Knowledge, practice and attitude towards HPV vaccination

among college students in Beijing, China

Yingnan Liu,a Na Di,b and Xia Taoa,b

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ABSTRACT
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Introduction
Cervical cancer is the most common cancer of the female genital system in China, with an
estimated 98.9 thousand new incident cases in 2015.1 HPV not only promotes the
development of cervical cancer but is also a causative agent responsible for genital warts,
anal cancer and other genital diseases.2 Currently, three vaccines, namely, Gardasil (HPV 16,
18, 6 and 11), Cervarix (HPV 16 and 18) and Gardasil 9 (HPV 16, 18, 6, 11, 31, 33, 45, 52
and 58), are available worldwide. Clinical trials have shown that Gardasil and Cervarix
provide 70% protection against intraepithelial neoplasia/adenocarcinoma in situ. Gardasil 9
can provide 90% protection safely with limited side effects.3–5 The HPV vaccine has been
recommended as a routine vaccination for adolescent females aged 9–26 years and males
aged 9–21 years.6 However, some parents are hesitant about childhood vaccinations due to
uncertainty regarding the safety and side effects, which may influence vaccination coverage.
More information and high-quality communication act as key components improving public
trust.7 In China, HPV vaccines have been introduced in Hong Kong since 2006, but HPV
vaccination is not included in the government vaccination program. Despite extensive
campaigns promoting HPV vaccination over the past decade, the vaccination rate is unknown
due to the absence of population data, and it is believed that the vaccination rate is less than
20% among the population.8 In Hong Kong, the vaccination rate was 13.3% among university
students.9 HPV vaccines have been licensed in mainland China since 2017, and Gardasil 9
was introduced to mainland China on April 28, 2018. There are few statistics regarding the
uptake rate of HPV vaccines in mainland China. Our aim is to assess the level of knowledge
about HPV and the practice and attitude towards the HPV vaccine among college students
attending Peking University in Beijing, which is the capital of China. College students have
the ability to accept new knowledge quickly, and can make decisions independently. Their
HPV vaccination status can be easily influenced by policies or public education. Therefore, it
is essential to explore their vaccination status. The findings of this study can assist the
government and colleagues establish health policies and take appropriate measures to
increase students’ awareness of the risks associated with HPV infection and increase the
vaccination rate, which may help effectively prevent HPV infection and cervical cancer.
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Materials and methods

Study design and participants

A cross-sectional survey of the knowledge, practice and attitude towards HPV and HPV
vaccination was conducted between September 2018 and December 2018. The inclusion
criteria consisted of full-time undergraduates at Peking University in Beijing, China. Students
aged 18 years of age and foreign students were excluded. Questionnaires missing information
regarding the demographic variable “gender” or information about the knowledge, practice
and attitude towards HPV vaccination were excluded. A pilot study was conducted randomly
among 30 students, and we modified the questionnaire to enhance its logicality. The 30
students have not been included in the final sample. In the pilot test, 50% of the students
knew of the HPV vaccine. Considering a 50 percent HPV awareness with 5 percent allowable
error and 95 percent CI, a sample of 400 was required. This requirement was doubled, i.e.,
800, to ensure a sufficient comparison of vaccinations among female students.

Data collection and questionnaire

The survey instrument was a self-administered anonymous questionnaire. The questionnaires
were given to each participant on weekends in university teaching buildings. We randomly
selected 10 classrooms in three main buildings, and we gave the questionnaires to 20–30
students in each classroom. The questionnaire covers demographic information, knowledge,
practice and attitude towards HPV vaccination and sexual experience. The demographic
information included gender, age, family residence, grade, major, etc. (Table 1). To assess
knowledge of HPV and its vaccine, we first asked the participants whether they had heard
about HPV or the HPV vaccine. Among the students who had previously heard about HPV or
the HPV vaccine, we further investigated their knowledge of HPV and the vaccine by asking
them 8 questions. We measured the Cronbach’s alpha of these 10 questions about the HPV
and its vaccine. The value of Cronbach’s alpha was 0.867, which means that these questions
are reliable or in a high internal consistency. The participants were asked to indicate their
HPV vaccination status as follows: (1) whether they had completed the full course or had
begun the course, and (2) if not, whether they had scheduled an appointment for vaccination
in the following 6 months. Men are not allowed to be vaccinated against HPV in mainland
China. Thus, the male participants were not required to answer the questions about the
vaccination status. The female participants were asked to indicate their reasons for receiving
or refusing the vaccine. Furthermore, we asked both the female and male participants whether
they would recommend HPV vaccines to other females and their reasons. The participants
were asked to indicate whether they had sexual experiences, including vaginal, oral and anal
sex.
Table 1.
Baseline demographic characteristics of the male and female participants.

Male n Female n (%) Total n (%)*

(%)

Total Number 361(43.7) 466(56.3) 827(100)

 Male n Female n (%) Total n (%)*
(%)

Age (year)

≤22 205(56.8) 251(53.9) 456(55.1)

>22 156(43.2) 215(46.1) 371(44.9)

Family residence

Rural 97(26.9) 120(25.9) 217(26.4)

Urban 263(73.1) 343(74.1) 606(73.6)

Grade**

Low (grades 1–4) 228(64.2) 270(58.6) 498(61.0)

High (grades 5–12) 127(35.8) 191(41.4) 318(39.0)

Major

Nonmedical 214(59.8) 263(56.7) 477(58.0)

 Male n Female n (%) Total n (%)*
(%)

Medical 144(40.2) 201(43.1) 345(42.0)

Smoking status

Nonsmoker 341(95.8) 453(97.6) 794(96.8)

Smoker 15(4.2) 11(2.4) 26(3.2)

Family income (RMB/year/person)***

Low (<150,000) 284(81.1) 361(78.8) 645(79.8)

High (≥150,000) 66(18.9) 97(21.2) 163(20.2)

Father’s education background

Below college 186(52.0) 219(47.1) 405(49.2)

College or above 172(48.0) 246(52.9) 418(50.8)

 Male n Female n (%) Total n (%)*
(%)

Mother’s education background

Below college 209(58.4) 237(51.1) 446(54.3)

College or above 149(41.6) 227(48.9) 376(45.7)

Relationship with doctors****

Non 185(51.7) 232(49.9) 417(50.7)

Have 173(48.3) 233(50.1) 406(49.3)

Awareness of HPV

Never heard about HPV 112(31.0) 82(17.6) 194(23.5)

Heard about HPV 249(69.0) 384(82.4) 633(76.5)

Awareness of HPV vaccination

 Male n Female n (%) Total n (%)*
(%)

Never heard about HPV vaccine 125(35.1) 99(21.4) 224(27.4)

Heard about HPV vaccine 231(64.9) 363(78.6) 594(72.6)

Vaccinated family members or friends

No one 286(84.1) 300(65.6) 586(73.5)

Someone vaccinated 54(15.9) 157(34.4) 211(26.5)

HPV vaccination status

Unvaccinated # 410(90.5) 411(90.5)

Vaccinated (injected 1–3 times) # 43(9.5) 43(9.5)

If not vaccinated, plan of vaccination

No plan in the following 6 months # 280(68.6) 281(68.6)

 Male n Female n (%) Total n (%)*
(%)

Plan to become vaccinated in the following 6 months # 128(31.4) 128(31.4)

Sexual history

No sexual experience 222(68.5) 350(77.8) 572(73.9)

Sexual experience(s) 102(31.5) 100(22.2) 202(26.1)

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# Men have not yet been allowed to be vaccinated against HPV in mainland China.
* Numbers for some characteristics do not add up to the total number of the study population due to missing
values.
** “Grade” was defined as the years of the participants since they entered the college.
*** “RMB” is abbreviation of the Chinese currency. 1 RMB ≈ 0.14 $.
****”Relationship with doctors” means a social acquaintance with a medical doctor or having a closer
relationship with a medical doctor (e.g., familial, romantic).

Ethical considerations
The participants were informed of the study’s objectives and their right to refuse or terminate
their participation in the study at any time without penalty. In addition, we obtained their
verbal consent. After completing the questionnaires, we provided the right answers and
relevant knowledgeof HPV and the vaccine. The study was approved by the Institutional
Ethics Committee of Peking University First Hospital.

Statistical analyses
According to the number of correct answers among the 8 knowledge questions about HPV
and the vaccine, each participant’s state of knowledge about HPV and its vaccination was
divided into the following two groups: low level and high level. A low level means that the
participant answered 0–4 questions correctly, while a high level means that 5–8 questions
were answered correctly.
EpiData 3.1 was applied for the data entry of the questionnaires. Then, the data collected by
EpiData were exported to SPSS 23 software and analyzed. Incomplete questionnaires were
excluded. Descriptive statistics were used to analyze the demographic items and attitudes
towards HPV vaccination. A chi-square test and logistic regression model were applied to
examine the differences in (1) knowledge among the 3 groups (i.e., participants who had or
had never heard about HPV, participants who had or had never heard about the HPV vaccine,
and participants with high and low levels of knowledge) and (2) practices between the 2
groups (i.e., vaccinated and unvaccinated females and females who did or did not have a plan
to become vaccinated in the following 6 months). To identify the significant factors related to
the participants’ knowledge, practice, demographic factors, sexual experience and other
factors related to knowledge or vaccination status were included in the chi-square tests. ( Tables
2
and 3). The tests were two-sided, and a p-value less than 0.05 was considered statistically
significant. Only the variables that had a p-value <0.1 in the chi-square test were considered
in the logistic regression model.
Table 2.
Bivariate analysis of knowledge among different groups.

Heard about HPV Heard about HPV High level of related

vaccine knowledge

OR(95% CI) p OR(95% CI) p OR(95% CI) p value

value value

Female 2.106(1.52– <0.001 1.984(1.45– <0.001 1.938(1.46– <0.001

2.92) 2.71) 2.57)

Older age(>22 years) 1.913(1.37– <0.001 2.373(1.72– <0.001 2.734(2.06– <0.001

2.68) 3.30) 3.63)

Urban Family 1.191(0.83– 0.340 1.003(0.71– 0.986 0.904(0.66– 0.524

 Heard about HPV Heard about HPV High level of related
vaccine knowledge

OR(95% CI) p OR(95% CI) p OR(95% CI) p value

value value

1.71) 1.42) 1.23)

High grade(grades 5–12) 2.147(1.50– <0.001 2.474(1.75– <0.001 2.983(2.23– <0.001

3.08) 3.50) 4.00)

Medical science major 5.656(3.70– <0.001 4.243(2.93– <0.001 5.543(4.10– <0.001

8.65) 6.14) 7.50)

Smoker 0.669(0.29– 0.351 0.780(0.33– 0.568 0.824(0.37– 0.630

1.56) 1.83) 1.82)

High family income 1.306(0.85– 0.219 1.611(1.05– <0.05 1.136(0.81– 0.467

2.00) 2.46) 1.60)

Higher father’s education 1.028(0.75– 0.866 0.981(0.72– 0.903 0.906(0.69– 0.482

background 1.42) 1.34) 1.19)
 Heard about HPV Heard about HPV High level of related
vaccine knowledge

OR(95% CI) p OR(95% CI) p OR(95% CI) p value

value value

Higher mother’s 1.036(0.75– 0.832 0.915(0.67– 0.575 0.818(0.62– 0.153

education background 1.43) 1.25) 1.08)

Have relationship with 1.491(1.08– <0.05 1.437(1.05– <0.05 1.021(0.78– 0.882

doctors 2.07) 1.96) 1.34)

Sexual experience(s) 1.532(1.02– <0.05 1.844(1.24– <0.01 2.293(1.65– <0.001

2.31) 2.75) 3.19)

Vaccinated family # # # # 6.066(4.21– <0.001

member or friends 8.74)

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#When the participant knew families or friends had been vaccinated, they must know of the HPV or the HPV
vaccine. So the study didn’t analyze the relationship between this factor and “Heard about HPV” or “Heard
about HPV vaccine”.

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Results
In total, 884 college students were invited to complete the questionnaires, and 841
questionnaires were collected. After excluding the incomplete and undesirable responses, a
data analysis was performed based on the remaining 827 responses (effective response rate
was 93.5%). 43% of the participants were male, and 56.3% of the participants were female.
The participants’ age ranged from 18 to 39 years, with a mean of 22.8 ± 3.6 years. In total,
59.8% of the males and 56.7% of the females were nonmedical students. Most of the
participants (69.0% of the males and 82.4% of the females) had heard about HPV. In total,
64.9% of the male and 78.6% of the female students had previously heard about HPV
vaccines. Only 9.5% of the female students had begun or completed the HPV vaccination.
Among the female students who were not vaccinated, 31.4% planned to become vaccinated
in the following 6 months, while 68.6% still had no plan (Table 1).
Most participants had heard about HPV and the vaccine before this survey (76.5% and
72.6%, respectively). Among the students who had heard about HPV, 40.0% knew that the
HPV virus can be classified as high-risk HPV and low-risk HPV. Nearly half of the
participants knew that HPV is associated with cervical cancer (52.8%), HPV is sexually
transmitted (46.8%) and frequent sex is a risk factor for infection (55.1%). Regarding
questions about HPV vaccination, only 4.0% of the participants realized that the HPV
vaccine does not cover all types of the HPV virus, 49.5% of the participants knew the best
period for vaccination, 64.2% of the participants knew that HPV vaccination can effectively
prevent cervical cancer, and 65.9% of the participants knew that regular screening should be
performed after vaccination.
Statistically, the participants who were female, older than 22 years, at a high grade (grades 5–
12) or medical students were more likely to have heard about HPV and the vaccine and have
a high level of knowledge (p < .05). In addition, the participants who had sexual
experience(s) or had a relationship with doctors were more likely to have heard about HPV
and the vaccine than those who had no sexual experience and no relationship with doctors
(p < .05). The participants whose family income was high (≥150,000 RMB/year/person) were
more likely to have heard about HPV vaccine than those from relatively low-income families
(<150,000 RMB/year/person) (p < .05). The participants who had sexual experience(s) and
whose family members or friends had been vaccinated had a significantly higher level of
knowledge than those who had no sexual experience and who had no family members or
friends who had been vaccinated (p < .001) (Table 2)
In the logistic regression model, the female gender(OR 1.831, 95% CI (1.27–2.64), p < .001),
age above 22 years (OR 1.734, 95% CI (1.17–2.56), p < .01), a medical science major (OR
4.910, 95% CI (3.14–7.67), p < .001), and relationship with doctors (OR 1.508, 95% CI
(1.05–2.18), p < .05) were significant predictors for having heard about HPV. Similarly, the
female gender (OR 1.798, 95% CI (1.26–2.56), p < .001), age above 22 years (OR 2.251,
95% CI (1.55–3.28), p < .001), a medical science major (OR 3.568, 95% CI (2.40–
5.30), p < .001), and a high family income (≥150,000RMB/year/person) (OR 1.921, 95% CI
(1.20–3.09), p < .01) were significant predictors for having heard about the HPV vaccine.
Among the participants who had heard about HPV or the HPV vaccine, three factors,
including age, major and family vaccination status, were significantly associated with the
level of knowledge. This finding suggests that the participants who were aged 23 years and
older (OR 1.731, 95% CI (1.16–2.58), p = .007) and those who were pursuing a medical
science major (OR 3.351, 95% CI (2.24–5.02), p = .000) knew more than the younger,
nonmedical student participants. The participants whose family members or friends had been
vaccinated were likely to know more than those who had no family members or friends who
had been vaccinated (OR 13.751, 95% CI (5.92–31.95), p = .000) (Figure 1).
Figure 1.
Logistic regression model of knowledge among the different groups. Vertical coordinates represent
the significant predictors (p < .05). The female gender, an older age (>22 years), a medical science
major and relationship with doctors were significantly related to “have heard about HPV”; the female
gender, an older age (>22 years), a medical science major and a high family income were significantly
related to “have heard about HPV vaccine”; an older age (>22 years), a medical science major and
vaccinated family members or friends were significantly related to “high level of related knowledge”.
Among the students who had heard about HPV and the vaccine, the primary source of
information was social media (67.3%). College education (48.0%), families or friends
(41.7%), and doctors or health-related workers (37.3%) were also main sources of
information. When asked the question “Which way do you want to obtain knowledge about
HPV and its vaccination?”, 68.8% of the students ranked college education first, followed by
social media (61.4%) and doctors or friends (55.5%).
Among the female students, some characteristics, including an age over 22 years, a high
grade, prior knowledge of HPV or the HPV vaccine, a high level of knowledge, the
vaccination of a family member or friend, and sexual experience(s), were significantly
associated with the vaccination status (p < .05). In addition, the female students who had
relationships with doctors were more likely to be vaccinated than those who had no
relationship with doctors (p < .01). Among the female students who were not vaccinated, the
students from urban, high-income families were more likely to have planned to become
vaccinated in the following 6 months (p < .01). However, a medical science major seemed to
not be significantly associated with the students’ vaccination status in the bivariate analysis
(Table 3).
Table 3.
Bivariate analysis of vaccination status among different groups.
 Vaccinated (1–3 courses of Plan to become vaccinated in the
vaccine) following 6 months

OR(95% CI) p-value OR(95% CI) p-value

Older age (>22 years) 3.348(1.67–6.70) <0.001 2.650(1.73–4.07) <0.001

Urban family 0.949(0.46–1.96) 0.886 2.121(1.24–3.62) <0.01

High grade (grades 5–12) 2.961(1.53–5.72) <0.001 3.348(2.16–5.180) <0.001

Medical science major 1.302(0.69–2.44) 0.410 0.893(0.58–1.37) 0.603

Smoker 0.950(0.12–7.61) 1.000 0.678(0.63–0.73) 0.068

High family income 1.563(0.77–3.18) 0.215 1.989(1.20–3.30) <0.01

Higher father’s education 0.993(0.530–1.87) 0.983 1.294(0.85–1.97) 0.230

background

Higher mother’s education 1.333(0.71–2.51) 0.372 1.458(0.96–2.22) 0.079

background
 Vaccinated (1–3 courses of Plan to become vaccinated in the
vaccine) following 6 months

OR(95% CI) p-value OR(95% CI) p-value

Have relationship with 2.471(1.25–4.87) <0.01 0.985(0.65–1.50) 0.945

doctors

Heard about HPV 10.151(1.38–74.87) <0.01 3.915(1.94–7.88) <0.001

Heard about HPV vaccine 12.613(1.71–92.88) <0.01 3.592(1.91–6.74) <0.001

Vaccinated family members 19.882(7.63–51.80) <0.001 2.730(1.73–4.30) <0.001

or friends

Sexual experience(s) 3.444(1.79–6.64) <0.001 1.688(1.01–2.83) 0.045

High level of related 9.900(3.51–28.46) <0.001 3.521(2.25–5.51) <0.001

knowledge

In the logistic regression model, relationships with doctors (OR 2.288, 95% CI (1.12–
4.65), p < .05), sexual experience(s) (OR 2.809, 95% CI (1.41–5.61), p < .01) and a high
level of knowledge (OR 8.400, 95% CI(2.92–24.21), p < .001) were predictors of
vaccination. Among the unvaccinated students, a high level of knowledge (OR 3.635, 95%
CI(2.11–6.25), p < .001), a high grade level (OR 3.207, 95% CI(1.96–5.25), p < .001), an
urban family (OR 2.067, 95% CI(1.12–3.80), p < .05) and a high family income (OR 1.800,
95% CI(1.02–3.19), p < .05) were significantly associated with plans to become vaccinated in
the following 6 months. However, the medical students were less likely tobecome vaccinated
in the next 6 months than the nonmedical students (OR 0.489, 95% CI (0.28–0.85), p < .05)
(Figure 2).

Figure 2.
Logistic regression model of vaccination status among the different groups. Vertical coordinates are
the significant predictors (p < .05). A high level of related knowledge, sexual experience(s) and
relationship with doctors were significantly related to being “vaccinated (1–3 courses of vaccine)”. A
high family income, an urban family, a medical science major, a high grade level (grades 5–12) and a
high level of related knowledge were significantly related to having a “plan to become vaccinated in
the following 6 months”.
Among the students who had been vaccinated or planned to become vaccinated in the
following 6 months, when asked about the reasons for getting vaccinated, 87.1% of the
students believed that the HPV vaccine is effective in preventing cervical cancer and other
diseases. Half of the students were in a good economic condition (53.8%) or influenced by
the propagation of HPV-related knowledge (50.9%). Recommendations of family members
and friends accounted for 31.6% of the students who were vaccinated or had plans to become
vaccinated in the following 6 months. Only 16.4% of the student vaccinations were
associated with a doctor’s recommendation. Among the students refusing to become
vaccinated, the top four common reasons were as follows: “Have never heard about or know
little about HPV and the vaccine” (46.1%), “The vaccine is too expensive” (30.4%), “I don’t
think that I would become infected with HPV” (27.1%), and “Worry about the side effects”
(23.6%).
When asked “Would you recommend for other females to the HPV vaccine?” 82.3% of males
and 76.1% of females were willing to make this recommendation. In the bivariate analysis,
the female gender, a high level of knowledge, being vaccinated and planning to become
vaccinated in the following 6 months were significantly associated with the willingness to
recommend vaccination (p < .05). In the logistic regression model, only a high level of
knowledge (OR 4.145, 95% CI (2.42–7.10), p < .001) and planning to become vaccinated in
the following 6 months (OR 10.446, 95% CI (4.08–26.77), p < .001) were predictors of the
willingness to recommend vaccination. When asked about the reasons for refusing to
recommend vaccination, most participants (63.7%) said that they had never heard about HPV
or the HPV vaccine.
The costs of the total courses of the three vaccines in mainland China (Gardasil, Cervarix and
Gardasil 9) are 1800 RMB, 2400RMB and 3900 RMB, respectively. Regarding the maximum
amount the participants were willing to spend on HPV vaccination, the average was 2625
RMB; 23.9% of the students would pay less than 1000 RMB, 23.6% of the students would
pay 1000 to 2000 RMB, 21.7% of the students would pay 2000 to 3000 RMB, 27.4% of the
students would pay 3000–4000 RMB, and only 3.3% of the students could afford an amount
over 4000 RMB.
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Discussion
This study is the first to report the knowledge and attitude towards HPV and its vaccine and
examine the HPV vaccination rate in college students in mainland China since HPV vaccines
were introduced to mainland China. This study found that most students had heard about
HPV and the HPV vaccine and had a low-moderate level of knowledge (3.78/8). This finding
suggests that the students did not have sufficient perceptions about HPV. In other Asian
countries or regions, awareness of HPV is generally low. In Pakistan, 57% of college students
reported that they had already heard of HPV.10 Similarly, 36.5% of Lebanon college students
had never heard of the vaccine, and their knowledge was poor to moderate, with a median
knowledge score of 52.7.11 A survey conducted at a tertiary institution in Singapore reported
that students’ knowledge of HPV was low, with a median score of 7/14.12 Moreover, in the
logistic regression model, we found that the female gender, an age above 22 years and having
family members or friends who were vaccinated were predictors of a high level of knowledge
about HPV and the vaccine. This finding suggests that more measures can be taken to
improve students’ perceptions towards HPV and the vaccine, especially in male, younger
(aged under 22 years) or nonmedical students. Another study also reported that female
students knew more about HPV and the vaccine than male students.13 It is possible that HPV
infection and cervical cancer are mainly associated with females, explaining this
phenomenon. In a survey conducted in 2015, there was a need to improve the education of
young males about HPV infection, its associated diseases and the benefits of the
vaccination.14 In addition to male adolescents, parents also play an important role in
vaccination. Parents’ intentions to vaccinate their sons was significantly associated with a
need for additional information about HPV vaccination.15 This phenomenon suggests that we
should also increase parents’ knowledge of HPV vaccination.
In our study, the vaccination rate among the female college students was 9.5%. This
proportion is close to the level of vaccine uptake in college students in Hong Kong, which is
13.3%.9 The rate of vaccination in adolescent girls in Hong Kong is only 7.2%-9.1%.8,16 In
Lebanon, 16.5% of female college students were already vaccinated.11 In Singapore, the
vaccination rate among 15 to 22-year-old female students is only 9.8%.12 It is essential to
identify the factors that influence student vaccinations, which could help establish policies
related to improving the vaccination rate. Our study showed that relationships with doctors,
sexual experience, and a high level of knowledge about HPV and the vaccine were predictors
of vaccination. Similarly, it was reported that high levels of awareness about HPV and the
vaccine and sexual experience are related to a greater willingness to become vaccinated. 17 In a
study conducted at an American college, the level of awareness and health education were the
best predictors of improvement in vaccinations.18 Students with sexual experience are more
likely to become vaccinated. Students who have had a sexual experience or have a
relationship with doctors may tend to learn more about sexually transmitted diseases or
obtain health knowledge, which may help these students gain knowledge of HPV and the
vaccine. Some studies have reported that a high maternal level of education is associated with
student vaccination.8,19 We found that parents’ educational background and the family’s
economic status were not predictors of student vaccination. In our study, there was no
significant difference in the vaccination rate between medical and nonmedical students
(p = .410), which was also reported in a study conducted among college students in Hong
Kong.20
When we asked about the reasons for refusing vaccination, the primary and most common
reason was that they had never heard about or knew little about HPV, which was also the
main reason for refusing to recommend the vaccine to others. This finding was also reported
among Turkish college students.17 Students who had high-level knowledge about HPV were
more willing to recommend vaccination (p < .001). This association was also reported in a
survey targeting female students attending an American college (p = .005).18 This result
reflects that knowledge of HPV and the vaccine can influence students’ willingness to receive
or recommend the HPV vaccine. Therefore, increasing the knowledge of HPV and the
vaccine can effectively improve students’ vaccination uptake. However, in this study, when
asked how the participants wanted to receive information about HPV and the vaccine, most
students ranked college education first. However, only 48.0% of students who had heard
about HPV and the vaccine obtained this knowledge from college education. This finding
suggests that college education is essential but is currently insufficient.
Similarly, we found that doctors were an important source of information for students.
Healthcare providers have been shown to play a pivotal role in promoting vaccination in
different settings and other risk groups.21–23 Colleges could cooperate with healthcare
providers in providing health education, which may be an effective measure to increase
students’ knowledge of HPV. The primary and most common source for obtaining
knowledge was social media, which was also the second source from which students wanted
to obtain knowledge. In other countries, the Internet and social media were used to seek
health-related information.24,25 This finding suggests that colleges or governments must
consider social media a part of their communication strategy to promote appropriate Web use
for disseminating HPV vaccine-related information to college students or the general
population.
Because of the high financial burden, the HPV vaccine will not be integrated into the Chinese
national immunization program for a long time. Therefore, it is essential for the government
and colleges to take some measures and establish policies, such as those mentioned above, to
enhance the public’s awareness about HPV and improve the uptake of HPV vaccines, such as
by adding health-related education to the school curriculum.
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Limitations
Although the college, Peking University, which we surveyed is a famous public university in
China, this population may not be representative of the general Chinese college population.
Because of Peking University’s high level of education and its location in Beijing, the
vaccination rate we calculated may be higher than the mean vaccination level in China in
general, which means that, in the future, multicenter studies involving large samples are
needed nationwide to obtain more accurate data. Furthermore, we investigated only students
who were studying in teaching buildings, a location where students may be more
hardworking and may have more knowledge about health. We should not neglect recall bias
and social desirability bias since the topic of HPV vaccine was popular during the study
period due to the availability of the 9-valent HPV vaccine in mainland China. And only when
we obtained their verbal consent, could we gave them the questionnaires. Therefore, no
information about non-responders available and it maybe a response bias. Another limitation
of our study is that we did not ask about the history of sexually transmitted infections, which
is reported to be a predictor of vaccination.17 Finally, in our study, the vaccination rate was
not significantly different between medical students and nonmedical students, but we did not
distinguish the students with clinical majors from the medical students. There may be a
significantly higher vaccination rate in students with clinical majors than in medical students
because of their frontier knowledge and positive attitude towards the HPV vaccine.
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Conclusion
This study found that the knowledge of the HPV vaccine among college students at Peking
University was low to moderate, and that the vaccine uptake was only 9.5%, which was
significantly associated with knowledge of HPV, the vaccine and other factors. There is a
need for school-based education to improve HPV knowledge, because school was the
primary and most common source from which students hoped to obtain information. The
government should take some measures to enhance public awareness about HPV and the
vaccine, such as health education programs via social media, to increase HPV vaccine uptake.
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