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Europe is increasingly described as the region in the world with the least confidence in vaccination, and particularly in the safety of vaccines. The aim of this systematic literature review was to gather and summarise all peer-reviewed and grey literature published about determinants of Human Papillomavirus (HPV) vaccine hesitancy in Europe. Ten thematic categories were identified across the 103 articles which were included in the review. Participants from European studies most commonly reported issues with the quantity and quality of information available about HPV vaccination; followed by concerns about potential side effects of the vaccine; and mistrust of health authorities, healthcare workers, and new vaccines. Comparative analyses indicated that confidence determinants differed by country and population groups. This evidence supports the need to develop context-specific interventions to improve confidence in HPV vaccination and design community engagement strategies aiming to build public trust.

Health education can have unexpected effects, sometimes even harmful, in particular when dealing with, on the one hand, multiple risk pathologies and, on the other, one risk factor that is connected to various different pathologies. Certain unexpected effects can be the result of too much information on prevention or when prevention is too focused on one target. In the first scenario, relativity of the information could arise faced with certain health risks or be used against public health objectives. When information is too focused on one target group, it can create discriminatory reactions for the groups at risk, which can translate into denial of the potential risk by those outside of the target group. Other prevention actions can have an unexpected effect, or none at all, because the target behavior is considered functional for the individual. In order to prevent a risk behavior, it is necessary to take into account the threats it is meant to avoid (concurrent risks) and other risk factors meant to attain the same objectives (substitutable risks). In order to understand and avoid different obstacles, people's beliefs and knowledge, which are often rooted in daily behavior and hence difficult to change, must be taken into account. It is also important to situate behavior in context, identifying its function and the concurrent and substitutable risks, which means researching as well the social sciences. In the future, the need for a global health approach will be evident because prevention of risk behaviors increasingly refers to multiple risks in one same pathology as well as concomitant prevention of multiple pathologies.