https://orcid.org/0000-0002-6271-1858
ABSTRACT
This study investigated the influences of mother-daughter communication and social media on mothers’ HPV vaccine refusal for their daughters aged 9–17. A cross-sectional online survey among 11,728 mothers of girls aged 9–17 in Shenzhen, China was implemented between July and October 2023. Multi-level logistic regression models were fitted. Among 11,728 participants, 43.2% refused to have their daughters receive an HPV vaccination. In multivariate analysis, more openness in the mother-daughter communication (AOR: 0.99, 95%CI: 0.98, 0.99), perceived more positive outcomes of mother-daughter communication (AOR: 0.77, 95%CI: 0.75, 0.79), higher frequency of exposure to testimonials about daughters’ HPV vaccination (AOR: 0.81, 95%CI: 0.78, 0.85) and information encouraging parents to vaccinate their daughters against HPV on social media (AOR: 0.76, 95%CI: 0.73, 0.79), and thoughtful consideration of the veracity of the information specific to HPV vaccines (AOR: 0.80, 95%CI: 0.77, 0.83) were associated with lower vaccine refusal. Mothers who were not the main decision-makers of daughters’ HPV vaccination (AOR: 1.28 to 1.46), negative outcome expectancies of mother-daughter communication (AOR: 1.06, 95%CI: 1.04, 1.08), and mothers’ HPV vaccine refusal (AOR: 2.81, 95%CI: 2.58, 3.06) were associated with higher vaccine refusal for their daughters. The level of mothers’ HPV vaccine refusal for their daughters was high in China. Openness and outcome expectancies of mother-daughter communication and information exposure on social media were considered key determinants of HPV vaccine refusal for daughters. Future HPV vaccination programs should consider these interpersonal factors.
Introduction
Human papillomavirus (HPV) infection can cause cervical, oropharyngeal, vaginal, and vulvar cancers among females, presenting a significant public health challenge in China. With the second-highest incidence and mortality rates of HPV-related cancers globally, the country has witnessed a concerning upward trend in these rates over the past three decades.Citation1–6
The efficacy of HPV vaccination in preventing cancers associated with vaccine-type strains among females is well-established, with a favorable safety profile.Citation7,Citation8 China initiated the national HPV vaccination program in 2016, which was later than other developed nations.Citation2 In line with the recommendations made by international health authorities,Citation9 China recommends HPV vaccination for females aged 9–45 years.Citation10 By 2023, the country approved five HPV vaccines for use in females, including three bivalent vaccines (Cervarix, Cecolin, and Walrinvax), one quadrivalent vaccine (Gardasil 4), and one 9-valent vaccine (Gardasil 9). The cost of the whole course of these vaccines ranges from ¥1,080 (US$148 for Cecolin) to ¥3,993 (US$547 for Gardasil 9).Citation2,Citation11 Although basic health insurance in China covers the cost of the bivalent and quadrivalent vaccines, it does not cover the 9-valent vaccine. A pilot scheme under the national HPV vaccination program was launched in 2022, offering free bivalent vaccines to girls aged over 13 in Guangdong and Jiangsu provinces.Citation12 Girls aged 9–17 years in these provinces can also receive quadrivalent and 9-valent HPV vaccines following the arrangement of the national HPV vaccination program. At the time of this study, HPV vaccination is not yet available for boys in mainland China.
HPV vaccination for children prior to the onset of sexual activities is the most efficacious.Citation13 Parents are key decision-makers in children’s HPV vaccination.Citation14 Data on uptake rate and level of HPV vaccination refusal among girls aged 9–17 years is important to inform policymaking and service planning. Several studies have examined mothers’ refusal regarding daughters’ HPV vaccination.Citation15–17 Despite the presence of a free and school-based HPV vaccination program, 12% of mothers in Canada refused to have their 9- to 10-year-old daughters receive the HPV vaccine.Citation15 Over half of the parents in the United States (58%) refused to have their daughters receive the HPV vaccine as they were concerned that such vaccines were relatively new.Citation16 In China, relatively few studies investigated parental refusal or hesitancy toward HPV vaccination for their daughters. Studies reported that 12.4–50.0% of Chinese mothers or guardians refused to vaccinate their daughters aged 9–18 years against HPV.Citation18–20 Another study found that only 4.5% of Chinese girls aged 9–14 years either received the HPV vaccine or had made an appointment to do so. These studies mainly investigated determinants of parents/guardians’ refusal at the individual level. Significant determinants included characteristics of the parents/guardians (i.e., education and income, history of HPV-related diseases, knowledge about HPV vaccination) and the age of the girls.Citation15,Citation18-22 In addition, parents/guardians who refused to receive HPV vaccination were less likely to vaccinate their girls against HPV.Citation19,Citation20,Citation23
According to the socio-ecological model, factors in the interpersonal level refer to those related to a person’s social network or relationship with others (i.e., family members, friends, coworkers).Citation24 In the present day, such interactions may occur both online (through the internet and social media) and offline. This study focused on potential determinants of HPV vaccine refusal for daughters at the interpersonal level. Mother-daughter communication related to HPV vaccination is a group of interpersonal factors that may influence the decisions for daughters’ vaccination. Mothers played more critical roles than fathers in communicating with their daughters about vaccination, reproductive health, and sexual behaviors.Citation25,Citation26 Parents’ open and receptive communication style is one aspect of good parent-child relationships that fosters a positive family environment, improves family functioning, and contributes to effective parent-adolescent communication.Citation27 Studies found that openness in parent-adolescent communication was associated with a lower likelihood of sexual risk behaviors, depression, anxiety, or participating in antisocial activities among children.Citation28,Citation29 In addition, outcome expectancies of mother-daughter communication on HPV vaccines may influence parental vaccine refusal. Previous studies showed that positive outcome expectancies (i.e., expectations about the outcomes of conversation having positive effects) were positively associated with mother-daughter communication about sexual behaviors among adolescents.Citation30,Citation31 However, no study investigated the associations between HPV vaccine refusal and openness or outcome expectancies of mother-daughter communication among mothers.
Social media is an important place where parents can receive and share health information from and with others. Many parents use social media as one of the major sources of health information related to HPV vaccination.Citation32 Some studies found that exposure to negative or anti-vaccine contents was associated with lower vaccination rates.Citation32 Parents’ exposure to information related to Coronavirus disease (COVID-19) vaccines (i.e., SARS-CoV-2 infection after completing primary vaccine series) on social media was associated with a higher COVID-19 vaccine refusal for children aged 3–11 years in China.Citation33 Misinformation related to vaccination is widespread on social media.Citation34 Previous studies showed that thoughtful consideration of the veracity of the information on social media could mitigate the negative impact of misinformation,Citation35 which was associated with higher acceptance of vaccination.Citation36,Citation37 This study also investigated the association between HPV vaccine refusal and information exposure on social media and thoughtful consideration of the veracity of the information on social media.
To our knowledge, there was a dearth of studies investigating the associations between interpersonal level factors (i.e., mother-daughter communication and social media influence) and parental refusal toward HPV vaccination for their daughters. A knowledge gap exists. To address the knowledge gaps, an online survey was conducted in Shenzhen, China, to explore mother-daughter communication and social media influence on HPV vaccine refusal for daughters aged 9–17 years among mothers in China. We hypothesized higher openness in parent-adolescent communication, positive outcome expectancies of such communication, higher exposure to positive vaccine contents on social media, and thoughtful consideration of the veracity of the vaccine information on social media would be associated with lower vaccine refusal. Negative outcome expectancies of mother-daughter communication on HPV vaccines would be associated with higher vaccine refusal.
Materials and methods
Study design
This cross-sectional online survey was implemented among 11,728 mothers of girls aged 9–17 between July and October 2023 in Shenzhen, China. Shenzhen is a city in the Guangdong province where the pilot scheme under the national HPV vaccination program is implemented.
Participants and data collection
Inclusion criteria were: 1) mothers having at least one daughter aged 9–17 years at the date of the survey, 2) able to read simplified Chinese, 3) the daughter was studying in a primary or secondary school in Shenzhen at the time of the survey, and 5) had a smartphone with internet access. In case the participant has more than one eligible daughter aged 9–17 years, she referred to the one whose birthday is closest to the survey date (the index daughter) when answering questions. We confine our sample to mothers who are the primary decision-makers for children’s vaccination in China.Citation38
In 2022, there are 343 primary and 475 secondary schools with over 1.7 million students in Shenzhen, China. The research team input the names of all primary schools into an Excel file and those of all secondary schools into another Excel file. Using the “select random cells” function, the research team randomly selected 3% of these primary/secondary schools. All selected schools (11 primary schools and 13 secondary schools) have established WeChat groups involving parents and teachers to deliver school notices. In this study, the research team developed an online questionnaire using Questionnaire Star, a commonly used survey platform in China. Teachers of the participating schools posted the study information and a quick response code to access the online questionnaire in the WeChat groups and invited all mothers of female students to participate. The teachers also sent out reminders in the WeChat groups twice during the study period. The teachers and participants were asked not to disseminate the survey access link to people outside the WeChat groups. Before starting the online survey, the participants read a statement indicating that participation was voluntary, refusal would have no consequences, the survey would not collect personal contacts or other identifying information, and the data would only be used for research and kept confidential. Electronic informed consent was obtained. Each WeChat account was allowed to access the online survey once. The questionnaire had 90 items, about 15 items per page for six pages, which took about 15 minutes to complete. The online survey platform performed a completeness check before the submission of each questionnaire. In case there was a missing answer, the survey platform would automatically highlight the question and remind the participant to complete it before she could submit the questionnaire. In this study, we defined a completed survey as answering all questions and successfully submitting the questionnaire. Participants could review and change their responses before submission. No incentive was given to the participants. All data, protected by a password, were stored on the survey platform server. Only the corresponding author had access to the database. Ethics approval was obtained from the Ethics Committee of the Shenzhen Longhua District Maternity and Child Healthcare Hospital (ref: 2022122201).
Sample size planning
The target sample size was 10,000. Assuming the level of parental refusal in the reference group (with a facilitating condition of HPV vaccination) to be 10–50%, the sample size could detect the smallest odds ratio of 1.12 between mothers with and without the facilitating conditions, with a power of 0.80 and an alpha of 0.05 (PASS 11.0, NCSS LLC). We assumed the response rate to be 70% and aimed to invite 14,000 mothers to join the study. In 2022, the median number of students in primary/secondary schools was about 800. Assuming half of these students were female, the median number of eligible female students was around 400 in primary and 800 in secondary school. The number of eligible female students in the 24 participating primary and secondary schools should be sufficient to meet the target sample size.
Measurements
Development of the questionnaire
A panel of experts, including epidemiologists, clinicians, and CDC employees, developed the questionnaire for this study. To assess its clarity and readability, the questionnaire was pilot-tested with ten mothers. All participating mothers in the pilot study found the questionnaire easy to understand. Based on their feedback, the panel finalized the questionnaire. These ten mothers were not involved in the actual survey.
Background characteristics
The questionnaire collects sociodemographic characteristics of the mothers (age, education level, relationship status, employment status, and monthly household income), mothers’ self-reported history of HPV-related diseases, and the age of their index daughters.
HPV vaccination uptake and refusal
We first asked mothers whether their index daughters had received an HPV vaccination. For mothers whose index daughters had not received an HPV vaccination, we further asked about their likelihood of having their daughters receive an HPV vaccination in the next year (response categories: 1 = very unlikely, 2 = unlikely, 3 = neutral, 4 = likely, and 5 = very likely). Vaccine refusal was defined as “very unlikely,” “unlikely,” or “neutral.” The same definition was commonly used in published studies.Citation39–42 Two similar questions were used to measure mothers’ refusal to receive an HPV vaccination. Participants and/or their daughters who had received the HPV vaccination were asked for some details, such as the types of vaccines they received and/or their daughters and the time and location of the vaccination.
Mother-daughter communication related to HPV vaccination
We used the validated Openness Subscale of the Parent-adolescent Communication Scale to measure the openness of mother-daughter communication.Citation43,Citation44 This subscale is commonly used in previous studies across countries and cultures.Citation43,Citation44 The Cronbach’s alpha for this subscale was .93. The high value (>.90) of Cronbach’s alpha indicated the homogeneity of scale items. Participants were asked whether they had communicated with the index daughters regarding HPV vaccination. Two scales were constructed for this study to measure outcome expectancy of mother-daughter communication related to HPV vaccination. Three items measured perceived positive outcomes of mother-daughter communication associated with HPV vaccination (i.e., the index daughter will feel that you care about her) (response categories: 1 = disagree, 2 = neutral, and 3 = agree). Another three items measured perceived negative outcomes of mother-daughter communication, such as the perception that the communication would confuse the daughter with the same response categories. The Positive Outcome Expectancy Scale (Cronbach’s alpha: .69) and the Negative Outcome Expectancy Scale (Cronbach’s alpha: .62) were created by summing individual item scores. In addition, mothers were asked who mainly decided whether the index daughter should receive the HPV vaccination (response categories: the mother, the father, the index daughter, other family members, or a shared decision among family members).
Influence of social media related to HPV vaccination
We adapted validated questions to measure the frequency of exposure to information related to HPV vaccination on common social media platforms in China (i.e., WeChat Moments, Weibo, TikTok, and Red) in the past month. This measurement is commonly used in previous studies.Citation33,Citation45 This information included: 1) testimonials given by parents about daughters’ HPV vaccination; 2) negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines); 3) negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects); and 4) information that encourages parents to vaccine their daughters against HPV. Another validated measurement was used to measure thoughtful consideration about the veracity of information specific to HPV vaccines.Citation35 The response categories to the questions above were 1=almost none, 2=seldom, 3=sometimes, and 4=always.
Statistical analysis
Descriptive statistics were presented. The mean and standard deviation (SD) of the items and scales measuring mother-daughter communication and the influence of social media related to HPV vaccinations were also calculated. The dependent variable was HPV vaccine refusal for the index daughters. Multilevel logistic regression models (level 1: schools; level 2: individual participants) were fit to analyze the factors associated with the dependent variable. Random intercept models were used to allow the intercept of the regression model to vary across schools, which could account for intra-correlated nested data. Multilevel logistic regression models are commonly used in studies using similar sampling methods.Citation46,Citation47 A univariate two-level logistic regression model first assessed the significance of the association between each of the background characteristics and the dependent variables. Background characteristics with p < .05 in univariate analysis were adjusted in the multivariate two-level logistic regression model. Subgroup analyses were conducted for girls aged 9–12 years (ineligible for the free HPV vaccination program) and those aged over 13 years (eligible for the free program). Crude odds ratio (OR), adjusted odds ratios (AOR), and their 95% confidence intervals (CI) were reported. Hosmer and Lemeshow goodness-of-fit tests were conducted to evaluate the strength of the logistic regression models in this study.Citation48,Citation49 The insignificant Hosmer and Lemeshow goodness-of-fit test (p > .05) indicates that the model’s estimates fit the data at an acceptable level. The analyses were performed using SPSS (version 29.0; IBM, Armonk, NY, USA). A significance level of p < .05 was used.
Results
Background characteristics
During the study period 11,728 mothers completed the survey; the response rate was 83.8% (there were about 14,000 female students aged 9–17 years in the participating schools). Participants were between 28 and 61 years old. About half of the mothers had received tertiary education (48.2%) and were not employed full-time (58.4%). The majority of them were married (95.8%), had a monthly household income of more than ¥5,000 (USD 685) (83.3%), and did not have a history of HPV infection (95.9%) or HPV-related diseases (97.8%). Over half of their index daughters were 9–12 years old (61.0%). The differences in background characteristics between subgroups of mothers having daughters of different ages (9–12 years versus 13–17 years) were presented in .
Table 1. Background characteristics of the participants (n = 11,728).
HPV vaccination uptake and refusal
Among the index daughters of all participants, 18.9% had received the HPV vaccination. Among index daughters who had taken up HPV vaccination, 50.6% received domestic bivalent vaccines. All participants were able to provide details related to their daughters’ HPV vaccination (Appendix 1). The level of HPV vaccine refusal was 43.2% for the index daughters and 36.9% for themselves. Index daughters who were 9–12 years old had a lower HPV vaccination uptake than those who were 13–17 years (5.7% versus 39.5%; p < .001). The level of vaccine refusal was higher among mothers having daughters aged 9–12 years compared to those having daughters aged 13–17 years (52.2% versus 29.2%; p < .001) ().
Table 2. HPV vaccine uptake and refusal, mother-daughter communication, and influence of social media related to HPV vaccination.
Mother-daughter communication and social media Influence on HPV vaccination
Over half of the participants reported being the main decision-makers for their index daughters’ HPV vaccination (53.5%). Item responses and scale scores related to mother-daughter communication among all participants and different subgroups are shown in . Among all participants, less than 30% of the participants were sometimes/always exposed to testimonials given by parents about daughters’ HPV vaccination (29.1%), negative information about HPV vaccines (27.7%), and other vaccine incidents (25.8%) on common social media platforms. About half of them were sometimes/always exposed to information encouraging parents to vaccinate their daughters against HPV through such channels (49.1%). About half of them sometimes/always consider the veracity of information specific to HPV vaccines in the past month (50.5%). Compared to mothers with daughters aged 9–12 years, those aged 13–17 perceived more positive outcomes of discussing HPV vaccines with the index daughters ().
Factors associated with HPV vaccine refusal for the index daughters
Among all participants, mothers who were older, better educated, currently single, with higher monthly income, and had a history of HPV infection had lower HPV vaccine refusal for their index daughters. The older age of the index daughters was also associated with lower vaccine refusal. In contrast, mothers without a full-time job had higher vaccine refusal (). The associations between background characteristics and the dependent variables were similar between different participant sub-groups, except for age group and relationship status. Older age was associated with higher vaccine refusal among mothers having daughters aged 13–17 years. However, the association between the age group and vaccine refusal was not statistically significant among mothers with daughters aged 9–12. Being single was associated with lower vaccine refusal among mothers with daughters aged 9–12 years but not among those with daughters aged 13–17 years ().
Table 3. Associations between background characteristics and HPV vaccine refusal for the index daughters.
After adjusting for these significant background characteristics and among all participants, more openness in the mother-daughter communication (AOR: 0.99, 95%CI: 0.98, 0.99) and perceived more positive outcomes of mother-daughter communication (AOR: 0.77, 95%CI: 0.75, 0.79) were associated with lower HPV vaccine refusal for the index daughters. Negative outcome expectancies of mother-daughter communication (AOR: 1.06, 95%CI: 1.04, 1.08) and not being the main decision-makers of daughters’ HPV vaccination (AOR: 1.28 to 1.46) were associated with higher HPV vaccine refusal. Regarding the social media influence, higher frequency of exposure to testimonials given by parents about daughters’ HPV vaccination (AOR: 0.81, 95%CI: 0.78, 0.85) and information encouraging parents to vaccinate their daughters against HPV (AOR: 0.76, 95%CI: 0.73, 0.79) were associated with lower vaccine refusal. Thoughtful consideration of the veracity of the information specific to HPV vaccines was also associated with lower vaccine refusal (AOR: 0.80, 95%CI: 0.77, 0.83). In addition, mothers who refused to receive HPV vaccination were more likely to have vaccine refusal for their index daughters (AOR: 2.81, 95%CI: 2.58, 3.06). The aforementioned logistic regression models had acceptable fits (Hosmer and Lemeshow test ranged from .06 to .88). The associations between interpersonal level variables and the dependent variables were similar between different sub-groups of participants (). The logistic regression models in subgroup analysis also had acceptable fits.
Table 4. Associations of mother-daughter communication and social media influence with HPV vaccine refusal for the index daughters.
Discussion
Understanding mothers’ vaccine refusal is pivotal to facilitating the successful implementation of the national HPV vaccination program targeting girls aged 9–17 years in China. Our study provided the latest level of HPV vaccine refusal among mothers in Shenzhen, which is useful to predict actual vaccine uptake in this age cohort. Our findings contributed to the literature by exploring the influences of interpersonal-level factors, such as mother-daughter communication and social media influence, on HPV vaccine refusal in a large sample of mothers. Furthermore, our findings provided a knowledge basis to guide the development of health promotion initiatives and service planning.
The HPV vaccine uptake rate among index daughters was less than 20%, and 43.2% of mothers refused to have their daughters receive the HPV vaccination. This level of vaccine refusal surpasses those reported in other studies from China,Citation18 Canada (12.0%),Citation15 the United States (18.0%-23.0%),Citation50,Citation51 and Australia (34.0%).Citation19–20,Citation50–53 Several reasons could explain the discrepancy between our findings and those of others. Firstly, China initiated its HPV vaccination programs approximately a decade later than these countries. As proposed by the Diffusion of Innovation Theory, adopting innovations, such as HPV vaccination for girls, requires time to reach a critical mass in order to have a self-sustaining adoption rate.Citation54,Citation55 In China, the diffusion of HPV vaccination has yet to attain such a critical mass. Unlike many developed nations, China has not incorporated HPV vaccination into its childhood vaccination scheme.Citation10,Citation56 As a result, mothers in China may perceive HPV vaccination as optional and less imperative for their daughters.
The older age of the index daughters was associated with lower HPV vaccine refusal among mothers. The belief that the child was too young to receive HPV vaccination was correlated with lower parental acceptance of HPV vaccination in previous studies.Citation57,Citation58 In line with previous studies, higher socioeconomic status (higher education, higher income, and full-time employment) was associated with lower HPV vaccine refusal in this study.Citation59–61 Mothers with higher socioeconomic status usually have better health literacy.Citation62,Citation63 To address the disparity, more attention should be given to mothers of lower socioeconomic status in future HPV vaccination promotion programs. Moreover, self-reported history of HPV infection among mothers was correlated with lower vaccine refusal for their daughters. It is possible that these mothers perceive a higher threat of HPV and, hence, a stronger need to vaccinate their daughters against HPV.
This study also had some practical implications for developing health promotion programs for mothers. First, openness in mother-daughter communication was associated with lower HPV vaccine refusal for daughters in this study. Previous studies showed that open parent-child communication is a protective factor of behavioral problems in youths (i.e., risky sexual behaviors, tobacco and alcohol use).Citation28,Citation29,Citation64 Mothers with an open communication style are more likely to communicate their opinions, concerns, and expectations for a health-related behavior (i.e., taking up HPV vaccination) directly to their children.Citation64 This study suggested that promoting open communication within the family may improve children’s healthy behaviors and well-being. Second, the majority of the mothers perceived some positive outcomes of communicating with their daughters about HPV vaccination. It is necessary to increase these positive outcome expectancies, as they were associated with lower refusal. However, about 30% of the mothers perceived some negative outcomes of mother-daughter communication about HPV vaccination (i.e., the daughter will get confused or argue with them), and such negative outcome expectancies were associated with higher vaccine refusal. Our findings were similar to previous studies that explored the impacts of outcome expectancies of parent-adolescent communication on other adolescent behaviors.Citation65,Citation66 Mothers who perceived more positive outcomes of parent-daughter communication would have more confidence to communicate directly with their daughters.Citation66 Testimonials of mothers about the positive outcomes of parent-daughter communication about HPV vaccination and learning skills to address daughters’ concerns and emotional responses to HPV vaccination may be useful to modify outcome expectancies. Furthermore, mothers being the main decision-makers of daughters’ HPV vaccination was associated with lower HPV vaccine refusal, which is consistent with previous studies.Citation67,Citation68
Our findings suggested that social media is a popular place for parents in China to share information related to children’s HPV vaccination, as 30–50% of our participants were sometimes/always exposed to information encouraging parents to vaccinate their daughters against HPV and testimonials given by parents about their daughters’ HPV vaccination in the past month. Higher exposure to these topics was associated with lower vaccine refusal. Such exposure may become a strong cue to action, a known facilitator of HPV vaccine acceptance, for parents in China.Citation14 Health authorities should consider using their official social media accounts to disseminate health promotion messages related to HPV vaccination. These official social media channels were regarded as credible information sources among Chinese people.Citation35 In line with previous studies,Citation35–37 thoughtful consideration of the veracity of information specific to HPV vaccination played an important role in reducing vaccine refusal. Thoughtful consideration may mitigate the negative impacts of misinformation on parental acceptability of HPV vaccination for their daughters. It is encouraging to observe that over half of the mothers sometimes/always considered the veracity of HPV vaccination-related information, and there is room for improvement.
Subgroup analyses suggested that mothers having daughters aged 9–12 years had higher HPV vaccine refusal than those with daughters aged 13–17 years. The pilot scheme under the national HPV vaccination program is implemented in Shenzhen, providing free HPV vaccines to girls aged 13 years or above. Mothers with daughters under 13 might prefer waiting until their daughters become eligible for the pilot scheme. The government should consider expanding the pilot scheme to cover girls aged 9–12 years to maximize its public health benefits. In this study, the associations between interpersonal level factors (i.e., mother-daughter communication, the influence of social media) and the HPV vaccination refusal were similar between different sub-groups of participants. Similar strategies can be used to reduce HPV vaccine refusals for mothers having daughters of different ages.
This study has several limitations. First, we only recruited participants from Shenzhen, where the pilot scheme providing a free HPV vaccination program for girls aged 13 years or above was implemented. Therefore, our findings could not be generalized to other Chinese cities without the pilot scheme. The level of HPV vaccine refusal for daughters among mothers in other Chinese cities is expected to be higher in the absence of free HPV vaccination. Second, we were not able to use medical records or laboratory testing to verify the HPV vaccination status due to the constraints of available resources. However, all mothers with vaccinated daughters were able to provide sufficient details (i.e., time, location, types of vaccines) related to their daughters’ HPV vaccination. Due to social desirability, mothers might still under-report HPV vaccine refusal for their daughters.Citation69 Third, this survey was anonymous, and we could not collect information from mothers who refused to answer the online questionnaire. Selection bias existed. Fourth, scales were self-constructed to measure outcome expectancies of mother-daughter communication. Although the internal validity of these scales was acceptable, they were not validated by separate studies. Fifth, this was a cross-sectional study and could not establish causality. Furthermore, Some binary variables, such as relationship status, self-reported history of HPV infection, and self-reported history of HPV-related diseases, have a low-frequency category (<5%). It can pose potential challenges, affecting the estimation of regression coefficients and potentially leading to biased estimates in this study. Finally, we did not collect data on the class of their index daughters and were not able to consider the cluster effects of girls from the same class in the analyses.
Conclusion
In conclusion, our study highlighted a notable level of HPV vaccine refusal among mothers in Shenzhen, China, concerning their daughters aged 9–17 years. The dynamics of openness and outcome expectancies in mother-daughter communication and the influence of information exposure on social media emerge as key determinants of this refusal. Future vaccination programs and policymakers may consider these interpersonal factors to address and mitigate HPV vaccine refusal effectively.
Author’s contributions
Conceptualization: Z.L., S.C., L.S., H.C., Z.W.; methodology: Z.L., S.C., L.S., H.C., Y.F., X.L., K.F.C., Z.W.; data curation: Z.L., L.S., H.C., J.C., B.L., C.W.; project administration: Z.L., L.S., H.C., J.C., B.L., C.W.; writing-original draft preparation: S.C., Z.L., L.S., H.C., Y.F., X.L., K.F.C., Z.W.; writing-review and editing: S.C., Y.F., X.L., K.F.C., Z.W. All authors have read and agreed to the published version of the manuscript.
Institutional review board statement
This study was conducted following the guidelines of the Declaration of Helsinki. Ethics approval was obtained from the Ethics Committee of the Shenzhen Longhua District Maternity and Child Healthcare Hospital (ref: 2022122201).
Informed consent statement
Prospective participants were informed that the survey was anonymous, their information will be kept strictly confidential, and they had the right to refuse to participate or withdraw from the study at any time. Refusal and withdrawal would not affect their access to any services. Electronic informed consent was obtained.
Appendix 1.docx
Download MS Word (14.6 KB)Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The datasets generated and/or analyzed during the current study are not publicly available as they contain sensitive personal behaviors but are available from the corresponding author on reasonable request.
Supplementary material
Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2333111.
Additional information
Funding
References
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