In this study, data saturation was obtained after 30 interviews. Finally, the data were categorized into 20 subcategories and seven categories. A total of 20 health professionals in different specialties and nine young adults participated in the study. Their mean age was 2.40 ± 0.224 and 24.86 ± 3.761, respectively. The participants' specifications are presented in Tables 1 and 2.
The Qualitative content analysis led to seven categories, including health value, knowledge, external stimuli, outcome expectations, perceived threat, healthcare services, and Contextual factors (Table 3).
This category consists of two subcategories, including taking care of health and taking responsibility for health.
Females uptake the vaccine to maintain their health and that of their partners, while males do not care about their health and uptake the vaccine only to maintain their partner's health.
"Girls uptake the vaccine for their health as well as those around them" (Young participant,27 years old).
The participants believed that males do not usually refer to a physician for their illness, and they believe the disease was unrelated to them.
"The problem of men in our society is that they care too much about themselves; they put all burden on women's shoulders. Go and uptake, and like preventing pregnancy from closing the tube, most men do not put the burden on their shoulders." (Young participant, 27 years old)
This category comprises two subcategories, including young people's lack of knowledge about HPV and its vaccine and its benefits, and lack of knowledge about health service clinics and the place to purchase the vaccine. Most of the participants emphasized the lack of knowledge about the disease, the vaccine, and its associated benefits.
"I did not inject the vaccine because I do not even know whether or not there is a vaccine, I do not even know its name" (Young participant, 27 years old)
"I google the address of pharmacies that had the vaccine in cities and Tehran for my students and told them. How should people know? Where should they buy the vaccine?" (Gynecologist, 63 years old)
This category consists of two subcategories, including the fear of vaccine side effects, the uncertainty of the vaccine's outcome.
Side effects, such as infertility of girls by vaccine uptake, can be a cause for both young people and parents as well as some physicians not to uptake the vaccine.
"If in the future, my daughter gets an ovulation disorder by uptake the vaccine, what should I do if something wrong will happen? It is my mistake that I decided for her." (Reproductive Health Specialist, 40 years old)
The participants were not sure of the benefits of the vaccine and feared that they would become ill with the vaccine.
"People's trust in the medical system has diminished, and this can play a role in non-uptake. She says maybe I will become ill with the vaccine" (psychologist, 31 years old)
This category consists of two subcategories called perceived danger, perceived severity.
The perceived danger is the belief that the young person is likely to get the disease. Most of the participants believed that girls were more at risk of illness than boys. Moreover, a lack of confidence in a future partner and having multiple partners are factors for vaccine uptake. Some of the participants did not consider themselves susceptible to the disease due to a lack of sex.
The boys believed that they are not vulnerable to the disease; since they have the devices to prevent sexually transmitted diseases, and they could prevent the disease. The factor that prompts the boys to uptake the vaccine is that their genitalia becomes ugly due to the disease, and as a result, their partner will avoid them.
“The boys in my relatives are not impressed. I talk to them about these issues, but it is useless. Unless I show them a picture of the disease and tell them you may be like this in the future, for example.” (Healthy young participant, 25 years old)
“Using condoms can make men think they are not vulnerable, and will never have a problem” (Psychologist, 31 years old)
The perceived severity is the belief that young people have about the losses from no- vaccination. Most of the participants reported that the cause of vaccination in girls is the fear of cancer.
“The most important cause of the uptake is fear, fear of cancer. This fear increases anxiety and causes to inject this vaccine.” (Psychosexualist, 45 years old)
This category consists of four subcategories, including education role, sex role, personality characteristics, and culture effects.
The participants mentioned that educated people find it easier to accept the health professionals’ words.
“Education is important for both knowledge and acceptance of the health professionals’ words and regular visits to the physician and various health professionals. Furthermore, it can be effective in vaccine uptake.” (Young participant, 23 years old)
Women are usually more likely to uptake vaccines because of their gender role of being a mother. Men, on the other hand, think that they do not need the vaccine because they are empowered. Men also consider the HPV vaccine a women-only vaccine and believe it has nothing to do with them.
"Boys think they do not get the disease at all because they think men are strong enough not to get it" (Reproductive Health Specialist, 49 years old)
Risky individuals are more likely to uptake vaccines than others, and some do not uptake the vaccine due to the fear of the needle.
“After finding out about the vaccine, I did not uptake again because I was afraid of the needle.” (Patient, 17 years old)
Culture is also one of the most effective factors for the vaccine uptake. The participants mentioned parents' failure to talk to their children about sex issues because of the values and culture prevalent in the society, as well as the fear of others’ negative view about them by vaccinating.
“The culture and values of the society is very important to a woman. And because of this fact she may not uptake the vaccine.” (Health Education Specialist, 58 years old)
This category consists of five subcategories, including peer effects, parental effects, physician effects, media effects, and observational learning.
In peer effects, usually, friends, who have knowledge, information, and experiences about the disease and HPV vaccine, can be useful in uptake the vaccine.
“Peers can be effective if they are aware of the disease.” (Reproductive Health Specialist, 40 years old)
Parents believe that uptake the vaccine by their children will increase their sexual freedom. Parents' lack of knowledge about HPV and its vaccine, family religiousness, and lack of belief in sexual intercourse outside marriage in their children can be the reasons for non-vaccination.
“Parents say that if their children get the vaccine, they can go and do any sexual activity.” (Health Education and Health Promotion, 36 years old)
Concerning the physicians’ effects on vaccine uptake, the participants believed that physicians could be a contributing factor to the vaccine uptake by scaring the patient about the disease risk. They also sometimes deny the illicit sex of young adults because of their religious affiliation.
“When physicians scare the patient about the disease and its complications, then patients search the internet, and they will be terrified. Then they come back and ask for the vaccine uptake.” (Gynecologist, 60 years old)
The media has created confusion in public with anti-vaccine advertising and misinformation about the vaccine side effects, and this can be a reason for non-vaccination.
In observational learning, the participants believed that young adults by modeling those who uptake the vaccine and seeing those who were protected with HPV vaccine uptake could be encouraged to uptake the vaccine.
“When a person sees those who uptake and finds that they have not been harmed and have been protected against the disease, it could be an encouragement to uptake the vaccine.” (Health Psychologist, 40 years old)
This category consists of two subcategories, including costs and service coverage.
Most of the participants mentioned the high cost of the vaccine as a reason for non-vaccination. They also demanded the government free vaccines or covered by insurance. Another factor that has delayed vaccine uptake was that young adults were busy. Moreover, the vaccine requires a three-period injection, which creates a barrier to uptake. It creates a barrier to uptake. The participants believed that health care providers' behavior could also affect vaccine uptake and non-uptake. Ill-treatment of the patient with the patient is a known cause of vaccine failure. Inappropriate physician's behavior with the patient is a known cause of non-uptake.
“The vaccine is costly, and it is a financial issue, and we do not uptake it.” (Dermatologist, 64 years old)
“One of the barriers to vaccine uptake can be time and being busy.” (Reproductive Health Specialist, 55 years old)
The participants believed that one of the reasons for the non-uptake in young adults is the vaccine shortage and not be readily available as well as the distance from the uptake location and the inappropriate place for the vaccine uptake privacy.
“I wanted to buy the vaccine. I even called the biggest pharmacy, I called the clinics, and they had no vaccine.” (Young participant, 27 years old)
“Most of my patients who bought the vaccine could not uptake it. I even told some of them to bring it, and I do the uptake for them.” (Gynecologist, 60 years old)
“I had patients coming from another doctor's office while they were crying. Even one of the doctors once called the police to take the patient and hand them over.” (Reproductive Health Specialist, 49 years old)
Strategies to increase vaccine uptake in a low-vaccine country
During the interview, all participants were asked to make suggestions on vaccine uptake enhancement strategies, including providing free vaccine, vaccine availability, and the educational process (Table 4).