HPV vaccine awareness and uptake in rural Indigenous communities in Guatemala: a cross-sectional study

Abstract

Objectives

To assess human papillomavirus (HPV) vaccine awareness and uptake among caregivers in rural Indigenous communities in Guatemala and to identify sociodemographic predictors of vaccine unawareness and non-uptake.

Methods

This cross-sectional survey was conducted across 12 rural Indigenous communities in Guatemala’s Central Highlands. Using a community-engaged research approach, trained multilingual health workers administered surveys in Spanish, Kaqchikel or K’iche’. Eligible participants were adults who served as primary caregivers to children. The survey assessed HPV vaccine awareness, vaccine attitudes and uptake among those with daughters aged 8 or older. Logistic regression was used to examine predictors of vaccine unawareness and bivariate analysis explored differences in vaccine uptake.

Results

Among 602 participants (92.5% identified as Indigenous), 95% expressed willingness to vaccinate a child against cervical cancer, yet only 56% had heard of the HPV vaccine. Of the 175 participants with eligible daughters, only 33.7% reported vaccination. Indigenous identity, older age and illiteracy were significantly associated with HPV vaccine unawareness. Speaking an Indigenous language at home was associated with greater awareness. Departmental differences were significant: participants from Sololá were more likely to be unaware of the vaccine, while those from Sacatepéquez had higher awareness and uptake. Community partners noted that access to information, geographic connectivity and social desirability may influence both awareness and response accuracy.

Conclusions

Despite strong willingness to vaccinate, significant knowledge gaps persist among Indigenous caregivers. Tailored, community-informed education strategies—delivered through trusted channels and adapted linguistically and culturally—are urgently needed to increase awareness and uptake of the HPV vaccine in underserved Guatemalan communities.

Correspondence to Dr Lucía Abascal Miguel; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Community-engaged design with multilingual data collection enhanced cultural and linguistic appropriateness.

• Use of trained Indigenous community health workers reduced interviewer-related barriers.

• Convenience sampling may limit representativeness of the broader population.

• Self-reported vaccination status may be subject to recall and social desirability biases.

• A small sample of vaccinated daughters limited multivariable analysis of uptake.

Introduction

Cervical cancer remains one of the leading causes of cancer-related death among women in Guatemala, particularly affecting rural and Indigenous communities. In 2020 alone, Guatemala reported approximately 1555 new cases and 872 deaths from cervical cancer, placing it as the second most prevalent and second deadliest cancer among Guatemalan women under 45 years old.¹ Nearly all cases of cervical cancer are caused by persistent infection with high-risk types of human papillomavirus (HPV).^{2 3} HPV vaccines, which are safe and highly effective in preventing the types of HPV that cause cervical cancer, are central to global strategies to eliminate the disease.⁴ In 2018, Guatemala introduced the HPV vaccine into its national immunisation programme, targeting 10-year-old girls. However, coverage has declined steadily, from 32% of girls completing the vaccine series in 2018 to only 18% in 2022.⁵ This is well below the Pan American Health Organization and WHO goal of 90% coverage by age 15.⁶ This decline was exacerbated by disruptions to routine immunisation services during the COVID-19 pandemic, and national coverage has not returned to prepandemic levels.⁵

Despite the introduction of the vaccine and the burden of cervical cancer in the country, disparities in HPV vaccine uptake persist—particularly among Guatemala’s Indigenous population, which represents over 40% of the national total.^{7 8} Of the more than six million Indigenous people in Guatemala, most live in rural departments where poverty, geographic isolation and lack of access to health infrastructure are longstanding challenges. For example, the departments, Guatemala’s equivalent of states or provinces, with the lowest vaccination coverage, including for childhood and HPV vaccines, tend to be those with the highest proportions of Indigenous residents.⁹ Structural barriers such as distance to health posts, lack of transportation and costs associated with travel are compounded by language differences, limited health education and experiences of systemic discrimination within the health system.^{10 11} In Guatemala, HPV vaccination is delivered through a mixed platform: free vaccination is offered by Ministry of Public Health and Social Welfare (MSPAS) at public health centres and permanent care centres, and during periodic outreach or vaccination campaigns. There has not been a sustained nationwide, school-based HPV vaccination programme.^12–14

Knowledge and awareness of HPV and cervical cancer remain low among Indigenous women. Studies have found that Indigenous women in Guatemala are significantly less likely to have heard of HPV, to have received cervical cancer screening or to receive follow-up care after abnormal screening results compared with non-Indigenous women.^{10 15} Additionally, HPV infection prevalence is higher among Indigenous women in Guatemala compared with non-Indigenous populations, contributing to disproportionate cervical cancer incidence and mortality rates.¹⁶ These disparities reflect broader patterns observed globally, where Indigenous populations face elevated risks for vaccine-preventable diseases due to systemic health inequities.¹⁷

Barriers to HPV vaccine uptake are multifaceted and include logistical constraints, cultural and religious beliefs, and concerns about vaccine safety. In Guatemala, the early rollout of the HPV vaccine lacked targeted education or outreach, and there has been limited adaptation of information into Indigenous languages or culturally appropriate formats.^{18 19} Reports indicate that many doses have gone unused due to lack of demand, misinformation and lack of organised campaigns, particularly in rural and Indigenous areas.²⁰ A growing body of literature from Guatemala and other Latin American countries points to the urgent need for culturally relevant, community-engaged approaches to HPV vaccine promotion in Indigenous communities.²¹

The aim of this study is to build on prior qualitative research by quantitatively assessing HPV vaccine awareness and uptake among caregivers in rural Indigenous communities in Guatemala. Specifically, the study sought to identify levels of knowledge about HPV and cervical cancer prevention, measure vaccine uptake among caregivers of eligible girls, and examine sociodemographic predictors of HPV vaccine unawareness and non-uptake.

Methods

This cross-sectional survey was part of a broader research initiative to develop culturally and linguistically relevant health education materials aimed at increasing HPV vaccination coverage and reducing cervical cancer disparities in Indigenous populations in Guatemala. The study was implemented through a collaboration between Stanford Center for Health Education’s Digital Medic initiative, the Institute for Global Health Sciences at the University of California, San Francisco and Wuqu’ Kawoq | Maya Health Alliance, a health-focused non-governmental organisation (NGO) based in Guatemala.

Setting

Wuqu’ Kawoq identified twelve communities in the Central Highlands of Guatemala for inclusion, based on their designation as priority health intervention areas by the MSPAS. These included six communities (equivalent to small towns) in Chimaltenango, three in Sololá, two in Sacatepéquez and one in Quiché. According to 2018 census data, population sizes in the selected towns ranged from approximately 14 000 to 1 45 000 residents.²² All sites were primarily rural, majority Maya communities with a high proportion of children and adolescents. Many face significant poverty, with rates exceeding 75% in several locations. Nine communities primarily speak Kaqchikel, while three primarily speak K’iche’.²²

Community-engaged approach

A community-engaged research framework guided all aspects of the study, including study design, formative research, survey implementation and dissemination. Wuqu’ Kawoq has over 15 years of experience delivering health services and culturally respectful education in these communities. Local, multilingual community health workers who are fluent in Indigenous languages and familiar with local customs conducted all data collection. Following data analysis, we shared preliminary findings with our community partners and invited their feedback on interpretation and framing. The full manuscript was then shared with co-author collaborators, and results were also presented in a community meeting open to broader stakeholders, including caregivers, health workers and local leaders. These engagements helped validate the relevance of our findings and provided valuable cultural and contextual insights to inform interpretation.

Participants and data collection

Data were collected between August and September 2024. Eligible participants were adults aged 18 and older who, at the time of the study, had children or cared for children and served as the primary decision-maker for the child’s health. Using a convenience sampling approach, trained community health workers recruited participants in central public spaces (eg, near health posts, markets, town centres). The survey was administered over a 2-week period. After obtaining informed consent, data were collected using mobile phones or tablets via the Qualtrics platform. Interviews were conducted in Spanish, K’iche’ or Kaqchikel depending on participant preference, and all survey instruments were culturally and linguistically adapted.

In Guatemala’s public health system, a single-dose HPV vaccine is available free of charge to girls aged 9–18 and boys aged 9. Individuals initiating the vaccine after age 18 can only access it in private clinics. Boys were added to the national programme in mid-2024, coinciding with the study period, and thus were not the focus of this study

Survey content

The survey covered awareness of HPV and the HPV vaccine, defined as whether participants had ever heard of HPV or the HPV vaccine; knowledge, defined as understanding of specific health consequences of HPV and ways to prevent cervical cancer; beliefs about cervical cancer prevention and attitudes towards HPV vaccination, including willingness to vaccinate. For participants with daughters over 8 years old, additional items assessed vaccine uptake, location of vaccination and motivations for or against vaccinating. Demographic variables included department of residence (Guatemala’s equivalent of states or provinces), age, gender, self-identification as Indigenous, home language, literacy (ability to read/write) and partnered status. Surveys were verbally administered by community research assistants.

Because no validated HPV survey exists for the Guatemalan context, we developed a new instrument informed by existing tools but adapted to local language, literacy and cultural needs. A key modification was the use of simple categorical questions rather than Likert-type scales, which prior vaccine research in Guatemala has shown to be difficult to interpret and less reliable.²³ The instrument was reviewed by community partners and multilingual CHWs to assess cultural and linguistic relevance. We pilot tested the survey with the first 50 participants, documenting comprehension challenges, interviewer observations, response patterns and interview flow. Minor wording and sequencing changes were made to improve clarity. As an additional validity check, we compared self-reported childhood vaccination patterns with clinic-level vaccination data from participating communities to confirm alignment with expected trends.

Outcomes and measurements

This study assessed both primary and secondary outcomes related to HPV vaccine awareness and uptake. All outcomes were captured through the cross-sectional survey (survey can be found as an ^{online supplemental file 1}). The primary outcomes were: (1) awareness of the HPV vaccine among all participants, measured through a single yes/no item asking whether participants had ever heard of the HPV vaccine and (2) self-reported HPV vaccine uptake among participants who reported having daughters over the age of eight, measured through a yes/no question asking whether any daughter had received the vaccine.

Potential confounders identified a priori included age, literacy, department of residence and self-reported Indigenous identity. Age was categorised into five groups (≤25, 26–36, 37–47, 48–58 and 59+years). Binary variables included literacy (yes/no), Indigenous identity (yes/no) and partnered status (yes/no). Department of residence was treated as a categorical variable.

Secondary outcomes assessed HPV-related knowledge and perceptions. Knowledge of HPV was measured through a series of yes/no questions, including whether participants had heard of HPV, whether they believed HPV is a serious health problem, and whether they knew HPV can cause specific conditions such as cervical cancer, infertility or urinary tract infections. Awareness of cervical cancer prevention strategies was measured through yes/no questions asking whether participants knew cervical cancer could be prevented, followed by a multiple-choice ‘select all that apply’ item listing preventive actions (eg, testing, vaccination, not smoking, eating well, exercising). Perceptions and concerns about HPV were measured with single yes/no questions (eg, concern about a child contracting HPV, belief that cervical cancer is a serious disease). Attitudes towards HPV vaccination, including willingness to vaccinate and reasons for declining vaccination, were measured through categorical single-response and multiple-response items.

Sample size

This cross-sectional analysis uses survey data from a larger three-arm intervention study, which surveyed approximately 600 adults to assess vaccination knowledge, beliefs and barriers. Based on standard cross-sectional sample size calculations, an estimated 384 participants would be needed to measure HPV vaccine awareness with 5% precision. Our final sample of 602 meets this threshold. However, only a subset of participants had daughters over age eight, limiting power for vaccine uptake analyses and preventing multivariable modelling for that outcome.

Statistical analysis

Descriptive statistics were calculated for all variables. Bivariate associations between sociodemographic variables and HPV vaccine awareness were tested using χ² or Fisher’s exact tests, as appropriate based on sample size. For multivariable analysis, we used logistic regression with HPV vaccine unawareness as the dependent variable. Independent variables included age category, literacy, Indigenous identity, partnered status and department of residence. These covariates were selected a priori based on theoretical relevance and prior research on vaccine awareness. We used standard logistic regression with robust standard errors. Model assumptions were evaluated by examining multicollinearity, linearity of continuous variables (none were continuous in the final model), and goodness of fit. Because the sample of participants with daughters over age eight was small, we did not conduct multivariable logistic regression for vaccine uptake; instead, differences by participant characteristics in this subgroup were assessed using χ² or Fisher’s exact tests. All analyses were conducted in Stata V.17.²⁴

Patient and public involvement

This study was grounded in a community-engaged research framework from inception through dissemination. Our work was conducted in partnership with Wuqu’ Kawoq | Maya Health Alliance, an organisation with over 15 years of experience delivering culturally and linguistically appropriate healthcare and health education in Indigenous communities in Guatemala. Community stakeholders contributed to the design of the study, development and translation of the survey instrument, and the selection of participating communities. All data collection was carried out by trained multilingual community health workers who live in and are trusted by the communities involved. Following analysis, findings were shared with our community partners to solicit feedback and validate interpretation. Co-authors representing community perspectives reviewed the manuscript and provided critical insight into how findings should be framed, particularly regarding Indigenous identity, language use and local perceptions of cancer and vaccination.

Results

Participant characteristics

A total of 654 individuals were screened by community health workers across the 12 participating communities. Of these, 602 individuals met the eligibility criteria, consented to participate and completed the full survey (^{table 1}). The remaining 52 individuals were excluded due to not meeting eligibility criteria. All eligible and consenting participants completed the survey in its entirety. Most participants identified as women (86.7%, n=522), and a large proportion identified as Indigenous (92.5%, n=557). The majority were able to read and write (90.9%, n=547), and approximately two-thirds (64.5%, n=388) reported being partnered. Participants were distributed across four departments, with the highest representation from Chimaltenango (46.4%), followed by Sololá (24.6%), Sacatepéquez (21.3%) and Quiché (7.8%). Awareness of the HPV vaccine varied significantly by department (p<0.001), with the highest awareness observed in Chimaltenango and none in Quiché. Significant differences were also observed by age group (p=0.001), literacy (p<0.001), and Indigenous identity (p=0.001), with lower awareness reported among older participants, those unable to read or write, and those who identified as Indigenous. No significant differences were found by gender (p=0.482) or partnered status (p=0.248).

Table 1

Participant characteristics by HPV vaccine awareness

Characteristic	Total (N=602)n (%)	Has heard of HPV vaccine		P value
		Yes (n=344)n (%)	No (n=258)n (%)
Department				<0.001
Chimaltenango	279 (46.4)	205 (59.6)	74 (28.7)
Quiché	47 (7.8)	47 (13.7)	0 (0.0)
Sacatepéquez	128 (21.3)	58 (16.9)	70 (27.1)
Sololá	148 (24.6)	34 (9.9)	114 (44.2)
Gender				0.482
Man	79 (13.1)	42 (12.2)	37 (14.3)
Woman	522 (86.7)	302 (87.8)	220 (85.3)
Age group				0.001
≤25	93 (15.4)	68 (19.8)	25 (9.7)
26–36	180 (29.9)	99 (28.8)	81 (31.4)
37–47	144 (23.9)	79 (23.0)	65 (25.2)
48–58	126 (20.9)	63 (18.3)	63 (24.4)
59+	59 (9.8)	35 (10.2)	24 (9.3)
Reads and writes				<0.001
Yes	547 (90.9)	331 (96.2)	216 (83.7)
No	55 (9.1)	13 (3.8)	42 (16.3)
Partnered				0.248
Yes	388 (64.5)	229 (66.6)	159 (61.6)
No	214 (35.5)	115 (33.4)	99 (38.4)
Identifies as indigenous				0.001
Yes	557 (92.5)	313 (91.0)	244 (94.6)
No	45 (7.5)	31 (9.0)	14 (5.4)

HPV, human papillomavirus.

HPV and cervical cancer knowledge and perceptions

Most participants were aware of HPV and perceived it as a serious health threat, with nearly all expressing concern about the risk of transmission to children in their care. Among those aware of HPV, over two-thirds recognised that it can lead to health problems, most commonly identifying cervical cancer as one of the potential consequences. However, some participants also associated HPV with conditions such as infertility or urinary tract infections, indicating areas of misinformation. When asked about cervical cancer, just over half of respondents believed it could be prevented. Vaccination was the most frequently cited prevention strategy, followed by screening and lifestyle behaviours such as healthy eating and exercise. A small number of participants were uncertain or unaware of any prevention options (^{table 2}).

Table 2

Knowledge and perceptions of HPV and cervical cancer among participants

Topic	Question/indicator	n (%)
HPV awareness	Heard of HPV	419 (69.6)
	Has not heard of HPV	163 (27.1)
HPV seriousness (N=419)	Believes HPV is serious	394 (94.0)
	Believes HPV is not serious	14 (3.3)
	Not sure	11 (2.6)
Knows HPV can cause health problems (N=419)	Yes	287 (68.7)
	No	131 (31.3)
Perceived health outcomes caused by HPV (N=419)*	Cervical cancer	262 (43.5)
	Infertility	41 (6.8)
	Urinary tract infections	43 (7.1)
	Other (infections or cysts)	8 (1.3)
Concern about HPV (N=419)	Concerned child could get HPVNot concerned child could get HPV	401 (95.7)418 (5)
Cervical cancer preventability (N=582)	Believes it can be prevented	343 (59)
	Does not believe or is unaware it can be prevented	239 (41)
Cervical cancer prevention strategies (N=343)*	Vaccination	256 (42.5)
	Screening and exams	134 (22.3)
	Healthy eating	44 (7.3)
	Exercise	35 (5.8)
	Not smoking	23 (3.8)
	Don't know	1 (2.3)

*One or more options could be selected.

HPV, human papillomavirus.

HPV vaccine attitudes and intentions

Nearly all participants (95.0%, n=580) reported that they would vaccinate their child to protect them from cervical cancer. Despite this strong intention to vaccinate, 44.0% (n=258) indicated that they had never heard of the HPV vaccine. The adjusted logistic regression (^{table 3}) found that Indigenous participants had 3.66 times higher odds of being unaware of the HPV vaccine compared with non-Indigenous participants (aOR=3.66; 95% CI 1.36 to 9.85; p=0.01). Age was also associated with unawareness in certain groups: participants aged 26–36 had significantly higher odds of unawareness compared with the youngest age group (aOR=1.76; 95% CI 1.02 to 3.05; p=0.041), as did those aged 48–58 (aOR=2.61; 95% CI 1.24 to 5.52; p=0.012). No statistically significant associations were observed for the 37–47 and 59+ age categories.

Table 3

Logistic regression predicting unawareness of the HPV vaccine adjusted for possible confounders

Predictor	Unadjusted model			Adjusted model
	OR	95% CI	P value	OR	95% CI	P value
Indigenous**	5.43	2.25 to 13.08	0.000	3.66	1.36 to 9.85	0.010
Age
18–25	Reference	Reference	Reference	Reference	Reference	Reference
26–36*	1.56	1.01 to 2.39	0.041	1.76	1.02 to 3.05	0.041
37–47	1.35	0.84 to 2.17	0.213	1.56	0.83 to 2.91	0.159
48–58*	2.35	1.31 to 4.18	0.004	2.61	1.24 to 5.52	0.012
59+	1.17	0.31 to 4.34	0.808	1.28	0.30 to 5.46	0.731
Cannot read/write**	2.10	1.18 to 3.74	0.011	2.78	1.31 to 5.89	0.007
Partnered	0.86	0.58 to 1.29	0.486	0.72	0.42 to 1.21	0.222
Department
Chimaltenango	Reference	Reference	Reference	Reference	Reference	Reference
Sacatepéquez***	0.43	0.26 to 0.70	0.001	0.37	0.22 to 0.64	<0.001
Sololá***	12.13	6.73 to 21.84	0.000	11.95	6.53 to 21.88	<0.001
Gender
Male	1.00	0.62 to 1.63	0.977	0.77	0.41 to 1.47	0.442

The Quiché department was excluded from the regression model due to perfect prediction; all participants from Quiché were aware of the HPV vaccine.

Only one participant identified as a gender other than man or woman; this individual was excluded from the analysis due to small sample size.

*p<0.05, **p<0.01, ***p<0.001.

HPV, human papillomavirus.

Participants who could not read or write had significantly greater odds of being unaware of the HPV vaccine compared with those who were literate (aOR=2.78; 95% CI 1.31 to 5.89; p=0.007). Department of residence was also a significant predictor. compared with participants from Chimaltenango, those from Sacatepéquez had lower odds of vaccine unawareness (aOR=0.37; 95% CI 0.22 to 0.64; p=<0.001), while those from Sololá had substantially higher odds (aOR=11.95; 95% CI 6.53 to 21.88; p=<0.001). The department of Quiché was excluded from the model due to perfect prediction, as all participants from that department reported being aware of the vaccine.

Among the full sample, 94.0% (n=545) stated that they would vaccinate their child if the HPV vaccine were available to them. Among those who would not vaccinate their child (n=35), the most common reason cited was lack of knowledge about the vaccine (77%, n=27). Other reasons included concern about side effects (n=5), uncertainty (n=11) and concerns about early sexual activity (n=2) or developmental harm (n=2). No participants cited infertility or lack of vaccine effectiveness as reasons.

HPV vaccine uptake and motivations

The following results focus on caregivers of girls over age eight. Among all participants, 30.1% (n=175) reported having daughters over the age of eight. Of these, 33.7% (n=59) reported that at least one daughter had received the HPV vaccine, while 66.3% (n=116) had not. Bivariate analysis found no significant associations between vaccine uptake and Indigenous identity, age, literacy, partnered status or speaking an Indigenous language. The only significant predictor of vaccine uptake was residing in Sacatepéquez. Among those who had vaccinated daughters (n=59), 47.5% (n=28) reported that vaccination occurred at school, 42.4% (n=25) at a health clinic, and 5.1% (n=3) at home. A small number reported other locations, such as combinations of school and clinic, or mobile vaccination visits.

When asked why they chose to vaccinate their daughters, the most frequently cited reason was a recommendation from a health provider (28.0%, n=49). Other common motivations included the belief that the vaccine prevents cancer (19.4%, n=34), influence from family members (20.0%, n=35) and influence from friends (3.4%, n=6).

Discussion

This study explored HPV vaccine awareness and uptake among caregivers in rural Indigenous communities of Guatemala, revealing significant informational gaps despite a high willingness to vaccinate. Although 95% of participants reported that they would vaccinate their child to prevent cervical cancer, only 56% had heard of the HPV vaccine. Among those with eligible daughters, only one-third had vaccinated them, consistent with national statistics.⁵ Multivariable analysis identified Indigenous self-identification, older age and illiteracy as significant predictors of vaccine unawareness. Participants residing in Sololá were also more likely to be unaware of the vaccine, while those in Sacatepéquez had lower odds of unawareness and higher reported vaccine uptake. Community partners noted that Sacatepéquez’s greater urban connectivity and proximity to the capital may facilitate better access to health services and information, while Sololá’s rurality and linguistic diversity may contribute to persistent informational barriers. The most commonly cited reason for vaccinating was a recommendation from a health provider, and school-based vaccination was the most frequently reported location.

These findings align with previous research indicating lower HPV and cervical cancer awareness among Indigenous women in Guatemala and other low- and middle-income countries. For instance, a study conducted in rural Guatemalan communities found that less than 40% of women were regularly screened for cervical cancer, with even fewer women screened in Indigenous communities.¹¹ Similarly, research in the Caribbean revealed that only 19.6% of Indigenous participants had heard of HPV, and 21.8% were aware of the HPV vaccine.²⁵ Studies from Honduras and Peru similarly report gaps in knowledge about HPV and cervical cancer prevention, particularly in communities with limited access to health services or school-based vaccination programmes.^{26 27} The high willingness to vaccinate paired with low awareness underscores an urgent need to address informational, not attitudinal, barriers to vaccination. This gap suggests that targeted educational interventions could significantly improve vaccine uptake in these communities.²⁸ Provider recommendation emerged as a key motivator, reinforcing the central role of the health system in influencing vaccine behaviour. Studies have shown that receiving a healthcare provider’s recommendation is a strong predictor of HPV vaccination, with parents who receive a clear recommendation having significantly higher odds of getting their children vaccinated.^{29 30}

Our findings have important implications for policy and practice in Guatemala’s HPV vaccination programme. To close this awareness gap, tailored communication strategies should be developed in targeting Indigenous people. Materials must be linguistically and culturally appropriate, delivered by trusted messengers, including health providers and community leaders, and shared through accessible channels like community health workers, schools and mobile teams. The contrasting outcomes between Sololá and Sacatepéquez also suggest that resource and infrastructure differences between departments may shape vaccine access and information exposure. Strengthening cross-departmental learning and directing additional support to underperforming regions could promote more equitable implementation. At the systems level, expanding and stabilising school-based HPV vaccination, integrating vaccine education into routine maternal and child health services, and leveraging widely used platforms such as WhatsApp could improve reach and uptake. Together, these findings highlight actionable opportunities for policymakers and implementers to address structural gaps and advance cervical cancer prevention in rural and Indigenous communities.

This study has several strengths, including its community-engaged design, linguistically inclusive data collection methods and a large, multisite sample spanning four departments. However, the findings should be interpreted in light of key limitations. The cross-sectional design limits causal interpretation, and the use of convenience sampling may affect generalisability. Because the study relied on convenience sampling within selected Indigenous communities prioritised by our implementing partner, the findings may not be generalisable to all rural or Indigenous populations in Guatemala or other settings. These communities, while predominantly Indigenous and rural, may differ from the broader Indigenous population in Guatemala in ways that affect HPV awareness and uptake, including access to health posts, exposure to outreach activities, language distribution and local infrastructure. For this reason, the sample should not be viewed as representative of all Indigenous or rural populations in the country. Vaccine uptake was self-reported and not verified through health records, raising the potential for recall and reporting biases. Additionally, participants may have over-reported willingness to vaccinate due to social desirability bias, knowing that vaccination is perceived as the ‘correct’ or expected response. The small sample of vaccinated daughters also limited our ability to conduct multivariable regression on vaccine uptake. Future research should examine trends over time, particularly as Guatemala expands HPV vaccination to boys.

In conclusion, despite strong willingness to vaccinate, many caregivers, particularly those in Indigenous and rural communities, remain unaware of the HPV vaccine. Addressing this gap through culturally appropriate, community-informed education and outreach strategies will be critical to achieving equity in cervical cancer prevention in Guatemala.

Footnote

Contributors LAM led the study design, oversaw data collection activities, conducted the analysis, drafted the manuscript and served as the guarantor. ND-S provided supervisory support throughout the study, contributed to the analytic approach and critically revised the manuscript. JSJ and VW contributed to manuscript editing and interpretation of findings. RGB and AKD coordinated field implementation, supervised community health workers and supported data collection and community engagement. All authors reviewed and approved the final manuscript.

Funding This work was supported by Global Impact through their Vaccine Confidence Fund grant, award # VCF-001.

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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