Missed Opportunities for Human Papillomavirus Vaccine Prescription in French Military Primary Care: A KAP Survey With Scenario-Based Modeling

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INTRODUCTION: Human papillomavirus (HPV) vaccination prevents HPV-related cancers, yet uptake remains suboptimal. In France, routine vaccination targets early adolescence (11-14 years), with catch-up vaccination recommended up to age 26 years. Reimbursement extension to age 26 became effective in December 2025, after the present survey. Within the French Military Health Service (Service de Santé des Armées, SSA), HPV vaccines are generally not administered in primary care units; prevention therefore relies on identifying eligible service members and initiating vaccination through prescription and referral to community-based administration. MATERIALS AND METHODS: A cross-sectional, anonymous online Knowledge, Attitudes, and Practices (KAP) survey was conducted in September 2025 among active-duty SSA military general practitioners (MGPs). The primary outcome was self-reported routine initiation of HPV vaccination via prescription. Responses were dichotomized as "Yes" versus "No." Univariate and multivariate analyses were performed to identify individual factors associated with HPV vaccine prescription. Barriers (non-prescribers) and implementation difficulties (prescribers) were described. Model-based scenario analyses estimated predicted probabilities of routine initiation under modifiable levers (increased opportunities via prompts/standardized visits, comfort with sexual-health discussions, and HPV knowledge), with uncertainty assessed using non-parametric bootstrap (500 resamples). RESULTS: Among approximately 800 active-duty military physicians contacted through institutional channels, 186 completed the survey and met the inclusion criteria for the present analysis, corresponding to approximately one quarter of contacted physicians. Among respondents, 70 (38%) reported routinely initiating HPV vaccination. Routine initiation was independently associated with gynecology-related clinical activity within the unit (aOR 2.53, 95% CI 1.03-6.46) and higher HPV knowledge (aOR 1.17 per point, 95% CI 1.02-1.36), and inversely associated with difficulty discussing sexual health (aOR 0.30, 95% CI 0.13-0.64). Sociodemographic characteristics were similar between groups. Among non-prescribers, the leading barrier was omission ("I don't think about it," 65%), followed by lack of an on-site delivery pathway ("vaccine unavailability within the unit," 47%); fear of refusal was uncommon. Scenario analyses suggested larger gains from increasing opportunities (routinized prompts/standardized encounters) and improving communication comfort than from knowledge gains alone, with additive effects when combining levers. CONCLUSIONS: In SSA primary care, routine initiation of HPV vaccination via prescription appears constrained mainly by missed opportunities and organizational friction rather than clinician opposition. With expanded catch-up recommendations and extended reimbursement up to age 26 years, implementation efforts within the French armed forces are timely; systematic prompts, streamlined prescription-to-vaccination pathways, and brief communication-focused training may increase initiation rates.

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