The Attitude‐Uptake Gap in HPV Vaccination Among Young Adults in Poland: Sociodemographic and Psychosocial Correlates

1. Introduction

Persistent infection with oncogenic human papillomavirus (HPV) types is a necessary cause of nearly all cervical cancers and contributes to cancers of the anus, penis, vulva, vagina, and oropharynx. Prophylactic HPV vaccination is therefore both an infection-prevention intervention and a primary cancer-prevention strategy. Population-level evidence has demonstrated substantial reductions in vaccine-type HPV infection, anogenital warts, high-grade cervical lesions, and, with sufficiently long follow-up, cervical cancer [1,2,3,4,5].

The World Health Organization identifies HPV vaccination as a central component of the global strategy for cervical cancer elimination [2]. Poland introduced a nationwide publicly funded HPV vaccination program in 2023 and subsequently broadened access. At present, girls and boys aged 9 to <14 years can receive Cervarix or Gardasil 9 free of charge in the universal program; Cervarix is fully reimbursed up to age 18 years, while adults older than 18 years are eligible for 50% reimbursement [6]. These changes improve access for children and adolescents but leave a catch-up population of young adults who must initiate vaccination independently and may still face financial, informational, and organizational barriers.

HPV vaccination behavior is unlikely to be explained by factual knowledge alone. Behavioral frameworks emphasize perceived susceptibility and benefits, confidence in vaccine safety and effectiveness, social norms, cues to action, and structural opportunity [7,8]. In young adulthood, these factors intersect with transition away from pediatric care, variable use of preventive services, uncertainty about catch-up vaccination, and the historically female-centered framing of HPV prevention. Polish studies have documented persistent knowledge gaps, gendered perceptions, and incomplete vaccination uptake even in educationally advantaged populations [9,10,11,12,13].

The present study aimed to quantify the attitude-uptake gap and identify sociodemographic and psychosocial correlates of self-reported HPV vaccination among young adults in Poland. We specifically examined whether vaccine trust, perceived personal threat, social exposure to vaccinated persons, sex, age, education, urbanicity, region, and health-related educational or occupational background were independently associated with uptake. We also characterized information sources, motivations, and barriers among unvaccinated respondents.

2. Materials and Methods

2.1. Study Design, Setting, and Participants

Before the main survey, the author-developed questionnaire underwent pilot testing in a group of 26 young adults, including 13 women and 13 men, within the same age range as the target study population. The pilot assessment was designed to evaluate the clarity, comprehensibility, relevance, wording, response options, and overall usability of the questionnaire. Participants were also asked to identify any ambiguous, difficult-to-understand, or potentially misleading items. To assess temporal stability, the same questionnaire was administered again to the same participants after a two-week interval. Comparison of responses between the two administrations showed 97% agreement, indicating very high test–retest stability of the questionnaire. No major problems regarding item comprehension or questionnaire structure were identified during the pilot phase, and the final version was subsequently used in the main study.

This cross-sectional study used an anonymous online questionnaire distributed through social media, principally Facebook. Data were collected from 12 January 2025 to 14 August 2026. Eligible participants were adults aged 18–45 years residing in Poland. Persons older than 45 years were excluded. Participation was voluntary and no directly identifying information was collected. The analytic dataset contained 334 complete responses.

Because recruitment was open through social media and the number of individuals who viewed the survey invitation was unknown, a conventional response rate could not be calculated. The dataset contained no identical full response profiles after timestamps were removed; however, because participation was anonymous, repeated participation by the same individual cannot be excluded with certainty. The sampling strategy was non-probability based and the sample should not be interpreted as nationally representative. Reporting was guided by the STROBE recommendations for cross-sectional studies [14].

2.2. Questionnaire and Variables

The author-developed questionnaire comprised 42 items covering sociodemographic characteristics, awareness and knowledge of HPV, information sources, perceived importance and risk, vaccination status, safety concerns, social and cultural influences, accessibility, and potential motivators. Several questions permitted multiple responses.

The primary outcome was self-reported receipt of HPV vaccination (yes/no). An exploratory objective knowledge score (0–5 points) was derived from five elements: awareness that HPV vaccines exist; correct recognition of sexual transmission without endorsement of respiratory transmission; recognition of cervical cancer as HPV-related; recognition of at least one non-cervical HPV-related condition (anal cancer, oropharyngeal cancer, or genital warts); and awareness that oncogenic HPV types may cause cancer. Vaccine trust was rated from 1 (no trust) to 5 (complete trust). Perceived personal threat from HPV was coded from 1 (definitely not) to 5 (definitely yes), with “do not know” placed at the midpoint for the primary exploratory model. Knowing a vaccinated person was coded yes versus no/do not know.

Education was grouped as secondary or lower, higher education ongoing, and higher education completed. Place of residence was categorized as rural, town <20,000 inhabitants, town/city 20,000–100,000, or city >100,000 for descriptive analyses and as urban versus rural for multivariable modeling. Region was analyzed as Greater Poland versus all other voivodeships because 134/334 participants (40.1%) lived in Greater Poland and the remaining individual regional strata were too small for stable adjusted estimates. Although the questionnaire underwent pilot testing and demonstrated high test–retest stability, no full psychometric validation of the derived composite knowledge score was performed.

2.3. Statistical Analysis

Categorical variables are presented as counts and percentages. Multiple-response questions were analyzed by counting each selected option independently; percentages may therefore sum to more than 100%. The objective knowledge score is summarized using mean and standard deviation (SD). Unadjusted differences in vaccination status across sociodemographic groups were examined with Pearson chi-square tests. For sex, the unadjusted comparison was restricted to women and men because only two respondents selected other/prefer not to say.

A multivariable binary logistic regression model was fitted with self-reported HPV vaccination as the dependent variable. Covariates were selected to represent demographic, structural, knowledge, confidence, and social-exposure domains: female sex, age category (dummy-coded with <20 years as reference), education, urban versus rural residence, Greater Poland versus other regions, medical/health-related study or work, objective knowledge score, vaccine trust, knowing a vaccinated person, and perceived personal HPV threat. The two respondents selecting other/prefer not to say for sex were excluded from this model, yielding N=332 and 112 vaccinated participants. Adjusted odds ratios (aORs), 95% confidence intervals (CIs), and two-sided p values are reported. Discrimination was summarized with the area under the receiver operating characteristic curve (AUC). No missing values were present for variables included in the model, and no imputation was performed.

As a sensitivity analysis, respondents answering “do not know” to personal threat were excluded and peer exposure was modeled as three categories (yes, no, do not know), rather than combining no and do not know. This analysis was used to assess whether the main findings depended on the ordinal placement of uncertainty responses. Statistical significance was defined as p<0.05. Analyses were performed using Python with SciPy and statsmodels.

2.4. Ethics

The study was approved by the Ethics Committee of Calisia University (decision No. 7/26). Electronic informed consent was obtained before survey completion. The study was conducted in accordance with the Declaration of Helsinki.

3. Results

3.1. Participant Characteristics and Vaccination Uptake

The final sample comprised 334 respondents: 253 women (75.7%), 79 men (23.7%), and 2 participants (0.6%) reporting other/prefer not to say. The largest age groups were 20–22 years (107/334; 32.0%) and >25 years (95/334; 28.4%). Overall, 208/334 (62.3%) were studying or working in a medical or health-related field, and 134/334 (40.1%) lived in Greater Poland.

HPV vaccination was reported by 113/334 respondents (33.8%). In unadjusted analyses, uptake differed by sex, age, education, place of residence, and medical/health-related study or work, but not by residence in Greater Poland versus other voivodeships (Table 1). Vaccination was reported by 39.9% of women versus 13.9% of men, and by 48.6% of participants aged 20–22 years compared with 17.9% of those aged >25 years.

3.2. Knowledge, Attitudes, Information Sources, and Barriers

Awareness that HPV vaccines exist was reported by 289/334 participants (86.5%), while 297/334 (88.9%) recognized that oncogenic HPV types may cause cancer. The objective knowledge score was 3.87±1.38 points, and 142/334 participants (42.5%) achieved the maximum score of 5.

Declarative support for vaccination was substantially higher than realized uptake: 300/334 (89.8%) considered HPV vaccination important, 300/334 (89.8%) supported free vaccination for young people, and 217/334 (65.0%) supported or rather supported school-based vaccination. At the same time, 276/334 (82.6%) considered HPV education in Poland insufficient, 224/334 (67.1%) perceived a social taboo around sexual health/HPV prevention, and 291/334 (87.1%) believed that negative social attitudes can influence individual prevention decisions (Table 2).

The most frequently reported information sources were media/internet/press (190/334; 56.9%), healthcare professionals (141/334; 42.2%), university classes (119/334; 35.6%), social campaigns (106/334; 31.7%), and family/friends (104/334; 31.1%). Protection against HPV-related cancers was the dominant stated motivation for vaccination (258/334; 77.2%). Among the 221 unvaccinated respondents, lack of a clinician recommendation (83/221; 37.6%) and cost (75/221; 33.9%) were the most common barriers, followed by insufficient knowledge (50/221; 22.6%), limited access (36/221; 16.3%), and concern about adverse effects (33/221; 14.9%).

3.3. Multivariable Correlates of HPV Vaccination

In the adjusted model (N=332), knowing a vaccinated person was the strongest correlate of vaccination (aOR 7.73, 95% CI 4.02–14.86; p<0.001). Each one-point increase in vaccine trust was associated with higher odds of vaccination (aOR 1.70, 95% CI 1.17–2.45; p=0.005). Female sex was also associated with uptake (aOR 2.49, 95% CI 1.10–5.65; p=0.029). Compared with participants aged <20 years, those aged 23–25 years (aOR 0.33, 95% CI 0.12–0.86; p=0.024) and >25 years (aOR 0.27, 95% CI 0.09–0.86; p=0.026) had lower odds of vaccination, while the 20–22-year group did not differ significantly from the reference group.

Objective knowledge, higher education, urban residence, Greater Poland residence, and medical/health-related study or work were not independently associated with vaccination. Perceived personal threat showed a borderline positive association (aOR 1.24 per category, 95% CI 0.99–1.54; p=0.061). Model AUC was 0.846 (Table 3). In the sensitivity analysis (N=294), the associations for vaccine trust (aOR 1.56, 95% CI 1.06–2.30) and knowing a vaccinated person (aOR 9.21, 95% CI 3.22–26.32) remained evident; estimates for sex and the oldest age category became less precise, supporting cautious interpretation of these demographic associations.

4. Discussion

This study identified a pronounced attitude-uptake gap among surveyed young adults in Poland. Nearly nine in ten respondents considered HPV vaccination important, yet only one in three reported having been vaccinated. The contrast is notable because the sample was educationally advantaged and included a high proportion of people studying or working in health-related fields. The findings therefore suggest that favorable general attitudes and factual awareness are not sufficient proxies for completed preventive behavior.

The strongest adjusted association was observed for knowing a vaccinated person. This finding is compatible with social-normalization and diffusion mechanisms: vaccination may become more cognitively available, acceptable, and practically understandable when peers disclose having received it. Qualitative research in young adults likewise indicates that interpersonal narratives and social context shape perceptions of feasibility and acceptability [8]. However, the magnitude of the observed association should not be interpreted causally. Vaccinated respondents may be more likely to discuss HPV prevention or belong to social networks with greater preventive-health engagement; reverse causation and network homophily are plausible explanations.

Vaccine trust remained independently associated with uptake, whereas the objective knowledge score did not. This distinction is important for intervention design. Factual knowledge addresses recognition of transmission, disease consequences, and vaccine availability, whereas confidence addresses whether the vaccine, recommending professionals, and institutions are perceived as sufficiently credible and safe. Reviews of HPV vaccination behavior consistently identify confidence, perceived benefits, provider endorsement, and social influences as recurring correlates of acceptance and uptake [15,16,17,18]. The present results argue against relying on information-only campaigns that assume a linear progression from knowledge to vaccination.

The lack of an independent association between objective knowledge and vaccination should not be interpreted as evidence that education is irrelevant. More than 40% of respondents reached the maximum score, limiting discriminatory capacity, and the score measured biomedical facts rather than procedural knowledge, decisional confidence, or ability to navigate vaccination services. Education may also act indirectly through perceived susceptibility and trust. Polish studies have similarly shown that knowledge and favorable attitudes can coexist with incomplete vaccination [9,10,11,12,13]. Effective communication should therefore connect accurate information with personalized cancer-prevention benefits and a clear route to vaccination.

Age showed a marked gradient in the primary model, with lower adjusted uptake among participants aged 23–25 and >25 years compared with those <20 years. This pattern is plausible in the context of rapid changes in Polish vaccination policy: younger respondents have had more opportunities to encounter adolescent vaccination initiatives, whereas older young adults were more likely to age out before universal publicly funded access was established. Nevertheless, attenuation of the oldest-age association in sensitivity analysis indicates that this finding should be interpreted as suggestive rather than definitive. The broad >25-year category, extending to age 45, also limits age-specific inference.

Female sex was associated with uptake in the primary model, but this estimate was imprecise and became non-significant in sensitivity analysis. Historical framing of HPV vaccination around cervical cancer may have increased awareness and recommendation among women while inadvertently signaling lower relevance to men. Polish representative research has described this “feminized vaccine” perception [10]. The current data support gender-neutral communication emphasizing prevention of cervical, anal, penile, and oropharyngeal cancers, while avoiding overinterpretation of sex differences in a sample containing relatively few men.

Two practical barriers deserve particular attention. Among unvaccinated respondents, lack of a clinician recommendation was the most frequently selected barrier, and only 42% of the whole sample identified healthcare professionals as an information source. Provider recommendation is one of the most consistently reported actionable factors in HPV vaccination [15,17]. A clear, routine, cancer-prevention recommendation coupled with an immediate vaccination option or direct referral may function as a stronger cue to action than a general suggestion that vaccination can be considered.

Cost was the second most frequent barrier. In Poland, adolescents benefit from broader public financing than adults: the universal program covers ages 9 to <14 years, Cervarix is fully reimbursed through age 18, and adults older than 18 years have 50% reimbursement [6]. The observed cost barrier therefore has a plausible structural basis and may contribute to the catch-up gap. Implementation reviews indicate that higher uptake is typically supported by multicomponent strategies combining provider recommendation, convenient delivery, reminders, and reduced financial barriers [16,17,18]. For young adults, universities, workplaces, pharmacies, and primary-care settings could provide lower-threshold opportunities for catch-up vaccination.

The central implication is that the gap between endorsement and uptake appears to arise from the interaction of confidence, social normalization, clinician cues, and access rather than from a simple deficit of HPV facts. This is consistent with a behavioral model in which distal factors such as age and gendered norms shape opportunity, intermediate factors such as trust and peer exposure shape motivation, and proximal factors such as recommendation, cost, and service convenience determine whether motivation is converted into vaccination. Prospective intervention studies are needed to test these mechanisms.

4.1. Strengths and Limitations

The study integrates sociodemographic characteristics, knowledge, confidence, perceived risk, social exposure, and access in a single analysis and includes respondents from all 16 Polish voivodeships. The expanded dataset permitted age to be modeled categorically rather than as a linear trend across unequal age intervals. A sensitivity analysis was also used to examine the treatment of uncertainty responses.

Several limitations materially constrain inference. First, convenience recruitment through social media, overrepresentation of women, and the high proportion of respondents connected with health-related study or work limit external validity; the observed 33.8% uptake must not be interpreted as a national coverage estimate. Second, vaccination status was self-reported and the questionnaire did not reliably distinguish series initiation from completion or identify vaccine product and dose history. Third, the cross-sectional design precludes causal interpretation and allows reverse causation, particularly for social exposure, trust, and perceived risk. Fourth, the questionnaire and composite knowledge score were not formally validated. Fifth, age was collected in broad categories and the >25-year group spanned a wide age range. Sixth, income, sexual history, parental attitudes, and the timing and strength of clinician recommendation were not captured in a form suitable for the main model. Seventh, anonymous recruitment prevented definitive verification that each respondent participated only once. Finally, the multivariable model is exploratory and the number of events limited assessment of interactions or more complex non-linear effects.

5. Conclusions

Among surveyed young adults in Poland, HPV vaccination uptake was substantially lower than declared support for vaccination. Social exposure to vaccinated persons and vaccine trust showed the most consistent adjusted associations with uptake, while objective knowledge and health-related educational or occupational background were not independently associated. Lack of clinician recommendation and cost remained prominent barriers. These findings support catch-up strategies that combine accurate information with strong clinician recommendation, gender-neutral cancer-prevention communication, social normalization, and affordable, convenient access. Because the study used non-probability sampling and a cross-sectional design, the associations should be regarded as hypothesis-generating and confirmed in representative or prospective studies.