Evolving Roles in Decision-Making About Human Papillomavirus Vaccination Among Middle School Girls in Yinzhou of Ningbo, Eastern China: A Qualitative Study With a Focus on the Educational Sector as an Influential Player

Human papillomavirus (HPV) vaccination is endorsed by the World Health Organization for cervical cancer prevention, but it is not part of China's national immunization program. This study explores the roles of various key interest holders in HPV vaccination decisions, focusing on a local pilot program in Yinzhou, Ningbo, eastern China, targeting first-year middle school girls. Data were collected from October 18 to November 14, 2023, using literature and policy reviews and in-depth interviews and focus group discussions with local key interest holders. Thematic analysis was performed using a Social Ecological Model (SEM) to identify determinants influencing HPV vaccination decisions across five levels. A total of 55 participants were interviewed. The results showed that the educational sector worked closely with health authorities in the program's design and implementation. Middle schools and teachers played a significant role in influencing both parents and students, despite limited direct benefits. At the interpersonal level, educators disseminated vaccine-related information and guided parents and students. At the organizational level, the collaboration between the educational and health sectors, as well as between teachers and health care professionals, strongly influenced decision-making. At the community level, health education provided to teachers extended to parents and students, enhancing awareness and support. The findings highlight the crucial role of educational sectors in promoting HPV vaccination and emphasize the importance of positive support from schools and effective partnerships with other key stakeholders. These insights may be applicable to other socioeconomically advanced regions in China considering similar HPV vaccination initiatives.