Factors associated with intention of human papillomavirus vaccination among Chinese college students: implications for health promotion

ABSTRACT

Human papilloma virus (HPV) is the most common reproductive tract virus. Most HPV infections occur during adolescence or young adulthood, and thus college students are one of the main target populations of HPV vaccination. However, data on knowledge of HPV and HPV vaccine as well as the intention to be vaccinated among Chinese college students were limited. The purpose of this study was to address this gap by investigating a sample of college students from four universities and analyzing the factors influencing their intention. College students (N = 343) filled in a survey comprised of demographic information, HPV and vaccine knowledge, and vaccination intention between September 2018 and January 2019. A descriptive statistical analysis was conducted to describe students’ HPV-related knowledge and vaccination intention. Logistic regression analysis was used to determine the predictors of HPV vaccination intention. The participants had low levels of HPV and HPV vaccine-related knowledge, as well as modest intention to be vaccinated. Significant differences were identified in gender, years of study, and perceived susceptibility of HPV infection. Students who perceived higher risk of HPV infection (OR = 6.659, p = .001), had higher level knowledge of HPV vaccine (OR = 2.697, p < .001), in junior (OR = 0.186, p = .006) and senior year (OR = 0.276, p = .015) had greater intention to get HPV vaccinated. The findings suggest that multiple-level efforts are continuously needed to target Chinese college students to increase their HPV vaccine knowledge and vaccination awareness to reduce HPV-related disease burden among this population.

KEYWORDS:

• Human papillomavirus
• HPV vaccine
• knowledge
• vaccination intention
• college students

Introduction

Human papilloma virus (HPV) is the most common reproductive tract virus. HPV is mainly transmitted through sexual contact and is prevalent among sexually active individuals worldwide. ¹ People at the age range of 20 and 39 years are the main targets of HPV. Most sexually active people at this age range will be infected with the virus at some stage in their lives and may even be repeatedly infected.² HPV infection is linked to various cancers, including cancer of the cervix, vagina, vulva in women, penis, and prostate in men, cancers of anus and oropharynx in both men and women, and recurrent respiratory papillomatosis.^3,4 In fact, 90.0% cases of cervical cancer can be traced back to HPV infection, and thus is by far the most common HPV-related disease.³

In China, the incidence of cervical cancer is 6 times of that in developed countries, and is rising at an annual rate of 2.0%–3.0%. The age of diagnosed people tends to be younger than before.⁵ The incidence of cervical cancer ranks third among women at the age range of 15 and 44 years in China. In 2018, it was estimated that 106,430 women in China were diagnosed with cervical cancer each year, accounting for about 19.7% of the global total.⁵ In addition, 47,739 Chinese women die of cervical cancer each year.⁵ Fortunately, HPV vaccination can prevent 70.0%–90.0% of HPV-related cancers, and the effectiveness is better when administered before the onset of sexual activity.³ The World Health Organization recommends the age range of 9–26 years as the optimal age of HPV vaccination. However, the vaccine coverage rate among all eligible groups remains low.⁶

Recent research found that HPV vaccine knowledge, attitudes, perceived effectiveness against HPV infection, and perceived benefits from the vaccine were significant predictors of HPV vaccination uptake among young and mid-age adults in the U.S.^7,8 Lots of studies have investigated knowledge of HPV and HPV vaccine as well as vaccination among different populations. However, the study findings showed regional and country differences, and were even mixed. For instance, studies in the U.S. found that male adults were less likely than female to be aware of HPV and HPV vaccine, and the male had lower awareness that HPV causes penile, oral, and anal cancers.^9,10 However, other researchers reported that male adults in the U.S. had greater HPV vaccine awareness than female, and there was no gender difference regarding the perceived effectiveness of the vaccine in preventing cervical cancer.¹¹ Apparently, current research on HPV vaccination was primarily from developed countries (e.g., USA), and data were mainly from general adults, with limited focus on young adults such as college students.

College is a critically important time for late HPV vaccination among individuals who are not previously immunized.¹² It is also a period when individuals start to assume increased responsibility and independence to make their own health-related decisions, including HPV vaccination uptake.⁷ In the meantime, college students are a group becoming sexually active and thus at high risks of HPV infection. With rapid socioeconomic development and globalization in China, there is a sexual culture shift from being traditional to more liberated, especially among young people.¹³ Current adolescents initiate sexual behavior at an earlier age than their counterparts in the past.¹⁴ Most adolescents have their first sex during college, and a proportion of them had risky sexual behaviors including no or ineffective contraception and multiple sexual partners.¹⁵ Therefore, Chinese college students are increasingly at a risk of being infected with HPV, and thus are one of the main target populations of HPV vaccination. In a recent Chinese study on attendees at a sexually transmitted disease clinic, epidemiological data showed that the overall HPV infection rate in females and males was 50.5% and 50.8%, respectively.²

Notably, the HPV vaccine was not approved until 2016 in Mainland China. Specifically, the bivalent Cervarix for girls aged 9 to 25 years, and the quadrivalent Gardasil for women aged 20 to 45 years were marketed in 2017. The nonvalent Gardasil-9 for women aged 16 to 26 years were marketed in 2018. However, these vaccines have not been included into the national immunization program in China, and thus people get vaccinated at their own expense.¹⁶ Apart from high price of HPV vaccine, lack of vaccination awareness and knowledge together contributed to low vaccination coverage in China.¹⁷ However, research data regarding knowledge, attitudes, and practices of HPV and HPV vaccine among Chinese college students were mostly collected before HPV vaccine approval in 2016. HPV and HPV vaccines have become a topic frequently covered in social media and the public since its approval in China. However, the vaccination rate is quite low. A survey in 2019 shows that less than 3.0% of women aged 18–45 years in mainland China have been vaccinated.¹⁸ Therefore, the study aimed at updating knowledge about HPV and vaccination intention among college students in China to understand the status and associated factors for improving vaccination uptake.

Materials and methods

Study design and sample

This cross-sectional descriptive study was conducted with a convenience sample of college students at four universities in Qingdao city of Shandong Province, China. The inclusion criteria were: (1) a student studying in the selected universities, (2) between 16 and 26 years of age, (3) able to fill out the questionnaire independently, and (4) willing to participate in the study. The sample size was estimated based on the rule of thumb for multivariable logistic regression analysis, i.e., at least 10 to 15 events per variables (EPV) were required and EPV≥20 generally eliminates bias in regression coefficients.¹⁹ This study included eight variables in sociodemographic characteristics, related knowledge, and perception, resulting in a required sample size of 160 for this study. With consideration of a response rate of 80%, a sample of 192 participants was determined.

Data collection

Data were collected after obtaining ethical approval by the ethics committee of the university where the study was conducted. By using convenience sampling, participants were recruited between September 2018 and January 2019. A questionnaire was designed to use for data collection. The survey took around 15–20 minutes for the participants to complete. Research members distributed the paper-based questionnaires on campus at noon or later afternoon when students had no class schedule. Specifically, research members approached potential participants in places such as dining halls and dormitory buildings where most students passed by every day. The researchers explained the study aims to the participants and assured voluntariness, anonymity and confidentiality for their participation. All the participants signed informed consent before participation. A total of 370 questionnaires were distributed and returned, of which 27 questionnaires were excluded due to incomplete filling by respondents, resulting in 343 valid questionnaires. The effective response rate was 92.7%.

Measures

Based on the research purpose and literature,^7,11,17 a self-designed questionnaire was developed to investigate knowledge of HPV and HPV vaccine, as well as intention to get HPV vaccinated among college students in Qingdao city. The questionnaire consisted of three parts: sociodemographic information (e.g., gender, school type, grade, and major), knowledge of HPV and HPV vaccine, and HPV vaccination intention.

The second part of the questionnaire, i.e., HPV and HPV vaccine knowledge, included 17 items. This part was reviewed by a dermatologist and gynecologist to validate the content being scientific and feasible. Specifically, there were 11 items about HPV infection knowledge in three aspects, i.e., the transmission routes, diseases associated with HPV, and the consequences of HPV. There were six items about HPV vaccine knowledge, including the optimal inoculation time, target population, vaccination place, and diseases prevented by HPV vaccination. Participants were provided with “True,” “False,” or “Don’t know” options in the 17 items. One point was assigned if participants responded with correct answer, and zero was assigned if participants responded with wrong answer or “Don’t know.” The total score was calculated by summing the score of each item, resulting in a total of 0–11 points in knowledge of HPV infection, and 0–6 points in knowledge of HPV vaccine, respectively, with higher score indicating better knowledge in the areas. In addition, students were asked about sources from which they obtained HPV-related information and could select all that applied. Another item “Do you think you have a risk of being infected by HPV?” was also included in the questionnaire to assess students’ perceived risk of HPV infection.

The third part of the questionnaire was participants’ intention to get HPV vaccinated, which was assessed by one item asking “Are you willing to get HPV vaccinated in the next year?” If participants responded with “No” option, they were asked to describe the reasons for reluctance to get vaccinated.

To be noted, the questionnaire was pilot tested before formal investigation through recruiting a few students to examine its face validity and internal reliability. A total of 6 students were interviewed informally to check whether the items were understandable. The Cronbach’s α coefficient of the questionnaire was 0.717, which was considered acceptable.

Data analysis

Data analyses were conducted using the Statistical Package for Social Sciences, SPSS 24.0. Descriptive analyses were performed to examine the distribution of all variables of interest, including normality, means, and frequencies. The data about HPV and HPV vaccine knowledge did not meet the normal distribution. Therefore, median (M) and lower/upper quartiles (P25, P75) were used to describe knowledge scores. The non-parametric tests including Mann–Whitney U and Kruskal-Wallis H were employed to compare the difference of knowledge between groups of students. Chi-square test was used to compare the intention of HPV vaccination between groups. The binary logistic regression analysis was used to explore the factors affecting intention of HPV vaccination. A value of P < .05 was considered as statistical significance.

Results

Sociodemographic characteristics

The 343 college students were aged 17 to 22 years, with mean age of 19.99 ± 0.93 years. The majority of the participants were female students (70.5%) and enrolled at a bachelor program (84.5%). Of the participants, 200 (58.3%) were in junior year, and 157 (45.8%) majored in healthcare science. Other characteristics of the sample are presented in Table 1.

Table 1. Sociodemographic characteristics of the participants

Participant characteristics	N(%) N = 343
Gender
Male	101 (29.5)
Female	242 (70.5)
Study program
Bachelor degree	290 (84.5)
Associate degree	53 (15.5)
Year of study
Freshman	28 (8.2)
Sophomore	50 (14.6)
Junior	200 (58.3)
Senior	65 (18.9)
Major
Healthcare science	157 (45.8)
Non-healthcare science	186 (54.2)
Attitude toward having sex among college students
Approval	202 (58.9)
Disapproval	141 (41.1)

Knowledge of HPV and HPV vaccine

Among the 343 participants, the majority (70.8%) had heard of HPV. They reported that the main source of HPV knowledge was the Internet (47.8%), followed by school education (32.1%), public advertising (28.8%), and newspaper/magazine (22.7%). Most participants knew that HPV could be transmitted during sexual intercourse (61.8%), but 37.0% reported not knowing the transmission route of HPV. Only a few (9.3%) knew all the three transmission routes of HPV. Slightly over a half of the participants knew that HPV could cause cervical cancer (51.9%), while 40.52% did not know any HPV-related disease. Specifically, the median score of HPV knowledge was 4 (0, 7) out of 11. Most participants (63.8%) provided right answers for less than 6 questions about HPV infection and only 1.5% correctly answered all the 11 questions about HPV infection. In addition, only a small number of students (23.9%) thought they were at risk of contracting HPV.

Regarding HPV vaccine-related knowledge, the majority of participants perceived necessity for both female and male to receive HPV vaccination. Specifically, 91.3% of the participants thought that female was supposed to get vaccinated, while a few participants (17.8%) perceived unnecessary for male to get HPV vaccination. A large proportion of the participants (93.0%) recognized the benefits of HPV vaccination in light of offering protection against related diseases. Nevertheless, only 36.4% were aware that the nine-valent vaccine (Gardasil-9) had been available in mainland China. A number of participants did not know both the optimal time (31.5%) of get HPV vaccinated and vaccination places (70.6%). The median score of HPV vaccine-related knowledge was 4 (3, 5) out of 6. Most participants (63.6%) correctly answered half of the six questions on HPV vaccine-related knowledge. Only 14.9% of the participants correctly answered all the 6 questions about HPV vaccine. Detailed information is shown in Table 2.

Table 2. Knowledge of HPV and HPV vaccine among college students

Questions about HPV/HPV vaccine	N(%) N = 343
Routes of HPV transmission *
Sexual Transmission	212 (61.8)
Indirect contact transmission	70 (20.4)
Maternal-neonatal transmission	159 (46.4)
Don’t know	127 (37.0)
Diseases associated with HPV *
Cervical cancer	178 (51.9)
Genital wart	142 (41.4)
Penile cancer	91 (26.5)
Anal cancer	56 (16.3)
Don’t know	139 (40.5)
Perceived risk of HPV infection †
Yes	82 (23.9)
No	261 (76.1)
Consequences of HPV infection *
Causes a variety of skin diseases including condyloma acuminatum	162 (47.2)
Becomes long-term latent infection or subclinical infection	166 (48.4)
Progresses into a tumor	142 (41.4)
Spontaneous regression	25 (7.3)
Don’t know	145 (42.3)
HPV vaccination for female †
Necessary	313 (91.3)
Not necessary	30 (8.7)
HPV vaccination for male †
Necessary	282 (82.2)
Not necessary	61 (17.8)
HPV vaccines offer protection against related diseases †
Yes	319 (93.0)
No	24 (7.9)
I know the nine-valent HPV vaccine is available in mainland China†
Yes	125 (36.4)
No	218 (63.6)
Know where to get HPV vaccinated †
Yes	101 (29.4)
No	242 (70.6)
The optimal time to get HPV vaccinated †
Before the first sex	220 (64.1)
After the first sex	15 (4.4)
Don’t know	108 (31.5)

* Multiple-choice question.

† Single-choice question.

HPV, Human papillomavirus.

Intention to get HPV vaccination

The majority of participants (75.5%) reported that they were willing to get HPV vaccination. For those who did not intend to receive HPV vaccine (24.5%), the reasons they offered included worrying about the side effects of the HPV vaccine (59.5%), believing no likelihood of being infected with HPV (54.8%), uncertainty about the effectiveness of the HPV vaccine (44.1%), limited availability of HPV vaccine (41.7%), and costing too much (32.1%).

Factors influencing HPV/HPV vaccine knowledge, and intention of HPV vaccination

As Table 3 shows, Mann-Whitney U test revealed that female, health science students, students perceived risk of HPV infection, and in associate degree program had significantly higher scores in knowledge of HPV and HPV vaccine than male, non-health science students, those perceived no risk of HPV infection, and students in bachelor degree program (P < .05), respectively. Kruskal-Wallis H test showed that students in different grades had significantly varying scores in the two domains. Further multiple comparisons indicate that junior and senior students had higher scores in HPV knowledge than freshman and sophomore. For HPV vaccine-related knowledge, junior and senior students had higher scores than sophomores. Senior student had higher scores in both HPV and HPV vaccine-related knowledge than junior students. However, for students who approved and disapproved sexual behaviors among college students, no statistically significant difference was found in both HPV and HPV vaccine-related knowledge.

Table 3. Comparison of HPV knowledge, HPV vaccine knowledge and intention to get HPV vaccinated

Variable	HPV knowledge [M(P25, P75)]	Z value	P-value	HPV vaccine-related knowledge [M(P25, P75)]	Z value	P-value	HPV vaccination intention (n)			χ^2 value	P-value
							Yes	No	Having intention
Gender		−3.925	<0.001		−6.192	<0.001				6.515	0.011
Male	2.0(0.0, 5.0)			3.0(3.0, 4.0)			67	34	66.3%
Female	4.0(2.0, 7.0)			4.0(3.0, 5.0)			192	50	79.3%
Major		−7.256	<0.001		−4.621	<0.001				6.935	0.008
Health science	6.0(3.0, 8.0)			4.0(4.0, 5.0)			129	28	82.2%
Non-health science	2.0(0.0, 5.0)			4.0(3.0, 4.0)			130	56	69.9%
Study program Bachelor degree Associate degree	4.0(0.0, 7.0) 5.0(3.0, 8.0)	−2.419	0.016	4.0(3.0, 5.0) 4.0(3.0, 6.0)	−2.472	0.013	216 74	43 10	83.4% 88.1%	1.071	0.301
Grade		15.902	<0.001		17.928	0.001				11.891	0.008
Freshman^(1)	2.5(0.0, 5.0)			4.0(3.0, 4.0)			22	6	78.6%
Sophomore^(2)	2.0(0.0, 5.3)			3.0(3.0, 4.0)			30	20	60.0%
Junior ^(3)	4.0(1.0, 7.0)			4.0(3.0, 5.0)			150	50	75.0%
Senior ^(4)	5.0(2.5, 8.0)			4.0(3.0, 5.0)			57	8	87.7%
Attitude toward having sex among college students		−0.067	0.947		−0.776	0.438				0.784	0.376
Approval	4.0(0.0, 7.0)			4.0(3.0, 5.0)			156	46	77.23%
Disapproval	4.0(0.0, 7.0)			4.0(3.0, 5.0)			103	38	73.05%
Perceived risk of HPV infection		−2.663	0.008		−4.871	<0.001				22.413	<0.001
Yes	5.0(2.0, 9.0)			5.0(4.0, 6.0)			78	4	95.12%
No	4.0(0.0, 7.0)			4.0(3.0, 5.0)			181	80	69.35%

Multiple comparison results: HPV knowledge (3)>(2)**, (3)>(1)**, (4)>(3),(2),(1)**. HPV vaccine knowledge (3)>(2)**, (4)>(2),(3)**. HPV vaccination intention: (3)>(2)*, (4)>(2)**, (4)>(3)*.

*P < 0.05; **P < 0.01.

HPV, Human papillomavirus; IQR, Inter quartile range.

Chi-square test showed that female (79.3%) and health science students (82.2%) had statistically greater intention to get HPV vaccinated than male (66.3%) and non-health science students (69.9%), respectively. Students who perceived risk of HPV infection (95.1%) reported statistically greater intention to HPV vaccination than those who perceived no risk (69.4%). The difference in intention was statistically significant among students in different grades. Specifically, senior and junior students had greater intention than sophomore, while senior students had greater intention than junior students. No significant difference in intention was found between freshman and sophomore, and between students holding different attitudes toward having sex among college students (Table 3).

A binary logistic regression analysis was performed with HPV vaccination intention as the dependent variable, and HPV knowledge, HPV vaccine-related knowledge, as well as demographic information as independent variables. The final regression model showed that perceived risk of HPV infection (OR = 6.659), HPV vaccine-related knowledge (OR = 2.697) and grade were the main significant predictors of HPV vaccination intention. Using freshman as the reference group, students in junior (OR = 0.186) and senior years (OR = 0.276) had greater intention to get HPV vaccinated (Table 4).

Table 4. Logistic regression analysis of influencing factors of HPV vaccination intention

Variable	B	SE	Waldχ^2	p-Value	OR value	95% CI
Constant	−0.005	1.346	0	0.997	0.995
HPV knowledge	−0.102	0.054	3.590	0.058	0.903	0.821 ~ 1.004
HPV vaccine-related knowledge	0.992	0.158	39.571	<0.001	2.697	1.980 ~ 3.675
Perceived risk of HPV infection	1.896	0.563	11.334	0.001	6.659	2.208 ~ 20.083
Attitude toward sex among college students	−0.081	0.325	0.062	0.803	0.922	0.487 ~ 1.744
Gender	−0.193	0.370	0.272	0.602	0.824	0.399 ~ 1.703
Grade
Freshman year (Ref)			8.045	0.045
Sophomore year	−0.881	0.667	1.741	0.187	0.415	0.112 ~ 1.533
Junior year	−1.682	0.607	7.669	0.006	0.186	0.057 ~ 0.612
Senior year	−1.286	0.531	5.868	0.015	0.276	0.098 ~ 0.782
Major	−0.277	0.375	0.547	0.460	0.758	0.363 ~ 1.581
Study program	−0.294	0.536	0.301	0.583	0.745	0.260 ~ 2.132

HPV, Human papillomavirus; SE, Standard error; OR, Odds ratio; CI, Confidence interval.

Nagelkerke’s R² = 0.373.

Discussion

Within the context of increasing prevalence of HPV infection and sexual behavior among college students in China, the present study sought to explore knowledge of HPV and HPV vaccine, intention to get HPV vaccinated, and the factors associated with HPV vaccination intention among college students.

Overall, the students reported deficient knowledge of HPV and HPV vaccine. In particular, students lacked knowledge about transmission routes of HPV, HPV-related diseases, and optimal time as well as places to get HPV vaccinated. Except for sexual contact, a proportion of the students did not know other transmission routes such as indirect contact transmission and maternal-neonatal transmission. This deficit of knowledge may explain that only a small proportion of students perceived risk of HPV infection in the present study. A little more than half of the participants (51.9%) knew that HPV could cause cervical cancer, while 40.5% did not know any HPV-related disease. Only 7.3% of participants knew the fact that about 90.0% of HPV infections will resolve spontaneously within 2 years without special treatment for the majority of individuals.²⁰ Compared with data before HPV vaccine approval in China in 2016,²¹ levels of HPV knowledge and vaccination awareness among adults appeared to rise. Nevertheless, HPV-related knowledge among college students in the present study was much lower than those from other developed areas such as Hong Kong and USA. For instance, studies showed that 78.0% of general adults¹⁰ and 74.0% of the college students⁷ in USA knew that HPV can cause cervical cancer. Researchers reported that 48.0% and 47.0% of the American college students correctly answered questions on HPV knowledge and HPV vaccine, respectively.⁷ In contrast, a number of participants in the present study were ignorant of the optimal time to get vaccinated and vaccination places. The deficient knowledge among Chinese college students may be attributed to delayed HPV vaccine approval and less related HPV vaccination program promotion in China compared to developed countries. To be noted, HPV vaccine supply in China could hardly meet the current demand, which causes the limited availability of HPV vaccine, especially in rural areas.¹⁶ In urban areas, only a few community health service centers (not including health centers in colleges) in China have HPV vaccines and provide HPV vaccination service. This poor availability of HPV vaccine could explain the result that a large proportion of college students in this study did not know where to get vaccinated.

Despite insufficient knowledge of HPV and HPV vaccine, the majority of students (75.5%) in the present study expressed intention of HPV vaccination and held a positive attitude toward the efficacy of HPV vaccine, indicating their desirability of seeking health-promotion behaviors. On the other hand, about one-quarter of the students refused to get vaccinated due to various psychosocial and structural barriers, including concern about the side effects of the HPV vaccine, perception of low susceptibility of HPV infection, uncertainty about the effectiveness, limited availability, and high cost of HPV vaccine. The results were partially consistent with that of a qualitative study which addressed safety and effectiveness of the HPV vaccine as the most salient information needed by college students to make decision about vaccination.²² Research has consistently proved that HPV vaccine is safe and efficient against HPV infection and related cancers.²³ Consequently, more efforts are warranted from social and structural levels to support Chinese college students to obtain protection against HPV infection by increasing their related knowledge and vaccine availability. Since HPV vaccines have recently been introduced into China, evidence-based information about the effectiveness and safety of HPV vaccine is particularly important for college students. Several studies found that vaccines being recommended by health professionals and being supported by government can substantially increase the uptake of vaccination.^22,24 These findings demonstrate that health professionals need to play their part in HPV-related educational interventions and vaccination campaigns by virtue of their valued and recognized influence.

Students in the present study reported that the Internet and school education were the main sources to obtain information about HPV and HPV vaccine, whereas most participants had low levels of knowledge. This suggests that the main sources of information did not play an adequate role in disseminating HPV-related information. A study confirmed that social media-based intervention was effective to engage college students for improving their knowledge and increasing HPV vaccination awareness.¹² College students in USA voiced that creating videos, and/or posting infographics and disseminating them on popular social media such as YouTube and Instagram as their preferred health education source.²² Similarly, current Chinese college students widely use social media and own a Smartphone in the information era. Therefore, future interventional programs could consider employing social media as the effective medium to help college students acquire and understand related HPV information for enhancing their vaccination intention.

Regarding factors influencing HPV knowledge and intention to get vaccinated, the present study found similar results with previous studies in terms of year of study, gender difference, and perceived susceptibility of HPV infection.^9–11,25 For instance, the year of study was positively associated with HPV knowledge and vaccination intention among nursing students in Turkey.²⁵ These findings highlighted the significance of placing younger college students as a priority in related health education programs, given that HPV vaccine plays a better preventive effect before individuals having sex.³ With regard to gender difference, it may be explained that traditional HPV vaccine promoting campaigns was largely female-centered and focused on cervical cancer, which ignored the male and contradicted the fact of both genders being the targets of current HPV vaccination schedule.¹⁰ In addition, research reported an increasing incidence of HPV infection and associated cancers in the male population.²⁶ The findings corroborate the continuous need of more involvement of males in HPV-related health education programs, especially in China where HPV vaccine was recently licensed and marketed in 2016.

Moreover, the present study found that health science students had higher scores in HPV and vaccine knowledge, as well as greater intention to get HPV vaccinated than non-health science students. This discipline difference was similar with a previous study in Hong Kong.¹⁷ Healthcare students receive some HPV-related information in their courses²⁵ and thus demonstrate being more knowledgeable about HPV and willing to receive vaccination. On account of this disparity, non-health science students need more attention in future interventional programs.

The logistic regression analysis revealed that HPV vaccine knowledge, perceived risk of HPV infection, and grade were significant predictors of intention to HPV vaccination. Research also revealed that knowledge about HPV vaccination was the strongest predictor for receiving vaccination⁷ and positive attitude toward HPV vaccination.¹⁷ Therefore, HPV vaccine knowledge plays a critical role in improving the uptake of vaccination among college students, and thus needs to be addressed with more focus in health education efforts. However, HPV knowledge was not included in the final regression model, indicating that HPV knowledge was not a direct factor of vaccination intention. While some previous studies have shown a positive association between HPV knowledge and vaccination status among college students,^17,27 others showed that HPV knowledge did not appear to directly influence vaccination.^28,29 Researchers proposed that knowledge of non-cervical HPV-related cancers (e.g., oral cancers) may be indirectly related to vaccination by modifying risk perceptions associated with certain sexual practices (e.g., oral sex), particularly among male population.⁹ The conflicting results suggest that more research is warranted to further examine the mechanism of HPV knowledge influencing vaccination. The Health Belief Model proposes that perceived susceptibility, perceived severity, and perceived benefits could change individuals’ attitude toward health-promoting behaviors and trigger them to take actions.³⁰ This theory explains that lower perception of HPV infection risk predicted lower intention of vaccination among college students in the present study.

Implications for practice

This study revealed that college students need to be equipped with more HPV-related knowledge, especially with respect to HPV transmission modes, HPV-related diseases, optimal time and places of HPV vaccination. The deficit of related knowledge was closely associated with perceived low risk of HPV infection and modest intention to get HPV vaccinated among college students. Therefore, healthcare providers need to highlight the above mentioned information when delivering health education programs for college students, with a focus on students in lower grades and from non-healthcare disciplines. In the meantime, considering the verified effectiveness of social media in increasing HPV vaccination (awareness)^12,31 and the fact of social media being favored by current college students,²² popular Chinese social media such as Wechat and Weibo could be utilized to disseminate related information to better reach college students and raise their awareness of HPV vaccine.

College students in China are increasingly sexually active and at increased risk of HPV infection. However, their intention of HPV vaccination remained modest, in which structural factors largely accounted for their reluctance to get HPV vaccinated. Policymakers and healthcare providers may address the concerns of college students about HPV vaccine by expanding vaccine availability in college healthcare clinics and by reducing the out-of-pocket cost of the vaccine via providing partial coverage through Health Insurance.

Limitations

This study has several limitations. First, this study used convenience sampling method with a relatively small simple size, which may lead to limitations in the generalization of the research results to other areas both in China and abroad. Selection bias may exist as junior students accounted for 58.3% in this study. This may be because questionnaires were distributed by junior nursing students who approached students in the same grade more conveniently. Future research needs to employ a stratified sampling method to achieve a more representative sample. Second, this study only analyzed the impact of the demographic characteristics and sexual attitude of college students on knowledge of HPV and HPV vaccine, and intention to be vaccinated. More psychosocial factors such as parental influence²⁹ and receipt of provider recommendation²⁴ as revealed by literature need to be included in future research to further examine their relationships with HPV vaccination intention. Finally, this study only examined the attitudes of the participants toward HPV vaccination while did not collect data about actual HPV vaccination. Therefore, the findings need to be interpreted with caution.

Conclusion

In general, college students in this study showed a poor knowledge of HPV and HPV vaccine, as well as modest intention to get HPV vaccinated. Perceived risk of HPV infection was the strongest predictor of intention to get HPV vaccinated, followed by HPV vaccine-related knowledge and grade. The barriers to HPV vaccination intention include personal knowledge deficit and structural factors such as limited accessibility and high cost of HPV vaccine in Mainland China. Effective health promotion efforts from multiple levels including structural forces are continuously needed to target Chinese college students to increase their knowledge of HPV vaccine and vaccination awareness to reduce HPV-related disease burden, with consideration of utilizing social media as one means.

Acknowledgments

We acknowledge, with thanks, the university where the study was conducted for financial support. We also sincerely thank the students for their participation in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the University as one of the Student Research Training projects under grant no. (Qingdao University X2018110650758).