, only 11 percent had heard of HPV, and 96.8 percent were unaware of the vaccine. A Turkish survey found that 71.5 percent of mothers had never heard of HPV vaccination at all. In Cyprus, where 227 parents were interviewed, higher education, female gender, age of 35 or above, and employment all predicted better knowledge. Mothers consistently outperformed fathers in awareness across multiple countries, a difference moderated by education, income, and employment status. Media outlets, particularly television and the internet, served as the dominant information source where healthcare providers had not filled the gap; in one Syrian study, only 18 percent of mothers knew about HPV, and half of those had learned of it from television.

The review’s application of the health belief model required careful interpretive work, because most included studies were not designed to measure the model’s constructs directly. The authors distinguish repeatedly between genuine perceived susceptibility, a parent’s subjective belief about their child’s risk, and mere factual awareness of HPV. In Israel, 47.6 percent of parents believed their children could contract HPV at some point in their lives, a genuine risk perception. Elsewhere, low perceived susceptibility dominated: parents assumed their children would not engage in premarital sex, trusted that their spouses could not transmit sexually transmitted infections, or, in one striking finding from Saudi Arabia, saw no point in vaccination or screening because they believed cervical cancer was untreatable. The finding most closely approximating a true severity effect came from a Saudi study in which parents who understood the link between HPV and cervical cancer were 1.794 times more likely to accept the vaccine, precisely the mechanism the health belief model predicts. By contrast, 76 percent of Iranian parents in one study were unaware of the severity of HPV infection.

Perceived barriers proved the most heavily documented construct. Safety concerns appeared repeatedly: in Oman, only 37.4 percent of 1,403 parents believed the vaccine was safe, 71.5 percent worried about complications, and 84.6 percent wanted confirmation that it would actually prevent infection. In Bahrain, 83.6 percent of parents required reassurance about safety before consenting. Cost constituted a second major barrier, cited by 57 percent of Turkish parents and 65.5 percent of Jordanian parents, with many participants stating they would vaccinate if the vaccine were free. Religious and cultural sensitivities formed a third cluster, with some parents worrying that vaccination might implicitly condone premarital sexual activity. Beyond the individual-level constructs of the health belief model, the review identified structural factors it argues the model was never designed to capture, most notably male guardianship, reported across multiple studies, in which mothers’ vaccination decisions were contingent on or constrained by male partner approval.

Cues to action, external prompts that trigger vaccination behavior, received the strongest and most consistent support of any construct in the review. Physician recommendation emerged as the single most powerful lever: 62.9 percent of Saudi parents in one study said they would vaccinate their children if their physician recommended it, and across countries the absence of provider advice was the most frequently cited reason for non-vaccination. Ministry of Health endorsement functioned as a complementary cue, with studies from Saudi Arabia and the UAE, the two countries with national programs, consistently reporting that official approval and school-based delivery increased perceived legitimacy and reduced hesitancy. The authors draw an important analytical distinction here: educational campaigns that build knowledge operate on susceptibility, severity, and benefits, whereas direct prompts such as a doctor’s explicit recommendation or a school vaccination notice can initiate action regardless of prior knowledge level.

Self-efficacy, defined as a parent’s confidence in their ability to arrange, obtain, and complete the vaccination series, was the least directly evidenced construct. After re-examining each study’s measurement approach, the reviewers found direct support in only two studies: one in Israel, where self-efficacy was positively associated with maternal acceptance of the vaccine, and one in Saudi Arabia, where educated parents demonstrated greater confidence in vaccine decision-making. Several findings initially classified under this construct were reclassified on closer inspection, including the confidence of healthcare professional parents, which the reviewers characterized as an occupational knowledge effect rather than a true self-efficacy measure. The scarcity of direct evidence is itself a meaningful result, the authors argue, because in contexts where cost, availability, and guardianship constraints limit parents’ ability to act on their intentions, self-efficacy may matter more than the current literature captures.

The review’s conclusions carry important caveats. Thirty-two of the 33 studies used cross-sectional designs, meaning the findings identify correlates of vaccination rather than causal effects, and the health belief model functions here as an interpretive lens rather than a validated predictive tool. The restriction to English-language publications may underrepresent research from Iran, Turkey, and other countries publishing in national-language journals, and with 13 of 33 studies conducted in Saudi Arabia, the evidence base is heavily weighted toward Gulf contexts. Generalizability was judged questionable in roughly one-third of studies, and confounding was inadequately addressed in six. Nevertheless, the country-level pattern is instructive: Saudi Arabia and the UAE, with national programs, showed higher awareness and stronger institutional cues, while Lebanon, Turkey, Jordan, and Iran, without such programs, more consistently reported cost and access as dominant obstacles. The authors conclude that closing the region’s willingness-uptake gap will require interventions that address not only knowledge and attitudes but also structural barriers, through financial coverage, embedding vaccination in national immunization schedules, engaging schools and primary care providers, and framing communication around religious permissibility and family protection rather than individual risk alone.

Subject of Research: Parental health beliefs and HPV vaccine acceptance in Middle Eastern countries analyzed through the health belief model

Article Title: Health beliefs and parental responses to human papillomavirus vaccination in the Middle East: a theory-informed narrative synthesis guided by the health belief model

Article References: Abuzoor, A., Jabin, M. S. R., & Jonker, C. (2026). Health beliefs and parental responses to human papillomavirus vaccination in the Middle East: a theory-informed narrative synthesis guided by the health belief model. Frontiers in Public Health, 14, Article 1853938. https://doi.org/10.3389/fpubh.2026.1853938

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1853938

Keywords: HPV vaccination, health belief model, Middle East, parental attitudes, vaccine hesitancy, cervical cancer, systematic review, vaccine uptake, health policy, public health, cues to action, self-efficacy