Awareness and determinants of HPV vaccination intentions among female university students in Guangzhou, China: a cross-sectional study

Globally, cervical cancer remains the fourth most common malignancy among women.¹ Recent surveillance data have shown an increasing trend in both incidence and mortality rates of cervical cancer in China, along with a progressively younger age of onset.^2,3 About 90% of cervical cancer cases are associated with high-risk HPV infection.⁴ Prophylactic HPV vaccination serves as the cornerstone of primary prevention. The administration of HPV vaccines carries significant public health implications for preventing HPV infections. Through the induction of antigen-specific immune responses, vaccination has been demonstrated to effectively mitigate the incidence of HPV-related diseases. Beyond clinical benefits, population-wide immunization confers substantial socioeconomic advantages by reducing healthcare expenditures and productivity losses, thereby enhancing the sustainability of public health systems and fostering socioeconomic stability. However, immunization coverage rates in China remain substantially lower than those in developed nations.

A critical barrier to vaccine uptake is vaccine hesitancy. The WHO’s 3C framework categorizes vaccine hesitancy determinants into three dimensions: confidence, complacency and convenience.⁵ Addressing these barriers is crucial for achieving the global goal of cervical cancer elimination.

Female university students represent a key demographic for targeted HPV vaccination efforts. They are in a sexually active age group and are at high risk for HPV infection.⁴ Understanding their awareness of cervical cancer, HPV, and HPV vaccines, as well as the factors influencing their vaccination decisions, is essential for developing effective prevention strategies. This study examines their awareness of cervical cancer, HPV, and vaccines, and analyzes determinants of vaccination decisions to inform prevention strategies and contribute to achieving global cervical cancer elimination goals.

METHODS

We conducted a cross-sectional survey among female undergraduates attending HPV vaccine educational lectures at four universities in Guangzhou, China, from August to November 2024.

Study Population

We conducted a cross-sectional survey among female undergraduates attending HPV vaccine educational lectures at four universities in Guangzhou, China, from August to November 2024. The minimum sample size was calculated using the following formula for cross-sectional studies:

$$n = \frac{u^2 \cdot p \cdot (1 - p)}{\sum_{\mathstrut}^{\mathstrut}Z}$$

Where p=0.34 (anticipated HPV vaccine awareness rate based on prior data⁶), u=1.96 (corresponding to α=0.05), and Σ=0.1p (permissible error). Accounting for a 5% invalid response rate, the final minimum sample size was determined as n=744.

Survey design and implementation

To construct the questionnaire, we first conducted extensive literature reviews and examined previous empirical studies to identify variables related to knowledge, attitudes, and practices concerning HPV and the HPV vaccine. Through the three-person method, the self-made items were used to adapt the relevant items in the existing scale. These items were compiled into a preliminary item pool covering HPV, cervical cancer, and the HPV vaccine. Next, experts evaluated the content and logical validity of this pool, helping us determine the final items. Finally, pilot testing was carried out to ensure the questionnaire’s validity and reliability. Key domains covered sociodemographic characteristics, awareness of cervical cancer, HPV, and the HPV vaccine, and willingness to vaccinate. The questionnaire underwent pilot testing and validation, with Cronbach’s α⁷= 0.617 and KMO = 0.743, ensuring internal consistency and factorability. From August to November 2024, participants attending HPV vaccine science lectures at four universities independently completed the questionnaires by scanning a QR code. Unfinished questionnaires were excluded during screening to ensure data validity. To prevent duplicate responses, each IP address was restricted to one submission. All participants were informed that participation in the survey was voluntary.

Statistical Analysis

Descriptive statistics were used to analyze all data, with frequency data expressed as counts or percentages. Stratified analyses were performed based on grade, geographic origin (urban/rural), and average monthly living expenses. Group differences were evaluated using the Mann-Whitney U test (non-parametric data), chi-square test, or Fisher’s exact test. Variables with P<0.05 in univariate analysis were included in a multivariate logistic regression model to calculate adjusted odds ratios (OR) with 95% confidence intervals (CI). All analyses were conducted using SPSS 25.0 and SPSSAU. SPSS served as the primary tool for its reliability and field standard, while SPSSAU provided complementary cross-verification of core results.

RESULTS

A total of 1,435 questionnaires were collected, with one male participant excluded from analysis. The final analytical sample consisted of 1,434 female students (effective response rate: 99.9%).

Sociodemographic Characteristics of Participants

Among 1435 questionnaires, 66.7% were from rural households and 33.3% from urban households. Most participants were freshmen (70.9%) and sophomores (15.4%). Students with monthly living expenses between £ 111 -<£ 222 accounted for 73.6%, and 95.7% reported no sexual activity (Table 1).

Awareness of cervical cancer, HPV and HPV vaccine

The study revealed substantial awareness of cervical cancer (88.4%) and HPV (85.6%), with 93.3% of participants aware of the HPV vaccine. Among respondents, 74.0% correctly identified sexual transmission as the primary route of HPV infection, while only 12.9% self-identified as high-risk for HPV infection. Additionally, 55.1% expressed concern about their personal risk of cervical cancer. Although 79.0% acknowledged the efficacy of HPV vaccines in cervical cancer prevention, only 42.7% understood the optimal vaccination timing (prior to sexual initiation). Most participants learned about the HPV vaccine through the internet (69.7%, 994 participants), hospital-based public lectures (64.1%, 921 participants), and public health campaigns (55.9%, 803 participants). Key knowledge sources are presented in Table S1-S3 in the Online Supplementary Document.

Univariate Analysis of HPV Vaccination Intention

Among 1,434 participants, 87.1% (1,250 participants) expressed willingness to receive HPV vaccination, while 12.9% (184 participants) exhibited vaccine hesitancy. Chi-square tests revealed significant associations between vaccination intention and the following variables (P<0.05). In sociodemographic factors, place of household registration from urban students showed higher intention than rural counterparts (34.59% vs. 65.41%, χ² = 6.855, P = 0.009); participants with higher expenditures demonstrated greater willingness (χ² = 19.465, P<0.001). Higher vaccination willingness was observed among those aware of cervical cancer (P<0.001), concerned about future cervical cancer risk (P<0.001), and aware of the HPV-cervical cancer link (P<0.001). Correct understanding of HPV sexual transmission (P<0.001), prior knowledge of the HPV vaccine (P<0.001), and belief in vaccine efficacy (P<0.001) were strongly associated with vaccination intention (Table 2).

Multivariate Analysis of HPV Vaccine Acceptance

To further elucidate determinants of HPV vaccine acceptance, factors statistically significant in univariate analysis were included in a multivariate logistic regression model. The results showed that individuals worried about their future cervical cancer (P < 0.001; OR = 1.840; 95% CI = 1.448-2.281), those who knew the route of HPV transmission (P =0.023; *OR =*1.198; 95% CI = 1.025-1.400), Those who had heard of the HPV vaccine (P < 0.001; OR = 3.447; 95% CI = 1.768-5.855), believed in the effectiveness of the HPV vaccine (P < 0.001; OR = 3.254; 95% CI = 2.061 - 3.902), and understood optimal timing (P < 0.001; OR = 1.347; 95% CI = 1.146-1.583) were more likely to express a willingness to be vaccinated (Table 3).

HPV Vaccination Status And Vaccine Hesitancy Factors

There are 189 cases of people who have been vaccinated. Among the remaining unvaccinated people, 152 began to make appointments for HPV vaccination after the lecture, and 90 of them have already received the vaccine. And we further explored reasons behind HPV vaccine hesitancy among participants. Of the 17 individuals who explicitly declined vaccination, safety concerns were the most frequently cited barrier (8 participants, 47.1%), followed by high cost (5 participants, 29.4%), complacency about personal health status (3 participants, 17.6%), and doubts about vaccine efficacy (2 participants, 11.8%). These findings suggest that by quantifying cognitive gaps and identifying modifiable determinants of vaccination intentions, we can achieve the global plan to eliminate cervical cancer by changing these factors.

DISCUSSION

Key Findings and Implications

Our survey of 1,434 female college students explored their awareness of cervical cancer and HPV vaccines, as well as factors influencing vaccination willingness. Our study found high awareness of cervical cancer and HPV vaccines among female college students, consistent with national surveys.⁸ A meta-analysis of Chinese and English literature from 2006 to 2015 reported that only 17.13% of the Chinese population had heard of the HPV vaccine, and 18.64% knew it could prevent cervical cancer, both lower than in other countries.⁹ In 2021, Ran Rui et al reported a 76.5% awareness rate for the HPV vaccine10. Furthermore, in 2018,¹⁰Zhang J et al revealed a 45.1% HPV vaccine awareness rate among Guangzhou university students.¹¹ The significant increase in awareness in our study may be due to sustained public health initiatives, such as the Guangzhou Center for Disease Control’s HPV vaccine awareness campaign launched in 2019 and the Guangdong Provincial People’s Government’s decision to include HPV vaccination in the provincial immunization program in 2022. These efforts highlight the effectiveness of targeted health education and policy changes in improving vaccine awareness and acceptance. While the majority of participants were aware of the HPV vaccine and expressed vaccination willingness, significant gaps in HPV-related knowledge persist. These findings can help professionals in the field make more informed decisions, develop effective strategies, and improve the quality of their work.

Barriers to Vaccination

Our survey revealed that 87.1% of female college students expressed a willingness to receive the HPV vaccine, while 12.9% exhibited vaccine hesitancy. This highlights that vaccine hesitancy remains a significant barrier to improving vaccination rates. The extent of knowledge about HPV vaccines was closely linked to vaccination willingness, a result consistent with previous research.¹² Moreover, respondents concerned about developing cervical cancer showed greater willingness to be vaccinated. This may be because this group is concerned about their own health or too afraid of the disease to produce anxiety, and HPV vaccine prevention measures can alleviate anxiety. At the same time, there are also some people who are complacent or lack of awareness of the seriousness of cervical cancer and reduce their willingness to vaccination. Thus, enhancing public understanding of HPV and its consequences through health education can elevate risk perception and boost vaccination willingness.

Our study found that the majority of respondents who explicitly refused HPV vaccination cited concerns about vaccine safety and affordability as their primary reasons. This highlights the crucial role of accurate and accessible information in health communication. According to the published “Chinese Expert Consensus on HPV Vaccine Safety,” existing evidence confirms the good safety profile of currently available HPV vaccines, with adverse reactions comparable to those of other vaccines.¹³ Meantime, our multivariate analysis confirmed that belief in the HPV vaccine’s efficacy was associated with higher vaccination uptake. However, public awareness of HPV vaccine safety remains insufficient, which may be a key factor contributing to vaccine hesitancy. Additionally, our survey revealed that most female college students acquire relevant knowledge through online platforms and hospital-organized health education sessions. Considering this, future health education campaigns could combine online and offline approaches, leveraging modern communication tools such as social media, online courses, and mobile applications to create a more convenient platform for accessing health information.¹⁴ Schools can also collaborate with professional medical institutions to regularly host health lectures and free clinics, bringing professional medical knowledge to campus. Through multi-channel publicity, public awareness of HPV vaccine safety and efficacy can be enhanced, misconceptions about vaccines can be corrected, and students’ attention to health issues, as well as their trust and acceptance of the HPV vaccine, can be improved.

Socioeconomic factors play a significant role in influencing the willingness to receive the HPV vaccine. Through market research, we found that the price range of each dose of the HPV vaccine currently available on the market is approximately £40 to £146, the total cost is around £120 to £438. In our survey, 73.3% of the students participating in the study have a monthly living expense between £111 and £222. For 73.3% of the students, the cost of completing the vaccination exceeds 50% of their monthly living expenses. And the univariate analysis indicated that urban residents and individuals with higher economic status exhibit a stronger inclination toward HPV vaccination. This observation may be attributed to the greater willingness of individuals in more affluent conditions to actively invest in their health. To address these barriers, optimizing vaccination policies is essential. The government can enhance accessibility by providing free HPV vaccination services through fiscal allocations and by incorporating HPV vaccination into the medical insurance reimbursement framework, thereby diversifying payment options.

Limitation

There may be some possible limitations in this study. First, non-probability sampling may limit generalizability beyond the surveyed universities. Second, the cross-sectional design precludes causal inference. Future longitudinal studies should track how knowledge interventions impact actual vaccine uptake.

CONCLUSIONS

Our findings reveal that while female college students in Guangzhou have a high awareness rate of the HPV vaccine, there are significant gaps in their in-depth knowledge of HPV. To boost vaccination rates, interventions such as enhancing health education, dispelling safety and efficacy doubts, and implementing multi - party cost - sharing mechanisms to reduce economic barriers are crucial. We call on policymakers and healthcare providers to prioritize the development of culturally appropriate vaccination strategies. These strategies can serve as a model for other low - and middle - income countries with similar cultural and socioeconomic contexts.

Acknowledgements

We are grateful to all participants and staff involved in data collection.

Disclaimer

None.

Ethics statement

This study was approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University (Approval No.: EY AF/SC-02-06-01/03.0). Informed consent was obtained from all participants involved in the study.

Data availability

The datasets generated and analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but they are available from the corresponding author on reasonable request.

Funding

None.

Authorship contributions

X.L, Y.Y and J.L had the idea for the article and suggested revisions to the manuscript. J.L assisted with gathering data, analyzing data, and writing the manuscript. The final manuscript was read and approved by all authors.

Disclosure of interest

The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.

Additional material

This article contains supplementary information as an Online Supplementary Document.

Correspondence to:

Yuebo Yang
Gynecology Department, The Third Affiliated Hospital of Sun Yat-sen University
No. 600 Tianhe Road, Guangzhou 510630
China
E-mail: yangyueb@mail.sysu.edu.cn

Xiaomao Li
Gynecology Department, The Third Affiliated Hospital of Sun Yat-sen University
No. 600 Tianhe Road, Guangzhou 510630
China
E-mail: lixmao@mail.sysu.edu.cn