Advancing cancer prevention through policy: State-level variation in HPV vaccine mandate in the United States

Purpose: Human papillomavirus (HPV) vaccination remains a cornerstone of cancer prevention, yet adolescent coverage in the United States is inconsistent. According to the National Conference of State Legislatures (NCSL), five jurisdictions - Hawaii, Puerto Rico, Rhode Island, Virginia, and the District of Columbia - require the HPV vaccine for school attendance, although mandate scope and enforcement vary. This study examined policy determinants influencing mandate adoption to inform equitable cancer prevention strategies. Methods: Guided by Kingdon's Multiple Streams Framework and Policy Diffusion Theory, a comparative qualitative policy analysis was conducted across eight purposively selected states representing variation in HPV vaccine mandate status and coverage. Data sources included state statutes, legislative records, health department documents, and CDC immunization data. A theory-driven coding and state-by-variable matrix identified patterns in mandate design, exemption structures, diffusion mechanisms, and implementation barriers. Results: Jurisdictions with HPV vaccine mandates achieved higher adolescent vaccination coverage compared with non-mandate states. Effectiveness was influenced by the scope of mandates, enforcement mechanisms, and availability of medical and nonmedical exemptions. Non-mandate states with high vaccination rates demonstrated comparable outcomes through robust public health infrastructure, provider engagement, and school-based education initiatives. Policy diffusion of mandates remains limited due to ideological resistance, politicization of adolescent vaccines, and the absence of coordinated federal or interstate incentives. Conclusions: HPV vaccine mandates can increase coverage when designed with clear enforcement provisions, limited exemptions, and strong public communication. Comparable progress may also be achieved through mandate-equivalent policies that strengthen provider engagement and community outreach. Findings highlight actionable strategies for policymakers, nursing leaders, and cancer prevention advocates to accelerate HPV vaccination and reduce HPV-related cancer disparities across U.S. states.