Keywords: Vaccination behaviour, psychosocial dimensions, general practitioners, HPV vaccine

Background:

Physician recommendation strongly influences HPV vaccine uptake. In Bulgaria, where hesitancy and misinformation persist, understanding GPs’ psychosocial drivers is key to improving immunization efforts.

Research questions:

To explore the psychosocial characteristics of Bulgarian GPs that shape their HPV vaccination behavior, with a focus on motivation, communication style, and professional commitment.

Method:

This study represents the qualitative phase of a PhD project on HPV vaccination behavior among Bulgarian GPs. It followed a cross-sectional survey (n = 364) using the validated Bulgarian version of the Pro-VC-Be questionnaire. The qualitative phase involved six focus groups with a total of 65 GPs, purposively selected to reflect variation in gender, age, practice type, and geographic region. A semi-structured discussion guide explored GPs’ communication strategies, perceived barriers, and motivational factors. Sessions were audio-recorded, transcribed verbatim, anonymized, and thematically analyzed using Braun and Clarke’s six-phase approach. Coding was performed independently by two researchers to ensure validity and reliability.

Results:

Four key themes emerged.
First, professional responsibility vs. system constraints - GPs expressed strong intrinsic motivation to recommend the HPV vaccine, yet felt constrained by short consultations, administrative burdens, and the vaccine’s non-mandatory status. Second, patient hesitancy and sociocultural barriers - common challenges included parental fears, misinformation, and discomfort discussing sexuality. Third, communication dilemmas - although most GPs applied patient-centred communication, many struggled with inconsistent messaging among providers and insufficient training in vaccine communication. Fourth, confidence in the HPV vaccine - GPs' trust in the vaccine’s safety and efficacy was a key driver of proactive recommendation practices.

Conclusions:

GPs are central to HPV vaccine acceptance. Strengthening their communication capacity and institutional backing is vital as Bulgaria expands vaccination to include boys.

Points for discussion:

How can national health authorities better equip GPs to advocate for HPV vaccination in the face of persistent hesitancy?