Discussion
higher-deprivation
In this cross-sectional study among adolescents aged 13–15 years in France, we identified several socio-educational inequalities in HPV vaccine awareness, uptake and vaccination intention, relating to lower parental education, languages spoken at home and higher local deprivation levels. Recent GP visits mitigated inequalities in vaccine uptake and school lessons on vaccination mitigated inequalities in vaccination intention among unvaccinated adolescents. Surprisingly, for unvaccinated adolescents, we found disparities in vaccination intention by parental education specifically among those who reported a recent GP visit.The use of other languages than French at home was associated with lower HPV vaccine awareness, uptake and vaccination intention, irrespective of parental education level. Following French research regulations on good ethical practice, we did not collect information on family origin, ethnicity or religious background, and consequently, we cannot fully interpret this disparity. However, given the independence from parental education level, the most relevant explanation may be language or cultural barriers leading to lower understanding of and lower feeling of being targeted by health promotion messages. This would be consistent with studies from the United States that have demonstrated the challenges faced by diverse communities regarding access to culturally and linguistically adapted HPV information [The fact that inequalities In HPV vaccine awareness were not mitigated by school lessons on vaccination or recent physician visit appears surprising. Further investigation is needed to explore the reasons behind such inequalities, including lower health literacy (capacity to understand the vaccine information) and selective information (to not mention HPV vaccines towards specific groups). To overcome inequalities in HPV vaccine awareness among adolescents, specific targeted interventions on HPV vaccine may be needed.The prominent role of GPs in our study echoes previous research highlighting that limited access to GPs, GPs not offering the vaccine and challenges faced by GPs in promoting the HPV vaccine act as major barriers to HPV vaccination in France [Knowledge and perceptions on HPV vaccine among teenagers have been well researched across Europe and the world [Adolescents’ HPV knowledge remains sub-optimal, with only 51.8% across 16 European countries [In the analysis of wider determinants, the opinion of the social environment on HPV vaccination was the dominant determinant of vaccine intention among unvaccinated adolescents, concordant with the existing literature [The mitigation of inequality by socioeconomic level in case of school lessons on vaccination was largely carried by an increase in intention in municipalities with higher deprivation levels, with little change in low-deprivation areas. Studies on free school-based HPV vaccine access in Belgium and in Canada have described a similar pattern, with such interventions benefiting higher-deprivation areas [Our study has several limitations. Firstly, a self-administered questionnaire among adolescents is at risk of low-quality answers given haphazardly or too quickly, particularly if respondents lacked interest or did not understand the question. We tried to minimise these effects by offering a ‘do not know’ answer modality. We did not analyse durations of questionnaire administrations, but teachers or school nurses were present and surveyed questionnaire administration, which should guarantee a minimal level of information quality. Additionally, the use of anonymous self-administration should have limited the risk of social desirability bias.Secondly, our participants were not a representative sample of middle school students in France, given the fact that participation depended on the school directors’ agreement and on parental non-opposition, which may have excluded students with parents with strongly negative attitudes towards vaccination. Prevalence estimates should therefore be interpreted with caution. Nevertheless, the HPV vaccine prevalence of 36% among girls and 9% among boys is close to the national estimates for 2021 (37% and 6%). Across all study participants, 21% reported a multilingual background, which corresponds to national survey data from the French Ministry of Culture [Finally, the requirement of parental consent to vaccination in France could have impacted in a differential way the vaccine intention expressed by adolescents in different socio-educational subgroups.