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. 2024 Mar 26;20(1):2333111. doi: 10.1080/21645515.2024.2333111

Exploring mother-daughter communication and social media influence on HPV vaccine refusal for daughters aged 9-17 years in a cross-sectional survey of 11,728 mothers in China

Zian Lin a,*, Siyu Chen b,*, Lixian Su c,*, Hongbiao Chen d,*, Yuan Fang e, Xue Liang b, Kwok Fung Chan b, Jianan Chen a, Biyun Luo a, Chuanan Wu a, Zixin Wang b,✉
PMCID: PMC10968318  PMID: 38530324

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.

KEYWORDS: HPV vaccine refusal, mothers of girls, mother-daughter communication, social media influence, China

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.1–6

The efficacy of HPV vaccination in preventing cancers associated with vaccine-type strains among females is well-established, with a favorable safety profile.7,8 China initiated the national HPV vaccination program in 2016, which was later than other developed nations.2 In line with the recommendations made by international health authorities,9 China recommends HPV vaccination for females aged 9–45 years.10 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).2,11 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.12 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.13 Parents are key decision-makers in children’s HPV vaccination.14 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.15–17 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.15 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.16 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.18–20 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.15,18-22 In addition, parents/guardians who refused to receive HPV vaccination were less likely to vaccinate their girls against HPV.19,20,23

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).24 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.25,26 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.27 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.28,29 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.30,31 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.32 Some studies found that exposure to negative or anti-vaccine contents was associated with lower vaccination rates.32 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.33 Misinformation related to vaccination is widespread on social media.34 Previous studies showed that thoughtful consideration of the veracity of the information on social media could mitigate the negative impact of misinformation,35 which was associated with higher acceptance of vaccination.36,37 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.38

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.39–42 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.43,44 This subscale is commonly used in previous studies across countries and cultures.43,44 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.33,45 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.35 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.46,47 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.48,49 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.

Table 1.

Background characteristics of the participants (n = 11,728).

  All participants (n=11,728) Participants with daughters aged 9–12 (n=7,154) Participants with daughters aged 13–17 (n=4,574) P values
N (%) N (%) N (%)
Age group, years        
 28–35 3175 (27.0) 2464 (34.4) 711 (15.5) <.001
 36–40 4863 (41.5) 2967 (41.5) 1896 (41.5)  
 41–61 3690 (31.5) 1723 (24.1) 1967 (43.0)  
Education level        
 Junior high or below 3321 (28.3) 1756 (24.5) 1565 (34.2) <.001
 Senior high or equivalent 2753 (23.5) 1568 (22.0) 1185 (25.9)  
 College and above 5654 (48.2) 3830 (53.5) 1824 (39.9)  
Relationship status        
 Married 11,236 (95.8) 6873 (96.1) 4363 (95.4) .07
 Currently single 492 (4.2) 281 (3.9) 211 (4.6)  
Employment status        
 Full time 4881 (41.6) 3103 (43.4) 1778 (38.9) <.001
 Part-time 860 (7.3) 489 (6.8) 371 (8.1)  
 Self-employed 3559 (30.3) 2098 (29.3) 1461 (31.9)  
 Unemployed 250 (20.1) 147 (2.1) 103 (2.3)  
 Housewife 1756 (15.1) 1058 (14.8) 698 (15.2)  
 Others 422 (3.6) 259 (3.6) 163 (3.6)  
Monthly household income, ¥ (US$)        
 <5000 (685) 1958 (16.7) 1033 (14.4) 925 (20.2) <.001
 5000–9999 (685–1369) 3562 (30.4) 2138 (29.9) 1424 (31.2)  
 10,000–15,000 (1369–2054) 1910 (16.3) 1188 (16.6) 722 (15.8)  
 >15,000 (2054) 3123 (26.6) 2083 (29.1) 1040 (22.7)  
 Refuse to disclose 1175 (10.0) 712 (10.0) 463 (10.1)  
Self-reported history of HPV infection        
 No 11,247 (95.9) 6868 (96.0) 4379 (95.7) .48
 Yes 481 (4.1) 286 (4.0) 195 (4.3)  
Self-reported history of HPV-related diseases (i.e., genital warts, cervical/anus/vagina cancers, and precancerous lesions)        
 No 11,467 (97.8) 7006 (97.9) 4461 (97.5) .15
 Yes 261 (2.2) 148 (2.1) 113 (2.5)  
Age of the index daughter, years        
 9–12 7154 (61.0) – – –
 13–17 4574 (39.0) – –  
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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).

Table 2.

HPV vaccine uptake and refusal, mother-daughter communication, and influence of social media related to HPV vaccination.

  All participants (n = 11,728) Participants with daughters aged 9–12 (n = 7,154) Participants with daughters aged 13–17 (n = 4,574) P value
N (%) N (%) N (%)
HPV vaccine uptake and refusal        
The index daughters have received HPV vaccines        
 No 9515 (81.1) 6748 (94.3) 2767 (60.5) <.001
 Yes 2213 (18.9) 406 (5.7) 1807 (39.5)  
Likelihood of having the index daughter take up HPV vaccines (among mothers whose index daughters have never received any HPV vaccines, n=9515)        
 Very unlikely/unlikely/neutral 5071 (55.3) 3735 (55.3) 1336 (48.3) <.001
 Likely/very likely 4444 (46.7) 3013 (44.7) 1431 (51.7)  
HPV vaccine refusal for their daughters        
 No 6657 (56.8) 3419 (47.8) 3238 (70.8) <.001
 Yes 5071 (43.2) 3735 (52.2) 1336 (29.2)  
HPV vaccine refusal among mothers        
 No 7396 (63.1) 4726 (66.1) 2670 (58.4) <.001
 Yes 4332 (36.9) 2428 (33.9) 1904 (41.6)  
Mother-daughter communication related to HPV vaccination        
Who will decide whether to have the index daughter take up HPV vaccines?        
 Mainly decided by you (the mother) 6273 (53.5) 3841 (53.7) 2432 (53.2) <.001
 Mainly decided by your husband 649 (3.5) 396 (5.5) 253 (5.5)  
 Mainly decided by the index daughter 400 (3.4) 166 (2.3) 234 (5.1)  
 A shared decision among family members 4406 (37.6) 2751 (38.5) 1655 (36.2)  
Perceived positive outcomes of discussing HPV vaccines with the index daughter        
 The index daughter will understand the purpose of taking up HPV vaccines 7235 (61.7) 4035 (56.4) 3200 (70.0) <.001
 The index daughter will feel that you care about her 9798 (83.5) 5894 (82.4) 3904 (85.4) <.001
 The index daughter will be more willing to take up HPV vaccines 8270 (70.5) 4749 (66.4) 3521 (77.0) <.001
Positive Outcome Expectancy Scale a, mean (SD) 7.9 (1.6) 7.7 (1.6) 8.1 (1.4) <.001
Perceived negative outcomes of discussing HPV vaccines with the index daughter        
 The index daughter will get confused 3829 (32.6) 2539 (35.6) 1280 (28.0) <.001
 The index daughter will ask you some questions that make your feel embarrassed 5071 (43.2) 3391 (47.4) 1680 (36.7) <.001
 The index daughter will argue with you 2728 (23.3) 1570 (21.9) 1158 (25.3) <.001
Negative Outcome Expectancy Scale b, mean (SD) 5.6 (2.0) 5.7 (1.9) 5.3 (2.0) <.001
The Openness Subscale c of the Parent-adolescent Communication Scale        
Mean (SD) 37.4 (6.7) 37.5 (6.8) 37.3 (6.6) .05
Influence of social media related to HPV vaccination        
Frequency of exposure to the following information on social media platforms (i.e., WeChat moments, Weibo, Tiktok, Red) in the past month        
Testimonials given by parents about daughters’ HPV vaccination        
 Almost none 3997 (34.1) 2474 (34.6) 1523 (33.3) .29
 Seldom 4314 (36.8) 2599 (36.3) 1715 (37.5)
 Sometimes 2710 (23.1) 1637 (22.9) 1073 (23.5)
 Always 707 (6.0) 444 (6.2) 263 (5.7)
 Item score, mean (SD) 2.0 (0.9) 2.0 (0.9) 2.0 (0.9) .26
Negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines)        
 Almost none 3667 (31.3) 2241 (31.3) 1426 (31.2) .34
 Seldom 4803 (41.0) 2889 (40.4) 1914 (41.8)
 Sometimes 2730 (23.2) 1693 (23.7) 1037 (22.7)
 Always 528 (4.5) 331 (4.6) 197 (4.3)
 Item score, mean (SD) 2.0 (0.9) 2.0 (0.9) 2.0 (0.8) .02
Negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects)        
 Almost none 3990 (34.0) 2419 (33.8) 1571 (34.3) .60
 Seldom 4719 (40.2) 2866 (40.1) 1853 (40.5)
 Sometimes 2468 (21.1) 1535 (21.5) 933 (20.5)
 Always 551 (4.7) 334 (4.7) 217 (4.7)
 Item score, mean (SD) 2.0 (0.9) 2.0 (0.9) 2.0 (0.9) .97
Information that encourages parents to vaccine their daughters against HPV        
 Almost none 2737 (23.3) 1724 (24.1) 1013 (22.1) <.001
 Seldom 3114 (26.6) 1993 (27.9) 1121 (24.5)  
 Sometimes 3688 (31.4) 2225 (31.1) 1463 (32.0)  
 Always 2189 (18.7) 1212 (16.9) 977 (21.4)  
 Item score, mean (SD) 2.5 (1.0) 2.4 (1.0) 2.5 (1.1) .005
Thoughtful consideration about veracity of information specific to HPV vaccines in the past month        
 Almost none 2566 (21.9) 1599 (22.4) 967 (21.1) .06
 Seldom 3239 (27.6) 2006 (28.0) 1233 (27.0)  
 Sometimes 4025 (34.3) 2434 (34.0) 1591 (34.8)  
 Always 1898 (16.2) 1115 (15.6) 783 (17.1)  
 Item score, mean (SD) 2.5 (1.0) 2.4 (1.0) 2.5 (1.0) .62
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aPositive Outcome Expectancy Scale, 3 items, Cronbach’s alpha: .69; one factor was identified by exploratory factor analysis, explaining for 63.2% of total variance.

bNegative Outcome Expectancy Scale, 3 items, Cronbach’s alpha: .62; one factor was identified by exploratory factor analysis, explaining for 57.1% of total variance.

cThe Openness Subscale of the Parent-adolescent Communication Scale, Cronbach’s alpha: .93.

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 Table 2. 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 (Table 2).

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 (Table 3). 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).

Table 3.

Associations between background characteristics and HPV vaccine refusal for the index daughters.

  All participants (n=11,728)
 Participants with daughters aged 9–12 (n=7,154)
 Participants with daughters aged 13–17 (n=4,574)
OR (95%CI) P values OR (95%CI) P values OR (95%CI) P values
Age group, years            
 28–35 Reference   Reference   Reference  
 36–40 0.85 (0.77, 0.93) <.001 0.91 (0.82, 1.02) .10 1.18 (0.97, 1.43) .10
 41–61 0.84 (0.76, 0.92) <.001 1.00 (0.88, 1.13) .96 1.36 (1.12, 1.66) .002
Education level            
 Junior high or below Reference   Reference   Reference  
 Senior high or equivalent 0.86 (0.78, 0.96) .005 0.80 (0.70, 0.92) .002 0.81 (0.68, 0.95) .01
 College and above 0.77 (0.71, 0.85) <.001 0.64 (0.56, 0.72) <.001 0.60 (0.51, 0.70) <.001
Relationship status            
 Married Reference   Reference   Reference  
 Currently single 0.72 (0.59, 0.86) <.001 0.68 (0.54, 0.87) .002 0.84 (0.61, 1.15) .28
Employment status            
 Full time Reference   Reference   Reference  
 Part-time 1.48 (1.28, 1.71) <.001 1.79 (1.47, 2.19) <.001 1.45 (1.13, 1.84) .003
 Self-employed 1.09 (0.99, 1.19) .07 1.09 (0.97, 1.21) .15 1.32 (1.13, 1.54) <.001
 Unemployed 1.41 (1.09, 1.83) .008 1.62 (1.15, 2.28) .005 1.45 (0.95, 2.22) .09
 Housewife 1.37 (1.22, 1.53) <.001 1.47 (1.28, 1.69) <.001 1.43 (1.18, 1.74) <.001
 Others 1.12 (0.92, 1.37) .26 1.12 (0.87, 1.44) .39 1.22 (0.86, 1.74) .27
Monthly household income, ¥ (US$)            
 <5000 (685) Reference   Reference   Reference  
 5000–9999 (685–1369) 0.84 (0.75, 0.94) .002 0.78 (0.67, 0.91) .002 0.74 (0.62, 0.88) <.001
 10,000–15,000 (1369–2054) 0.71 (0.62, 0.81) <.001 0.59 (0.50, 0.70) <.001 0.70 (0.57, 0.87) .001
 >15,000 (2054) 0.66 (0.59, 0.81) <.001 0.58 (0.50, 0.68) <.001 0.46 (0.37, 0.57) <.001
 Refuse to disclose 0.99 (0.86, 1.16) .98 0.92 (0.75, 1.11) .37 0.92 (0.73, 1.17) .52
Self-reported history of HPV infection            
 No Reference   Reference   Reference  
 Yes 0.81 (0.75, 0.88) <.001 0.82 (0.65, 1.05) .11 0.85 (0.61, 1.18) .32
Self-reported history of HPV-related diseases (i.e., genital warts, cervical/anus/vagina cancers, and precancerous lesions)            
 No Reference   Reference   Reference  
 Yes 0.84 (0.66, 1.09) .19 0.84 (0.61, 1.17) .31 0.93 (0.61, 1.41) .72
Age of the index daughter, years            
 9–12 Reference   –   –  
 13–17 0.39 (0.36, 0.42) <.001 – – – –
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Note. OR: crude odds ratios obtained from two-level logistic regression models (level 1: schools, level 2: individual participants).

CI: confidence interval.

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 (Table 4). 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.

  All participants (n = 11,728)
 Participants with daughters aged 9–12 (n = 7,154)
 Participants with daughters aged 13–17 (n = 4,574)
AOR (95%CI) P values Hosmer and Lemeshow test AOR (95%CI) P values Hosmer and Lemeshow test AOR (95%CI) P values Hosmer and Lemeshow test
HPV vaccine refusal among mothers                  
 No Reference   .38 Reference   .35 Reference   .31
 Yes 2.81 (2.58, 3.06) <.001 2.97 (2.67, 3.30) <.001 2.47 (2.15, 2.82) <.001
Mother-daughter communication related to HPV vaccination                  
Who will decide whether to have the index daughter take up HPV vaccines?                  
 Mainly decided by you (the mother) Reference   .26 Reference   .22 Reference   .06
 Mainly decided by your husband 1.28 (1.08, 1.52) .004 1.20 (0.97, 1.48) .09 1.44 (1.08, 1.90) .01
 Mainly decided by the index daughter 1.43 (1.16, 1.77) .001 1.85 (1.33, 2.56) <.001 1.17 (0.87, 1.58) .31
 A shared decision among family members 1.46 (1.44, 1.70) <.001 1.51 (1.36, 1.67) <.001 1.67 (1.45, 1.92) <.001
Positive Outcome Expectancy Scale 0.77 (0.75, 0.79) <.001 .16 0.78 (0.76, 0.81) <.001 .06 0.76 (0.72, 0.79) <.001 .06
Negative Outcome Expectancy Scale 1.06 (1.04, 1.08) <.001 .19 1.07 (1.04, 1.09) <.001 .20 1.05 (1.01, 1.08) .006 .06
The Openness Subscale of the Parent-adolescent Communication Scale 0.99 (0.98, 0.99) <.001 .88 0.99 (0.98, 0.99) <.001 .10 0.98 (0.98, 0.99) .002 .92
Influence of social media related to HPV vaccination                  
Frequency of exposure to the following information on social media platforms (i.e., WeChat moments, Weibo, Tiktok, Red) in the past month                  
Testimonials given by parents about daughters’ HPV vaccination 0.81 (0.78, 0.85) <.001 .41 0.81 (0.77, 0.85) <.001 .78 0.83 (0.77, 0.89) <.001 .07
 Negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines) 1.01 (0.96, 1.05) .84 .12 0.97 (0.92, 1.03) .35 .07 1.06 (0.98, 1.15) .12 .07
 Negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects) 1.01 (0.96, 1.05) .73 .06 0.97 (0.92, 1.03) .28 .06 1.08 (0.99, 1.17) .06 .06
 Information that encourages parents to vaccine their daughters against HPV 0.76 (0.73, 0.79) <.001 .50 0.76 (0.73, 0.80) <.001 .34 0.75 (0.71, 0.80) <.001 .16
Thoughtful consideration about veracity of information specific to HPV vaccines in the past month 0.80 (0.77, 0.83) <.001 .20 0.82 (0.78, 0.86) <.001 .69 0.78 (0.73, 0.83) <.001 .06
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AOR: adjusted odds ratios, odds ratios obtained from two-level logistic regression models (level 1: schools, level 2: individual participants) after adjusting for significant background characteristics listed in Table 3.

CI: confidence interval.

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,18 Canada (12.0%),15 the United States (18.0%-23.0%),50,51 and Australia (34.0%).19–20,50–53 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.54,55 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.10,56 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.57,58 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.59–61 Mothers with higher socioeconomic status usually have better health literacy.62,63 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).28,29,64 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.64 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.65,66 Mothers who perceived more positive outcomes of parent-daughter communication would have more confidence to communicate directly with their daughters.66 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.67,68

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.14 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.35 In line with previous studies,35–37 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.69 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.

Supplementary Material

Appendix 1.docx
KHVI_A_2333111_SM7694.docx (14.6KB, docx)

Appendix. Details related to HPV vaccination among the index daughters who had received HPV vaccines (n = 2213)

  n %
HPV vaccine uptake among the index daughters    
Number dose of HPV vaccination uptake among the index daughters (Among 2213 participants whose index daughters had received at least one dose of HPV vaccine)    
 1 dose 380 17.2
 2 doses 1495 67.6
 3 doses 221 10.0
 Uncertain 117 5.2
Type of HPV vaccination uptake among the index daughters (Among 2213 participants whose index daughters had received at least one dose of HPV vaccine)    
 Domestic bivalent vaccines 1120 50.6
 Imported bivalent vaccines 83 3.8
 Quadrivalent vaccine (Gardasil 4) 53 2.4
 9-valent vaccine (Gardasil 9) 436 19.7
 Uncertain 521 23.5
Venues of vaccination uptake among the index daughters (Among 2213 participants whose index daughters had received at least one dose of HPV vaccine)    
 Public hospitals or community health centers in Shenzhen 2032 91.8
 Private hospitals in Shenzhen 166 7.5
 Other provinces or cities 53 2.4
 Hong Kong, Macao or other countries 51 2.3
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Funding Statement

This study was funded by the Scientific Research Project of Medical and Health Institutions in Longhua District [Grant number: 2021162], the Social Welfare Research Grant in Longhua District [Grant number: 2548A20210414BA70D4A].

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.

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.

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.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2333111.

References

  • 1.Cao W, Chen HD, Yu YW, Li N, Chen WQ.. Changing profiles of cancer burden worldwide and in China: a secondary analysis of the global cancer statistics 2020. Chin Med J (Engl). 2021;134(7):783–12. doi: 10.1097/cm9.0000000000001474. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Wang H, Jiang Y, Wang Q, Lai Y, Holloway A. The status and challenges of HPV vaccine programme in China: an exploration of the related policy obstacles. BMJ Glob Health. 2023;8(8):e012554. doi: 10.1136/bmjgh-2023-012554. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Lu Y, Li P, Luo G, Liu D, Zou H. Cancer attributable to human papillomavirus infection in China: burden and trends. Cancer. 2020;126(16):3719–32. doi: 10.1002/cncr.32986. [DOI] [PubMed] [Google Scholar]
  • 4.Wang L. Accelerating cervical cancer prevention and control in China to achieve cervical cancer elimination strategy objectives. China CDC Wkly. 2022;4(48):1067–9. doi: 10.46234/ccdcw2022.215. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Duan R, Zhang H, Yu J, Deng S, Yang H, Zheng Y-T, Huang Y, Zhao F, Yang H. Temporal trends and projections of gynecological cancers in China, 2007–2030. BMC Women’s Health. 2023;23(1):346. doi: 10.1186/s12905-023-02384-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Guo M, Xu J, Du J. Trends in cervical cancer mortality in China from 1989 to 2018: an age-period-cohort study and joinpoint analysis. BMC Public Health. 2021;21(1):1329. doi: 10.1186/s12889-021-11401-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Centers for Disease Control and Prevention . HPV vaccine safety and effectiveness. 2023. [accessed 2023 Oct 17]. https://www.cdc.gov/vaccines/vpd/hpv/hcp/safety-effectiveness.html.
  • 8.Robinson CL. Advisory committee on immunization practices recommended immunization schedules for persons aged 0 through 18 years–United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(4):86–7. doi: 10.15585/mmwr.mm6504a4. [DOI] [PubMed] [Google Scholar]
  • 9.Centers for Disease Control and Prevention . HPV vaccination recommendations. 2023. [accessed 2023 Oct 17]. https://www.cdc.gov/vaccines/vpd/hpv/hcp/recommendations.html.
  • 10.National Health Commission of the People’s Republic of China . HPV vaccination policy. 2019. [accessed 2023 Oct 17]. https://www.gov.cn/xinwen/2019-09/24/content_5432699.htm.
  • 11.Pan XF, Li R, Pan A, Larson H. Human papillomavirus vaccine approval in China: a major step forward but challenges ahead. Lancet Infect Dis. 2016;16(12):1322–3. doi: 10.1016/s1473-3099(16)30450-9. [DOI] [PubMed] [Google Scholar]
  • 12.National Health Commission of the People’s Republic of China . Nation plans to launch free HPV vaccinations. 2022. [accessed 2023 Oct 17]. http://en.nhc.gov.cn/2022-01/14/c_85612.htm.
  • 13.Ellingson MK, Sheikha H, Nyhan K, Oliveira CR, Niccolai LM. Human papillomavirus vaccine effectiveness by age at vaccination: a systematic review. Hum Vaccines Immunother. 2023;19(2):2239085. doi: 10.1080/21645515.2023.2239085. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Wang Z, Wang J, Fang Y, Gross DL, Wong MCS, Wong ELY, Lau JTF. Parental acceptability of HPV vaccination for boys and girls aged 9–13 years in China – a population-based study. Vaccine. 2018;36(19):2657–65. doi: 10.1016/j.vaccine.2018.03.057. [DOI] [PubMed] [Google Scholar]
  • 15.Krawczyk A, Perez S, King L, Vivion M, Dubé E, Rosberger Z. Parents’ decision-making about the human papillomavirus vaccine for their daughters: II. Qualitative results. Hum Vaccines Immunother. 2015;11(2):330–6. doi: 10.4161/21645515.2014.980708. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.DiAnna Kinder F. Parental refusal of human papillomavirus vaccine: multisite study. J Pediatr Health Care. 2018;32(2):150–6. doi: 10.1016/j.pedhc.2017.09.003. [DOI] [PubMed] [Google Scholar]
  • 17.Dempsey AF, Lockhart S, Campagna EJ, Pyrzanowski J, Barnard J, O’ Leary ST. Providers’ time spent and tools used when discussing the HPV vaccine with parents of adolescents. Vaccine. 2016;34(50):6217–22. doi: 10.1016/j.vaccine.2016.10.083. [DOI] [PubMed] [Google Scholar]
  • 18.Xie H, Zhu H-Y, Jiang N-J, Yin Y-N. Awareness of HPV and HPV vaccines, acceptance to vaccination and its influence factors among parents of adolescents 9 to 18 years of age in China: a cross-sectional study. J Pediatr Nurs. 2023;71:73–8. doi: 10.1016/j.pedn.2023.03.007. [DOI] [PubMed] [Google Scholar]
  • 19.Wei Z, Liu Y, Zhang L, Sun X, Jiang Q, Li Z, Wu Y, Fu C. Stages of HPV vaccine hesitancy among guardians of female secondary school students in China. J Adolesc Health. 2023;72(1):73–9. doi: 10.1016/j.jadohealth.2022.08.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Zhang Z, Shi J, Zhang X, Guo X, Yu W. Willingness of parents of 9-to-18-year-old females in China to vaccinate their daughters with HPV vaccine. Vaccine. 2023;41(1):130–5. doi: 10.1016/j.vaccine.2022.11.016. [DOI] [PubMed] [Google Scholar]
  • 21.Abouelella DK, Watts TL, Rocke DJ, Barnes JM, Osazuwa-Peters N, Adjei Boakye E. Reasons for parental refusal of human papillomavirus vaccine during the COVID-19 pandemic in 2020. Public Health. 2023;223:e9–e11. doi: 10.1016/j.puhe.2023.01.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Zach R, Bentwich ME. Reasons for and insights about HPV vaccination refusal among ultra-orthodox Jewish mothers. Dev World Bioeth. 2023;23(4):300–11. doi: 10.1111/dewb.12372. [DOI] [PubMed] [Google Scholar]
  • 23.Chido-Amajuoyi OG, Talluri R, Jackson I, Shete SS, Domgue JF, Shete S. The influence of parent–child gender on intentions to refuse HPV vaccination due to safety concerns/side effects, national immunization survey – Teen, 2010–2019. Hum Vaccines Immunother. 2022;18(5):2086762. doi: 10.1080/21645515.2022.2086762. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77. doi: 10.1177/109019818801500401. [DOI] [PubMed] [Google Scholar]
  • 25.Ouma PO, van Eijk AM, Hamel MJ, Sikuku ES, Odhiambo FO, Munguti KM, Ayisi JG, Crawford SB, Kager PA, Slutsker L. Antenatal and delivery care in rural western Kenya: the effect of training health care workers to provide “focused antenatal care”. Reprod Health. 2010;7:1. doi: 10.1186/1742-4755-7-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Miller KS, Levin ML, Whitaker DJ, Xu X. Patterns of condom use among adolescents: the impact of mother-adolescent communication. Am J Public Health. 1998;88(10):1542–4. doi: 10.2105/ajph.88.10.1542. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Guilamo‐Ramos V, Jaccard J, Dittus P, Bouris AM. Parental expertise, trustworthiness, and accessibility: parent‐adolescent communication and adolescent risk behavior. J Marriage Fam. 2006;68(5):1229–46. doi: 10.1111/j.1741-3737.2006.00325.x. [DOI] [Google Scholar]
  • 28.Kotchick BA, Dorsey S, Miller KS, Forehand R. Adolescent sexual risk-taking behavior in single-parent ethnic minority families. J Fam Psychol. 1999;13(1):93. doi: 10.1037/0893-3200.13.1.93. [DOI] [Google Scholar]
  • 29.Barnes HL, Olson DH. Parent-adolescent communication and the circumplex model. Child Dev. 1985;56(2):438–47. doi: 10.2307/1129732. [DOI] [Google Scholar]
  • 30.Flores D, Barroso J. Century parent-child sex communication in the United States: a process review.” J Sex Res 2017;54(4–5):532-48. doi: 10.1080/00224499.2016.1267693. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Naftaly JP, Greenley RN. Mother-daughter communication about sexual behavior and reproductive health in females with chronic health conditions. J Pediatr Nurs. 2019;47:78–84. doi: 10.1016/j.pedn.2019.04.020. [DOI] [PubMed] [Google Scholar]
  • 32.Ortiz RR, Smith A, Coyne-Beasley T. A systematic literature review to examine the potential for social media to impact HPV vaccine uptake and awareness, knowledge, and attitudes about HPV and HPV vaccination. Hum Vaccin Immunother. 2019;15(7–8):1465–75. doi: 10.1080/21645515.2019.1581543. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Zhang K, Liang X, Tam KLW, Kawuki J, Chan PS, Chen S, Fang Y, Cao H, Zhou X, Chen Y. et al. Changes in COVID-19 vaccine acceptability among parents with children aged 6–35 months in China—repeated cross-sectional surveys in 2020 and 2021. Nato Adv Sci Inst Se. 2023;11(1):170. doi: 10.3390/vaccines11010170. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Kornides ML, Badlis S, Head KJ, Putt M, Cappella J, Gonzalez-Hernadez G. Exploring content of misinformation about HPV vaccine on twitter. J Behav Med. 2023;46(1–2):239–52. doi: 10.1007/s10865-022-00342-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Pan Y, Xin M, Zhang C, Dong W, Fang Y, Wu W, Li M, Pang J, Zheng Z, Wang Z, et al. Associations of mental health and personal preventive measure compliance with exposure to COVID-19 information during work resumption following the COVID-19 outbreak in China: cross-sectional survey study. J Med Internet Res. 2020;22(10):e22596. doi: 10.2196/22596. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Zhang K, Fang Y, Chan PS, Cao H, Chen H, Hu T, Chen Y, Zhou X, Wang Z. Behavioral intention to get a booster dose of COVID-19 vaccine among Chinese factory workers. Int J Environ Res Public Health. 2022;19(9):5245. doi: 10.3390/ijerph19095245. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Singh A, Lai AHY, Wang J, Asim S, Chan PS, Wang Z, Yeoh EK. Multilevel determinants of COVID-19 vaccine uptake among south Asian ethnic minorities in Hong Kong: cross-sectional web-based survey. MIR Public Health Surveill. 2021;7(11):e31707. doi: 10.2196/31707. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Liao Q, Lam WW, Cowling BJ, Fielding R. Psychosocial influences on parental decision-making regarding vaccination against seasonal influenza for young children in Hong Kong: a longitudinal study, 2012–2013. Int J Behav Med. 2016;23(5):621–34. doi: 10.1007/s12529-016-9551-1. [DOI] [PubMed] [Google Scholar]
  • 39.MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161–4. doi: 10.1016/j.vaccine.2015.04.036. [DOI] [PubMed] [Google Scholar]
  • 40.Wollebæk D, Fladmoe A, Steen-Johnsen K, Ihlen Ø. Right-wing ideological constraint and vaccine refusal: the case of the COVID-19 vaccine in Norway. Scan Polit Stud. 2022;45(2):253–78. doi: 10.1111/1467-9477.12224. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Zhou X, Wang S, Zhang K, Chen S, Chan P-F, Fang Y, Cao H, Chen H, Hu T, Chen Y, Changes in parents’ COVID-19 vaccine hesitancy for children aged 3–17 years before and after the rollout of the national childhood COVID-19 vaccination program in China: repeated cross-sectional surveys. Nato Adv Sci Inst Se. 2022;10(9):1478. doi: 10.3390/vaccines10091478. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Xiao J, Cheung JK, Wu P, Ni MY, Cowling BJ, Liao Q. Temporal changes in factors associated with COVID-19 vaccine hesitancy and uptake among adults in Hong Kong: serial cross-sectional surveys. Lancet Reg Health West Pac. 2022;23:100441. doi: 10.1016/j.lanwpc.2022.100441. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Zapf H, Boettcher J, Haukeland Y, Orm S, Coslar S, Wiegand-Grefe S, Fjermestad K. A systematic review of parent–child communication measures: instruments and their psychometric properties. Clin Child Fam Psychol Rev. 2023;26(1):121–42. doi: 10.1007/s10567-022-00414-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Barnes HL, Olson DH. Barnes and Olson communication scale. Child Development. [Google Scholar]
  • 45.Lama Y, Quinn SC, Nan X, Cruz-Cano R. Social media use and human papillomavirus awareness and knowledge among adults with children in the household: examining the role of race, ethnicity, and gender. Hum Vaccin Immunother. 2021;17(4):1014–24. doi: 10.1080/21645515.2020.1824498. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Pan Y, Fang Y, Xin M, Dong W, Zhou L, Hou Q, Li F, Sun G, Zheng Z, Yuan J, et al. Self-reported compliance with personal preventive measures among Chinese factory workers at the beginning of work resumption following the COVID-19 outbreak: cross-sectional survey study. J Med Internet Res. 2020;22(9):e22457. doi: 10.2196/22457. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Zhang KC, Fang Y, Cao H, Chen H, Hu T, Chen Y, Zhou X, Wang Z. Behavioral intention to receive a COVID-19 vaccination among Chinese factory workers: cross-sectional online survey. J Med Internet Res. 2021;23(3):e24673. doi: 10.2196/24673. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Patel MS, Niemann CU, Sally MB, De La Cruz S, Zatarain J, Ewing T, Crutchfield M, Enestvedt CK, Malinoski DJ. The impact of hydroxyethyl starch use in deceased organ donors on the development of delayed graft function in kidney transplant recipients: a propensity-adjusted analysis. Am J Transplant. 2015;15(8):2152–8. doi: 10.1111/ajt.13263. [DOI] [PubMed] [Google Scholar]
  • 49.Paul P, Pennell ML, Lemeshow S. Standardizing the power of the Hosmer-lemeshow goodness of fit test in large data sets. Stat Med. 2013;32(1):67–80. doi: 10.1002/sim.5525. [DOI] [PubMed] [Google Scholar]
  • 50.Szilagyi PG, Albertin CS, Gurfinkel D, Saville AW, Vangala S, Rice JD, Helmkamp L, Zimet GD, Valderrama R, Breck A, et al. Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US. Vaccine. 2020;38(38):6027–37. doi: 10.1016/j.vaccine.2020.06.074. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Nguyen KH, Santibanez TA, Stokley S, Lindley MC, Fisher A, Kim D, Greby S, Srivastav A, Singleton J. Parental vaccine hesitancy and its association with adolescent HPV vaccination. Vaccine. 2021;39(17):2416–23. doi: 10.1016/j.vaccine.2021.03.048. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Forbes TA, McMinn A, Crawford N, Leask J, Danchin M. Vaccination uptake by vaccine-hesitant parents attending a specialist immunization clinic in Australia. Hum Vaccin Immunother. 2015;11(12):2895–903. doi: 10.1080/21645515.2015.1070997. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Della Polla G, Pelullo CP, Napolitano F, Angelillo IF. HPV vaccine hesitancy among parents in Italy: a cross-sectional study. Hum Vaccin Immunother. 2020;16(11):2744–51. doi: 10.1080/21645515.2020.1744367. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Kepka D, Ding Q, Hawkins AJ, Warner EL, Boucher KM. Factors associated with early adoption of the HPV vaccine in US male adolescents include Hispanic ethnicity and receipt of other vaccines. Prev Med Rep. 2016;4:98–102. doi: 10.1016/j.pmedr.2016.05.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Rosen B, Goodson P. A recommendation to use the diffusion of innovations theory to understand school nurses’ role in HPV vaccine uptake. Int Q Community Health Educ. 2013;34(1):37–49. doi: 10.2190/IQ.34.1.d. [DOI] [PubMed] [Google Scholar]
  • 56.National Health Commission of the People’s Republic of China . Childhood vaccination scheme in China. 2021. [accessed 2023 Nov 14]. http://www.nhc.gov.cn/jkj/s3581/202103/590a8c7915054aa682a8d2ae8199e222/files/7559f978e6be4ec585a9a1fe0d9224f6.pdf.
  • 57.Yankey D, Elam-Evans LD, Bish CL, Stokley SK. Human papillomavirus vaccination estimates among adolescents in the Mississippi delta region: National Immunization Survey‑Teen, 2015–2017. Prev Chronic Dis. 2020;17. doi: 10.5888/pcd17.190234. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Bodson J, Ding Q, Warner EL, Hawkins AJ, Henry KA, Kepka D. Sub-regional assessment of HPV vaccination among female adolescents in the intermountain west and implications for intervention opportunities. Matern Child Health J. 2017;21(7):1500–11. doi: 10.1007/s10995-017-2274-3. [DOI] [PubMed] [Google Scholar]
  • 59.Zhu S, Chang J, Hayat K, Li P, Ji W, Fang Y. Parental preferences for HPV vaccination in junior middle school girls in China: A discrete choice experiment. Vaccine. 2020;38(52):8310–7. doi: 10.1016/j.vaccine.2020.11.020. [DOI] [PubMed] [Google Scholar]
  • 60.Gray A, Fisher CB. Factors associated with HPV vaccine acceptability and hesitancy among black mothers with young daughters in the United States. Front Public Health. 2023;11:1124206. doi: 10.3389/fpubh.2023.1124206. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Alhusayn KO, Alkhenizan A, Abdulkarim A, Sultana H, Alsulaiman T, Alendijani Y. Attitude and hesitancy of human papillomavirus vaccine among Saudi parents. J Family Med Prim Care. 2022;11(6):2909–16. doi: 10.4103/jfmpc.jfmpc_2377_21. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Khan MT, Zaheer S, Shafique K. Maternal education, empowerment, economic status and child polio vaccination uptake in Pakistan: a population based cross sectional study. BMJ Open. 2017;7(3):e013853. doi: 10.1136/bmjopen-2016-013853. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Lu P-J, O’Halloran A, Kennedy ED, Williams WW, Kim D, Fiebelkorn AP, Donahue S, Bridges CB. Awareness among adults of vaccine-preventable diseases and recommended vaccinations, United States, 2015. Vaccine. 2017;35(23):3104–15. doi: 10.1016/j.vaccine.2017.04.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Vincent Guilamo-Ramos V, Jaccard J, Dittus P, Bouris AM. Parental expertise, trustworthiness, and accessibility: parent-adolescent communication and adolescent risk behavior. J Marriage Fam. 2006;68(5):1229–46. doi: 10.1111/j.1741-3737.2006.00325.x. [DOI] [Google Scholar]
  • 65.Wong NCH. Predictors of information seeking about the HPV vaccine from parents and doctors among young college women. Commun Q. 2014;62(1):75–96. doi: 10.1080/01463373.2013.860905. [DOI] [Google Scholar]
  • 66.DiIORIO C, Resnicow K, Dudley WN, Thomas S, Terry Wang D, Van Marter DF, Manteuffel B, Lipana J. Social cognitive factors associated with mother-adolescent communication about sex. J Health Commun. 2000;5(1):41–51. doi: 10.1080/108107300126740. [DOI] [PubMed] [Google Scholar]
  • 67.Gauna F, Verger P, Fressard L, Jardin M, Ward JK, Peretti-Watel P. Vaccine hesitancy about the HPV vaccine among French young women and their parents: a telephone survey. BMC Public Health. 2023;23(1):628. doi: 10.1186/s12889-023-15334-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Peretti‐Watel P, Ward JK, Vergelys C, Bocquier A, Raude J, Verger P. ‘I think I made the right decision … I hope I’m not wrong’. Vaccine hesitancy, commitment and trust among parents of young children. Sociol Health Illn. 2019;41(6):1192–206. doi: 10.1111/1467-9566.12902. [DOI] [PubMed] [Google Scholar]
  • 69.Waller J, Marlow LA, Wardle J. The association between knowledge of HPV and feelings of stigma, shame and anxiety. Sex Transm Infect. 2007;83(2):155–9. doi: 10.1136/sti.2006.023333. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Appendix 1.docx
KHVI_A_2333111_SM7694.docx (14.6KB, docx)

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.

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