Urban–rural disparities in HPV vaccination knowledge, willingness, and uptake among women in the Tibet autonomous region: a multi-center cross-sectional study

Background: Urban-rural disparities may hinder HPV vaccination in Tibetan regions. This study quantified disparities in HPV vaccine knowledge, willingness, and uptake among women in Tibetan settings. Methods: A multi-center cross-sectional survey of women aged 18 to 45 years was conducted. HPV knowledge was measured using a 10-item score (range 0-10). Vaccination uptake was defined as self-reported receipt of at least 1 dose. Among unvaccinated participants, willingness was dichotomized as willing versus unwilling or undecided. Multivariable linear and logistic regression models accounted for within-site correlation using cluster-robust standard errors by survey site. Results: = 570), willingness was associated with urban residence (adjusted OR 1.32, 95% CI 1.01 to 1.73), knowledge (per 2-point increase: 1.46, 1.28 to 1.67), Bachelor's-or-higher education (1.83, 1.28 to 2.62), and prior HPV testing (1.62, 1.08 to 2.44). In the base uptake model, urban residence (1.67, 1.21 to 2.30) and knowledge (per 2-point increase: 1.34, 1.23 to 1.46) were associated with uptake. In the staged model adding prevention-service contact, Pap smear history (1.88, 1.39 to 2.56) and HPV testing history (2.41, 1.55 to 3.75) were strong predictors and the urban association attenuated (1.26, 0.93 to 1.71). Among unvaccinated participants, cost (46.7%) and safety concerns (33.7%) were common; rural residents reported substantially higher access or travel burden (47.5% vs. 7.1%) and supply or availability constraints (45.0% vs. 2.7%). The most common maximum willingness-to-pay category was 300 to 999 CNY (37.5%). Conclusion: Large urban-rural gaps in knowledge and vaccination uptake persist despite high willingness among unvaccinated women, indicating a substantial intention-to-behavior gap driven by affordability and delivery constraints. Interventions should pair education with financing and service delivery strategies that reduce travel burden and improve reliable vaccine availability in rural Tibetan settings.