Keywords: HPV vaccination, General practitioners, Vaccine confidence, Behavioral determinants, Pro-VC-Be survey

Background:

Physician recommendation is one of the most influential factors in HPV vaccine uptake. In Bulgaria, where vaccine hesitancy persists, little is known about the psychosocial and behavioral determinants shaping GPs’ vaccination behavior. The validated Bulgarian version of the Pro-VC-Be questionnaire enables systematic assessment of these factors.

Research questions:

What are the key behavioral drivers influencing HPV vaccination recommendations among Bulgarian GPs, as assessed by the Pro-VC-Be tool?

Method:

A national cross-sectional online survey was conducted between February and April 2025 among 364 GPs from all regions of Bulgaria. The Pro-VC-Be tool measured constructs such as vaccine confidence, complacency, perceived constraints, collective responsibility, and commitment. A range of quantitative analyses was applied: descriptive statistics, exploratory factor analysis, t-tests, ANOVA, and multivariate regression to explore associations between Pro-VC-Be scores, vaccination behavior, and demographic variables. Data were processed using SPSS v.21.

Results:

GPs reported high levels of proactive vaccine-related behavior (>80%) and strong awareness of vaccination benefits. Moderate-to-high vaccine confidence was observed, along with notable levels of trust in public health authorities. Higher scores in commitment and collective responsibility were associated with routine HPV vaccine recommendation (p < 0.01), while perceived constraints (e.g., time pressure, organizational barriers) and complacency negatively affected vaccination behavior. Positive vaccination attitudes also correlated with willingness for future COVID-19 vaccination and higher self-vaccination rates.

Conclusions:

This first national study using the Pro-VC-Be framework highlights the importance of behavioral determinants in HPV vaccine advocacy among Bulgarian GPs. Reducing practical barriers and reinforcing professional values could strengthen vaccination efforts in primary care.

Points for discussion:

How can behavioral insights guide HPV vaccination strategies in general practice?

What role do trust in public health authorities and professional commitment play in shaping GPs’ vaccine recommendation behavior?

How can healthcare systems address perceived constraints (e.g., time pressure, administrative burden) that hinder HPV vaccine advocacy among GPs?