?Mathematical formulae have been encoded as MathML and are displayed in this HTML version using MathJax in order to improve their display. Uncheck the box to turn MathJax off. This feature requires Javascript. Click on a formula to zoom.ABSTRACT
This cross-sectional epidemiological study aimed to investigate awareness regarding human papillomavirus (HPV) and willingness for vaccination among college students with or without medical background in Guizhou Province, China. A logistic regression model was used for univariate and multivariate analyses of cognition to determine factors influencing willingness for vaccination. In total, 2,540 questionnaires were collected, of which 2,360 were valid. The medical and nonmedical groups included 737 (31.2%) and 1,623 (68.8%) individuals, respectively. The medical group had heard of HPV and its vaccines more frequently than the nonmedical group, with the former also having greater awareness than the latter (P < .001). Females (1,325, 56.1%) had heard of HPV and its vaccines more frequently than males (1,035, 43.9%), with the former also having greater awareness than the latter. The cost, safety, and efficacy of the HPV vaccine and lack of knowledge regarding HPV and its vaccines were the main barriers for vaccination. The overall level of knowledge regarding HPV and its vaccines was lower in the nonmedical group and males than in the medical group and females. To help promote willingness for vaccination among the nonmedical group and males, strategies that deepen their knowledge regarding the HPV vaccine are needed.
Introduction
Human papillomavirus (HPV) is a nonenveloped DNA virus that mainly infects the human mucosa, anus, and genital tract.Citation1 HPV is mainly transmitted through intimate contact.Citation2 Although more than 200 types of HPV have been identified, not all of these are pathogenic. Fifteen HPVs, including HPV16, HPV18, HPV31, HPV33, HPV35, HPV39, HPV45, HPV51, HPV52, HPV56, HPV58, HPV59, HPV68, HPV73, and HPV82, have been considered high-risk pathogens. The most common high-risk HPVs are mainly HPV 16 and HPV 18. Persistent HPV infections with high-risk HPV, such as HPV16 and HPV18, have been widely recognized as one of the main factors for the development of penile cancer, oropharyngeal cancer, and most especially cervical cancer.Citation3 Morbidity and mortality rates associated with cervical cancer are on the rise, and this disease is mainly observed in young individuals in China.Citation4 The mortality from cervical cancer accounts for 17% of the overall cancer mortality in China.Citation5 Both HPV infection rates and incidence of oropharyngeal, penile, and anal cancers associated with HPV infection have also been on the rise.Citation6 Persistent infections with high-risk HPV types, such as HPV16 and HPV18, pose a serious threat to health.
HPV vaccines have been proven to be safe and effective and can be used to prevent the majority of cancers associated with HPV.Citation7 Currently, bivalent (2vHPV: type 16 and 18), quadrivalent (4vHPV: type 6, 11, 16, and 18), and nonavalent HPV vaccines (9vHPV: type 6, 11, 16, 18, 31, 33, 45, 52, and 58) are available in the market. Bivalent vaccines mainly protect against cervical cancerCitation8; tetravalent vaccines prevent oropharyngeal, penile, and anal cancers in both men and women; and nonavalent vaccines provide broader coverage in preventing related diseases caused by HPV infection.Citation9 Denmark, a country with a high prevalence of cervical cancer, has seen a decrease in the incidence of precancerous cervical lesions and squamous cell carcinoma after the inclusion of the HPV vaccine in the country’s vaccination program in 2009.Citation10 This highlights the positive health effects of HPV vaccination. Unfortunately, the HPV vaccination rate in China is only around 3%.Citation11,Citation12
The Chinese government is yet to include the HPV vaccine in its free vaccination program and is more focused on females for HPV vaccination.Citation13 Although college students are at a high risk for HPV infection, several Chinese students have limited knowledge regarding HPV.Citation14–16 As future healthcare workers, medical students play an important role in promoting the spread and availability of HPV vaccines. Promoting HPV vaccination is closely associated with college students’ perceptions and knowledge regarding HPV and its vaccines. There is an important correlation between the promotion of HPV vaccination among college students and their attitudes and knowledge toward HPV and its vaccines. However, only a few specialized literature reports on HPV awareness and willingness for vaccination among college students with or without medical background are available, Previous studies prioritized investigating women’s attitudes toward HPV and HPV vaccine. Therefore, the present study compared HPV awareness and willingness for vaccination between college students with and without a medical background and between males and females. We believe that our results would contribute toward improving HPV vaccination rates among college students.
Materials and methods
Study population
Between August to November 2022, a cross-sectional survey was conducted among college students from Guizhou Province, Southwest China. According to the literature survey, the estimated sample size was determined based on the following formula:
where d is the permissible error; Zα/2 is the 100α percentile, usually α = 0.05 and Zα/2 = 1.96 (95% CI); and p is the probability value or incidence of the expected event. Considering a 50% HPV awareness with a 3% allowable error and 95% confidence interval (CI), a sample size of 1,068 was determined. This value was doubled to 2,360 to ensure adequate comparison of vaccination intentions among college students.Citation17 The inclusion criteria were (1) college students, (2) those with cognitive capability, and (3) those who provided informed consent and were ready to voluntary participate in the survey. The exclusion criteria were as follows: (1) those with incomplete data and (2) those who took less than 30 s to complete the questionnaire.
Questionnaire
A questionnaire was designed to investigate awareness regarding HPV and its vaccines based on domestic and external literature.Citation13,Citation18 This questionnaire was reviewed by relevant experts from our school. Reliability analysis was also conducted on the questionnaire (Appendix Table 1). The questionnaire language was set to Chinese. The purpose, significance, and content of the survey were indicated in the cover of the questionnaire. Questionnaires were distributed through the survey platform (https://www.wjx.cn). This survey was conducted anonymously. This study used completely random sampling. With the help of college counselors throughout Guizhou Province, the questionnaires were distributed through the Internet and were filled out voluntarily. In addition, participants received no compensation for their cooperation. Participants younger than 18 years of age could participate in the survey with the consent of a counselor. The need for ethics approval was waived by Ethics Committee of Zunyi Medical University. Waiver for informed consent to participate was taken from Ethics Committee of Zunyi Medical University. All methods were performed in accordance with the relevant guidelines and regulations of Law on the Rights and Interests of College Students.
Investigation content
The questionnaire was designed to collect data regarding (1) general information (sex, age, ethnicity, origin, occupation, education level, sexual orientation, etc.); (2) knowledge about HPV (15 questions for a total of 15 points; correct answers were assigned 1 point, whereas incorrect answers were assigned 0 points); (3) knowledge about HPV vaccines (7 questions for a total of 7 points; correct answers were assigned 1 point, whereas incorrect answers were assigned 0 points); (4) willingness for HPV vaccination; and (5) factors influencing willingness for vaccination. The portion of the questionnaire that contained questions about sources of HPV and knowledge of HPV vaccine was completed only by those who answered “yes” to having heard of HPV or its vaccines.
Statistical analysis
All statistical analyses were conducted using SPSS version 17.0. Quantitative variables were expressed as mean ± standard deviation (M ± S), whereas categorical variables were expressed as number and percentage (%). Differences between groups were compared using rank sum and chi-square tests. Willingness for HPV vaccination (categorized as “yes” and “no”) was used as the dependent variable, and binary logistic regression analysis was used to analyze factors influencing willingness for HPV vaccination according to sex and presence or absence of a medical background. A two-sided p value of < .05 was considered statistically significant.
Results
Demographic characteristics of the participants
In total, 2,540 questionnaires were obtained, of which 2,360 were valid, with an effective rate of 92.91%. Participants were categorized into medical and nonmedical groups based on educational background. The medical and nonmedical groups had a mean age of 20.7 and 18.7 years, respectively. In the medical group, 510 (69.2%) were Han, 227 (30.8%) were ethnic minorities, 518 (70.3%) were from rural areas, 132 (17.9%) were from urban areas, and 87 (11.8%) were from rurban areas. In the nonmedical group, 969 (59.7%) were from rural areas, 389 (24.0%) were from urban areas, and 265 (16.3%) were from rurban areas. In the medical group, 664 (90.1%) were heterosexual, 25 (3.4%) were homosexual, and 48 (6.5%) were bisexual. In the nonmedical group, 1,469 (90.5%) were heterosexual, 29 (1.8%) were homosexual, and 125 (7.7%) were bisexual. Among the analyzed questionnaires, 1,035 (43.9%) and 1,325 (54.1%) were from males and females, respectively. The mean age of females and males was 19.2 and 19.4 years, respectively. Among males, 665 (64.3%) were from rural areas, 220 (21.3%) were from urban areas, and 150 (14.5%) were from rurban areas. Among females, 822 (62.0%) were from rural areas, 301 (22.7%) were from urban areas, and 202 (15.2%) were from rurban areas. Among males, 1,009 (93.3%) had a bachelor’s degree, whereas 26 (2.5%) had a master’s degree. Among females, 1,268 (95.7%) had a bachelor’s degree, whereas 57 (4.3%) had a master’s degree. Among males, 966 (93.3%) were heterosexual, 25 (2.4%) were homosexual, and 44 (4.3%) were bisexual. Among females, 1,167 (88.1%) were heterosexual, 29 (2.2%) were homosexual, and 129 (9.7%) were bisexual ().
Table 1. Demographic characteristics of study participants (n = 2360).
Knowledge regarding HPV and its vaccines
Our survey revealed that the medical group had significantly greater awareness regarding HPV (86.4%) and its vaccines (86.6%) than the nonmedical group (p < .001). Moreover, women had significantly greater awareness regarding HPV (78.6%, p < .001) and its vaccines (87.5%, p < .001) than men (). details the sources from which college students obtained information regarding HPV. The medical group learned about cervical cancer vaccine mainly through media (60.2%) and public welfare announcements (57.4%), followed by schools (54.4%), doctors’ recommendation or consultation (43.8%), and family or friends (38.5%). The nonmedical group learned about cervical cancer vaccine mainly through media (50.6%) and public welfare announcements (38.4%), followed by family or friends (29.7%), schools (24.3%), and doctors’ recommendation or consultation (17.4%). Females learned about cervical cancer vaccines mainly through media (63.4%) and schools (51.3%), followed by public welfare announcements (50.6%), family or friends (41.4%), and doctors’ recommendation or consultation (26.6%). Males learned about cervical cancer vaccines mainly through media (41.2%) and public welfare announcements (36.2%), followed by schools (30.9%), doctors’ recommendation or consultation (23.8%), and family or friends (21.0%).
Table 2. Number of people who have heard of HPV or the HPV vaccine.
Table 3. Sources of HPV vaccination-related knowledge.
summarizes awareness scores regarding HPV and its vaccines for the medical and nonmedical groups and females and males. Accordingly, awareness scores were significantly higher in the medical group than in the nonmedical group (p < .001). Moreover, awareness scores were significantly higher among females than males (p < .001). When asked “Do men get HPV” no significant difference in the scores was noted between the medical and nonmedical groups and between males and females.
Table 4. College students’ knowledge (based on scores) about HPV (out of 15 points) and HPV vaccination (out of 7 points).
Willingness for HPV vaccination and associated factors
Our analysis revealed that a total of 2265 (96.0%) participants were willing to receive the HPV vaccine, whereas only 95 (4.0%) were not willing. Willingness for vaccination was significantly higher in females than in males (98.3%; p < .001). No significant difference in willingness for vaccination was observed between the medical and nonmedical groups (). presents the factors promoting HPV vaccination in college students. The factors promoting HPV vaccination in the medical group included fear of future diseases such as genital warts, infertility, penile cancer, anal cancer, and oropharyngeal cancer (75.9%); fear of HPV infection (74.8%); and benefits from the HPV vaccine (68.5%). The factors promoting HPV vaccination in the nonmedical group included fear of HPV infection (64.7%); fear of future diseases such as genital warts, infertility, penile cancer, anal cancer, and oropharyngeal cancer (64.3%); and benefits from the HPV vaccine (61.1%). The factors promoting HPV vaccination among females included fear of HPV infection (73.6%); fear of future diseases such as genital warts, infertility, penile cancer, anal cancer, and oropharyngeal cancer (71.5%); and benefits from the HPV vaccine (63.5%). The factors promoting HPV vaccination among males included benefits from the HPV vaccine (63.2%); fear of future diseases such as genital warts, infertility, penile cancer, anal cancer, and oropharyngeal cancer (62.2%); and fear of HPV infection (60.1%). Concerns regarding vaccine safety and costs were the main reasons for college students’ unwillingness to be vaccinated ()
Table 5. Attitude toward HPV vaccination.
presents the results of our binary logistic regression analysis for factors associated with college students’ willingness to receive the HPV vaccine. Female sex (aOR = 3.10, 95% CI: 1.85–5.19), hearing about the HPV vaccine (aOR = 2.80, 95% CI: 1.72–4.55), high HPV knowledge score (aOR = 3.40, 95% CI: 1.67–6.91), and high HPV vaccine knowledge score (aOR = 10.56 95% CI: 1.39–80.53) were identified as significant predictors of willingness to receive the HPV vaccine. Stratified analysis according to educational background showed different results for the medical and nonmedical groups.
Table 6. Factors associated with the willingness to receive HPV vaccination.
Female sex (aOR = 3.07, 95% CI: 1.67–5.65) and hearing about the HPV vaccine (aOR = 2.41, 95% CI: 1.35–4.32) were identified as significant predictors of willingness for HPV vaccination in the nonmedical group. Female sex (aOR = 3.84, 95% CI:1.37,10.73), hearing about the HPV vaccine (aOR = 3.90, 95% CI: 1.51–10.11), and high HPV vaccine knowledge score (aOR = 5.95, 95% CI: 1.95–18.10) were identified as significant predictors of willingness for HPV vaccination in the medical group. Analysis stratified according to sex showed different results for females and males. Hearing about the HPV vaccine (aOR = 2.75, 95% CI: 1.57–4.82) and high HPV knowledge score (aOR = 3.54, 95% CI: 1.54–8.14) were identified as significant predictors of willingness for HPV vaccination in men. Hearing about the HPV vaccine (aOR = 2.99, 95% CI: 1.13–7.91) was identified as a significant predictor of willingness for HPV vaccination in women ().
When asked under what circumstances they would receive the HPV vaccine, effectiveness in preventing cervical cancer (19.6%), vaccine safety (19.4%), and inclusion in the national immunization program (14.8%) were identified as the main facilitators. Most people preferred to receive the HPV vaccine at the Centers for Disease Control and Prevention (33.0%). When asked regarding their preference for a domestically made or imported HPV vaccine, most people said both (67.5%). Moreover, most people (51.7%) were willing to pay < 1,500 yuan for their HPV vaccination ().
Discussion
HPV remains one of the most common sexually transmitted diseases worldwide. The efficacy of HPV vaccination peaks before participating in sexual behavior. Most college students in China engage in sex for the first time at around the age of 18 years.Citation19 Despite already having introduced sex education into the classroom, college students tend to have a one-sided understanding of sex due to the influence of traditional Chinese thinking and are even more helpless when facing sexually transmitted diseases. Notably, the growing number of homosexual men has contributed to a higher incidence of HPV-related cancers.Citation6 HPV vaccination has a direct impact on the risk of HPV infection; thus, it is crucial to not only promote vaccination among women but also consider incorporating men into vaccination strategies.
The current survey found that 72.4% and 77.7% of college students had heard of HPV and its vaccines, respectively. These results were similar to those for college students in Beijing and Zhengzhou.Citation16,Citation17 Awareness regarding HPV and its vaccines was closely associated with educational background and sex. Our survey found that awareness rates regarding HPV and its vaccines in the medical group were 86.4% and 86.6%, respectively, which were higher than those among medical students in Tianjin in 2020 (63.48%).Citation20 We speculate that this could have been caused by the increasing requirements for medical education. The present study found that the medical group had higher awareness rates for HPV and its vaccines than the nonmedical group. The main sources of information regarding HPV and its vaccines for the medical and nonmedical groups were media and public welfare announcements; however, medical students could also learn about HPV and its vaccines through textbooks, school, hospital practice, and other sources of information. In contrast, nonmedical students had limited knowledge regarding HPV and HPV vaccine-related pathways. This result is consistent with that reported by Manman Li.Citation16 Sex differences in awareness rates for HPV and its vaccines have been noted. In particular, the present study found that awareness rates for HPV and its vaccines were higher in females than in males, which is consistent with the results published by Gang ChenCitation13 and Zhenwei Dai et al.Citation19 This could be presumably attributed to general focus on females among studies on the consequences of HPV infection.
Cognition scores for HPV and its vaccines were 8.52 ± 4.087 (out of 14) and 3.97 ± 2.207 (out of 7) among college students in Guizhou Province, respectively. Despite the low cognition scores, these were slightly higher than those of college students in Guangzhou in 2018.Citation21 However, our results are similar to those reported by Wenzhou in 2022.Citation13 This could have been attributed to more people taking their health seriously due to increasing education levels and awareness of disease prevention. Unfortunately, Chinese college students have significantly lower knowledge regarding HPV and its vaccines than college students from developed countries such as the United States,Citation22 which may be closely related to national ideology and sex education. Awareness regarding HPV and its vaccines was significantly higher in the medical group than in the nonmedical group. College students with a medical background had more professional sources of knowledge, whereas college students without a medical background obtained their knowledge mainly through media. Therefore, it is necessary to improve the popularity of knowledge about HPV and its vaccines through Internet. Women have significantly greater knowledge about HPV and its vaccine than men, which may be related to the prevailing perception among males that only females should consider HPV vaccination. In addition, the HPV vaccine had initially been introduced to prevent cervical cancer,Citation23 overlooking the harm of HPV brings to males. Therefore, it is necessary to increase awareness regarding HPV-related diseases and the benefits of HPV vaccination among males in the future.
In summary, our findings indicate that medical students have higher overall awareness regarding HPV and its vaccines than nonmedical students. The understanding of HPV and its vaccines has a substantial effect on reducing the risk of self infection. As future healthcare workers, medical students play a significant role in promoting and popularizing HPV and its vaccines, which could considerably affect vaccination rates of future patients. Expectedly, nonmedical students had lesser knowledge regarding the risks of HPV and its infection. Considering that a majority of Chinese college students are enrolled in nonmedical courses, increasing the popularity of and knowledge regarding HPV and its vaccines among nonmedical students is necessary to increase vaccination rates and reduce the incidence rate of cervical, oropharyngeal, penile, and anal cancers throughout China.
Unlike previous studies, the present study found that the willingness of Chinese college students to receive HPV vaccines is on the rise.Citation12,Citation21,Citation24 However, in reality, very few Chinese college students have received an HPV vaccine, especially those without a medical background. HPV vaccine coverage rates have been closely related to whether the country has introduced the HPV vaccine. Many western countries have immunization plans targeting adolescents of appropriate age, resulting in a coverage rate much higher than that in China.Citation25–27 Our analysis found that hearing about the HPV vaccine; worrying about future genital warts, infertility, penile cancer, anal cancer, oropharyngeal cancer, and other diseases; and worrying about HPV infection were important factors influencing the willingness for HPV vaccination in different groups. Those who did not want to be vaccinated were mainly worried about the safety and effectiveness of the vaccine, which was consistent with the findings reported by Yan Huang and Khan TM.Citation23,Citation28 However, the safety and effectiveness of HPV vaccines have already been fully confirmed,Citation29,Citation30 indicating that the level of awareness regarding HPV affects their willingness to vaccinate. Therefore, it is particularly important to propagate correct and effective knowledge regarding HPV and its vaccines. This study found that cost was also a factor hindering HPV vaccination, which is consistent with that reported by Yan Huang.Citation29 Most college students can only afford HPV vaccination when priced at < 1,500 yuan considering that China has yet to introduce the HPV vaccine into the national immunization program. Currently, the price of an imported cervical cancer vaccine in the domestic market for three doses ranges from approximately 1,740–2,460 yuan,Citation31 which is higher than the price that most no-income college students can afford. Therefore, lowering the price of vaccines would certainly contribute to widespread vaccination. Given that China is not supported by the Global Alliance for Vaccines and Immunization (GAVI), it may not be able to receive extensive financial assistance to maintain the supply of HPV vaccines. Nonetheless, China has been actively cooperating with organizations such as the GAVI.Citation32 HPV vaccines have been confirmed to have high economic and protective benefits,Citation33 and the introduction of HPV immunization programs has resulted in a decrease in HPV infection and morbidity in various countries, such as the United Kingdom and Denmark.Citation25,Citation26 The inclusion of HPV vaccine expenses into the scope of available medical insurance systems would help improve the willingness of college students to undergo HPV vaccination. The “low knowledge – vaccine hesitancy – low coverage” chain can be corrected through educational intervention.Citation34 Therefore, the community should prioritize the dissemination of relevant knowledge to parents and teenagers of vaccination age. Similarly, universities should offer corresponding lectures on correct and effective methods for preventing HPV infection and on the benefits of HPV vaccination.
The present study has several limitations. First, this study used a completely random method for distributing the electronic questionnaires on the network platform, making it impossible to calculate the recovery rate. Second, despite selecting universities in Guizhou, a small number of students with high awareness could still be studying in other developed regions throughout Guizhou. Thus, our cohort may not fully represent the knowledge college students in Guizhou Province have regarding HPV and their willingness for vaccination. Finally, given the cross-sectional nature of this survey study, causal links could not be established, suggesting the need for caution when interpreting effects.
The present study found that awareness rates for HPV and its vaccines were high among college students in Guizhou Province; however, knowledge regarding HPV and its vaccines was significantly lower among nonmedical college students than among medical students. Moreover, we found that males had significantly lesser knowledge regarding HPV and its vaccines than females. However, most college students expressed their willingness to receive HPV vaccination. Strengthening health education regarding HPV and its vaccines and reducing HPV vaccine prices would definitely help improve HPV vaccination rates.
Author contributions statement
Qiongdan Hu: Conceptualization, Methodology, Investigation, Formal Analysis, Writing – Original Draft; Yuanqin Rui: Conceptualization, Methodology, Investigation, Formal Analysis, Writing – Original Draft; Jing Jiang: Data Curation, Visualization; Jing Yang: Investigation, Validation; HanYun Yao: Resources; XiaoFang Yang: Resources; Zhe Liu: Resources; Chencui Li: Resources; Hong Pan:Conceptualization, Resources, Supervision, Funding Acquisition; Yan Xie: Conceptualization, Funding Acquisition, Resources, Supervision, Writing – Review & Editing.
Ethics approval and consent to participate
The need for ethics approval was waived by Ethics Committee of Zunyi Medical University.
Waiver for informed consent to participate was taken from Ethics Committee of Zunyi Medical University.
All methods were performed in accordance with the relevant guidelines and regulations of Law on the Rights and Interests of College Students.
Appendix Table 1.xlsx
Download MS Excel (9.8 KB)Acknowledgments
We are grateful to all university students who volunteered to participate in this project.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
All the data and materials are available on requesting to the corresponding author.
Supplemental data
Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2295992.
Additional information
Funding
References
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