A Comparative Policy Analysis of HPV Vaccination Guidelines: Actors, Context, Content, and Process Across Eight Countries.

AIMS: To compare HPV vaccination policies across eight countries and examine how actors, context, policy content, and implementation processes influence program performance and coverage outcomes. DESIGN: Comparative policy analysis using a qualitative cross-case document analysis. DATA SOURCES: Official national HPV vaccination guidelines, technical advisory documents, WHO and UNICEF monitoring reports, and peer-reviewed literature published between January 2006 and December 2024. Sources were identified through structured searches of PubMed, CINAHL, Scopus, and Web of Science. METHODS: The Health Policy Triangle framework guided analysis across four domains: Actors, Context, Content, and Process. A standardized data extraction template was applied across eight countries: Australia, Brazil, Japan, Nigeria, Rwanda, Sweden, the United Kingdom, and the United States. Data were synthesized in comparative matrices and analyzed using iterative cross-case analysis, with coding verified by a second reviewer. RESULTS: Five policy archetypes were identified: school-based universal programs, decentralized federal models, gender-neutral vaccination strategies, resource-constrained but high-performing systems, and the policy recovery model exemplified by Japan. School-based delivery supported by nursing and school health workforces consistently achieved the highest and most equitable coverage. Rwanda achieved 98% coverage despite a girls-only, donor-supported model, indicating that governance quality and community trust may outweigh policy design alone. The global transition to single-dose HPV vaccination schedules requires country-specific adaptation that accounts for population-based eligibility exceptions and evidence gaps, including the absence of clinical trial data on single-dose protection in males and against non-cervical HPV-associated diseases. CONCLUSION: HPV vaccination outcomes are shaped by governance structures, implementation capacity, nursing workforce infrastructure, and public trust. Strengthening school-based delivery, expanding single-dose schedules where supported by evidence, and investing in nursing-led outreach are critical to accelerating progress toward WHO cervical cancer elimination targets. IMPACT: Nurses are central to HPV vaccination delivery worldwide. This analysis provides evidence to support nursing leadership in advocating for school-based models, workforce investment, and equitable immunization strategies across diverse health system contexts.